Population health examines the health outcomes of groups and the disparities in health among subgroups. This issue of the NCMJ illustrates population health efforts in the areas of obesity prevention, tobacco cessation, and clean water. Articles in this issue also discuss community health needs assessments, integrated health improvement, social determinants of health, and the Healthy North Carolina 2020 program.
Using Community Health Needs Assessments to Improve Population Health
Local health departments are the only health care entities responsible for protecting and promoting the health of every resident of the county (or counties) that a department serves. Health departments fulfill that responsibility in a variety of ways—by ensuring that all restaurants and temporary food establishments meet standards that prevent foodborne illness; by monitoring communicable diseases and working to assure that people with those diseases receive treatment and follow appropriate control measures, so that they do not expose or infect others; and by providing immunizations that prevent communicable diseases. Over the past few years, local health departments have also worked with other partners and with county commissioners to implement policies restricting smoking on college campuses and in government buildings and other locations, to prevent exposure to secondhand smoke, and they have established safe drop-off locations for unused prescription medications to help prevent unintended deaths from opioid overdoses.
For more than 20 years, local health departments have been required to conduct comprehensive community health needs assessments (CHNAs). A CHNA is based on data collection and analysis, and it includes a list of community health needs and issues, some of which are designated as priorities. Initially, local health departments completed a comprehensive CHNA once every 4 years. However, the Patient Protection and Affordable Care Act of 2010 called for changes to regulations for nonprofit hospitals, requiring them to perform CHNAs once every 3 years . As a result, local health departments in counties with a nonprofit hospital have also moved to a 3-year cycle for CHNAs, so that the community can simultaneously meet the needs of both the health department and the nonprofit hospital.
In some cases, collaboration extends beyond the area served by a single local health department. For example, many residents in Western North Carolina travel to Asheville for specialty hospital care, regardless of their county of residence. The hospitals and health departments in the Asheville area have therefore begun collaborating on a regional assessment with county-level data, so that each county can determine how its health status and issues relate to those of the region as a whole. To the extent possible, hospitals and health departments in Western North Carolina are also trying to use common strategies for addressing identified health priorities, so that they can improve health not only in the county or counties served by a particular health department but also region-wide.
The North Carolina General Assembly approved a mandatory accreditation system for all local health departments in 2005. CHNAs have since become the mechanism for demonstrating that a health department is meeting 2 accreditation requirements: to monitor health status and identify community health problems, and to diagnose and investigate health hazards in the community . Given these requirements, staff members of the North Carolina Division of Public Health have begun reviewing CHNAs to ensure that they include all of the necessary components. One requirement is that the CHNA bring together a group of local partners to plan for, collect, and review both primary data (collected directly from members of the community) and secondary data (available from other sources). The partners may vary from county to county but should include health care providers of all types, educators, business and civic leaders, social service professionals, elected leaders, and concerned community members. This group then uses the data collected to determine the community’s health needs and to develop plans to address the community’s top priorities. Since 2010 local health departments have also been required to link their top priorities to the goals and objectives of Healthy North Carolina 2020, and they are required to select health improvement strategies that are evidence-based, in order to provide the greatest chance for maximum impact.
A major goal of CHNAs is to use the data collected to create a climate for change that leads to improvement in the health of the community. The process allows communities to understand what the data say about the health status of their community and to find out whether subgroups of the population are disproportionately affected by diseases. This process also gives communities the opportunity to discover what their residents would like to see changed; which groups, organizations, and individuals are already trying to address key health issues; and what barriers hinder the community’s ability to achieve optimal health. By providing data documenting the community’s needs, CHNAs allow the community to build or enhance partnerships and coalitions that are working to improve health, to plan collaborative interventions that promote health, and to develop new resources or seek funding for new initiatives. Local health departments are encouraged to have every partner that participated in the CHNA process take responsibility for 1 or more of the goals, strategies, or interventions that are included in the improvement plan.
Community-wide involvement in CHNAs has been especially important over the past few years, as communities have begun to focus more on social determinants of health and on the creation of an environment where people can be healthy. For example, efforts to address social determinants of health include increasing the high school graduation rate, increasing access to affordable housing, and increasing access to jobs in the community. Examples that have focused on creating a healthy environment include eliminating “food deserts” (places in the community where it is difficult to purchase fresh fruits and vegetables) and providing more opportunity for appropriate physical activity by adding walking trails and reaching joint-use agreements. These types of changes do not focus on individuals with a specific health problem; rather, they target the health of the overall community (ie, population health).
Another way of improving population health is to find ways to increase access to health care in a community. Addressing this priority often involves finding creative ways to attract additional dentists, primary care providers, or specialists to a community. Previous research has shown that the convenience of health care services and people’s perceptions of their access to care affect their utilization of health care [3-5]. Travelling time and distance to care also affect population health .
In December 2013, to assess statewide efforts to prevent chronic disease, one of us (E.F., a chronic disease epidemiologist in the Chronic Disease and Injury Section of the North Carolina Division of Public Health) analyzed the CHNAs submitted in North Carolina in 2011, 2012, and 2013. The purpose of this study was to analyze the health concerns commonly identified in CHNAs, specifically those related to disease areas and outcomes that are the focus of the Chronic Disease and Injury Section. When a health concern that fell under the purview of the Chronic Disease and Injury Section was selected as a priority concern in a CHNA, it was recorded using the same description supplied in the assessment. (For instance, diabetes, heart disease, and stroke could each be designated as a priority health concern, but if a community lumped them together and identified “chronic disease” as a priority, then that is how the data were captured in the analysis.) Table 1 reports each health concern identified in this analysis and the percentage of all CHNAs that listed that concern as a priority. Obesity, diabetes, and “chronic disease” as a general category were the top 3 health priorities identified statewide. Of the 76 counties that designated obesity as a priority, 7 counties chose to focus specifically on childhood obesity.
The North Carolina Division of Public Health then brought together health directors (or their designees) from those counties that had selected any of the top 3 health concerns as a priority in their county, and these individuals were asked to consider 5 evidence-based strategies that could be used to address each health priority. They were then asked to select a single evidence-based strategy for each health concern, so that all of the counties could implement the same strategy; the hope is that a collective effort could make a significant impact at the statewide level.
As an evidence-based strategy to address obesity, the health directors and their designees selected the implementation of early care and education standards and policies that are designed to give children a healthier start by keeping them from becoming obese. The strategy selected for addressing diabetes was implementation of the Diabetes Education Recognition Program. The “chronic disease” priority was reframed as hypertension/stroke, and the evidence-based strategy selected for addressing this priority was the implementation of Healthy Living, a chronic-disease self-management program. The Chronic Disease and Injury Section will be working with the local health departments involved in this effort to implement the selected strategies between now and 2020, and this effort will seek to determine whether collective action can affect these health outcomes statewide.
The North Carolina Division of Public Health, local health departments, and community partners have an opportunity to improve North Carolina’s health status by engaging in more focused work and by collaborating on common goals. Now is the right time to move population health in a new direction. If we can together improve health outcomes for a few key indicators, perhaps we can make inroads in other areas as well, even with limited resources. Working together using evidence-based strategies and data-driven approaches may be the best way to improve the health of North Carolina’s population.
Potential conflicts of interest. J.F.R. and E.F. have no relevant conflicts of interest.
1. Internal Revenue Service. Internal Revenue Bulletin 2011-30. Notice 2011-52. Notice and request for comments regarding the community health needs assessment requirements for tax-exempt hospitals. July 25, 2011. http://www.irs.gov/irb/2011-30_IRB/ar08.html#d0e540. Accessed August 21, 2014.
2. 2005-369 NC Sess Laws 1319-1320. http://www.ncga.state.nc.us/sessions/2005/bills/senate/html/s804v3.html. Accessed August 21, 2014.
3. Zimmerman SM. Factors influencing Hispanic participation in prostate cancer screening. Oncol Nurs Forum. 1997;24(3):499-504.
4. Facione NC. Breast cancer screening in relation to access to health services. Oncol Nurs Forum. 1999;26(4):689-696.
5. Baron RC, Rimer BK, Breslow RA, et al; Task Force on Community Preventive Services. Client-directed interventions to increase community demand for breast, cervical, and colorectal cancer screening: a systematic review. Am J Prev Med. 2008; 35(1 suppl):S34-S55.
6. Gu W, Wang X, McGregor SE. Optimization of preventive health care facility locations. Int J Health Geogr. 2010;9:17.
Joy F. Reed, EdD, RN, FAAN retired head, Local Technical Assistance and Training Branch, Division of Public Health, Department of Health and Human Services, Raleigh, North Carolina.
Eleanor Fleming, PhD, DDS lieutenant, United States Public Health Service; epidemiologist, Chronic Disease and Injury Section, Division of Public Health, Department of Health and Human Services, Raleigh, North Carolina.
Address correspondence to Dr. Joy F. Reed, 3305 Brennan Dr, Raleigh, NC 27613 (firstname.lastname@example.org).