Community Health Assessment Paper

Community Health Assessment Paper

The implementation of any plan first starts with assessing the problem at hand, understanding what is causing the problem, and what’s needed to fix the problem. When it comes to our community needs that involve health care, this can be more complex when trying to understand what’s required in order to have an impact in a positive way. A community health needs assessment (CHNA) is the process of collaboration, systematic process of collecting and analyzing data to understand the health needs of a community and to implement plans for addressing those needs (Alfano-Sobsey, Ledford, Decosimo, & Horney, 2014).

Community Health Assessment Paper

Type of data needed

When collecting data required for making an informed community health assessment we will use parts of the Healthy People 2020, and gathering a population overview of the are using Nielson’s Claritas. The population overview will be broken down into age groups, education, and income. The framework used in the assessment consists of 12 topic areas. For our community focus on the following areas: Access to health services, Injury and Violence, Mental health, Substance Abuse, Maternal, Infant, and Child health, Nutritional, Physical Activity and Obesity, and Environmental Quality.

The access to health services shows the people in the community who are uninsured, have primary care providers, as well as how many providers are in the area relative to the populations. This data is vital because when routine medical care and preventive measures neglected, the risk for severe, acute conditions and expensive medical cost rise. Injury and Violence data is broken down into rates of suicide, homicide, motor vehicle crashes, and unintentional injuries.

When looking at the accidental and violent deaths, and the importance of its effect it has on everyone involved. Mental health is data on providers in the area. Research has shown the adults and children with undiagnosed and untreated mental health issues are at higher risk for unhealthy and unsafe behaviors. Gathering information on substance abuse in the community is essential due to the destructive behaviors and social networks that comes along with excessive drug use and alcohol abuse. Community Health Assessment Paper

The importance of understanding the populations of the community’s women and children is significant when looking at the future of the community, and helps predict the future of public health strengths and challenges. The nutritional, physical activity and obesity data are essential in getting a better understanding the communities to access to local grocery stores, and obese population. Evaluation of the quality of the environment can give data the effect of poor environmental quality on populations with impaired or weak immune systems, which is seen with hospitalizations or emergency department visits with patients such as asthma.

Method to collect data

The collections of data used for the community health assessment will use multiple different sources to gather the information needed. The first step of the evaluation will start with community input. Collecting data from the community will include the use of surveys, focus groups, and interviews with the goal of acquiring their opinions about the community health issues and personal health needs.

The survey period will be used to understand the communities use of, concerns with, and gaps in health services, as well as finding out better ways to provide the healthcare (Becker, 2014 Community Health Assessment Paper). The community survey will launch online using the Survey Monkey platform. It will consist of 20 questions for all respondents and 15 additional questions for health care providers. The focus groups will be conducted to engage the community in a more prominent setting, more intimate, to talk about health. Focus groups take advantage of the group effect of shared experiences by showing how people perceive them differently (Becker, 2014).

When conducting the interviews, the goal is to invite community leaders to participate who are involved in the local community with the hopes of the help of spreading the word of what we are doing to hopefully get the community to buy into the project (Becker, 2014). When gathering other secondary data for information for data related to the community, we would use resources from 2018 County Health Ranking, which measures health outcomes and associated factors. Another resource will be Truven Health Analytics, which is a search engine that discovers clinical shortages and outpatient statistics. Finally will use the United States Department of Agriculture (USDA) to collect information on food to assess issues and healthy food options.

Factors that impact the health and wellness

When conducting the assessment of the community, it’s important to understand the factors that influence community health and wellness. Barriers commonly found within the communities include: Transportation, Assesses to services, Uninsured and underinsured patients, Availability of providers, Lack of knowledge about health conditions, Language, and Fear of healthcare system. We expect to collect the majority of these factors during the community input portion of the assessment through the survey, interviews, and focus groups. Community Health Assessment Paper

Evaluating the data collected

After collecting and analyzing all the data, we are going to identify the health priorities: medical conditions, health behavior, and community conditions. During this process, we also look for the causes to the health issues and thus will lead us to the implementation of strategies to put in place to address these priorities. The plan will include ways to measure health improvement strategies and health outcomes with the development of obtainable goals (Pennel, McLeroy, Burdine, Matarrita-Cascante, & Wang, 2016 Community Health Assessment Paper).

References for Community Health Assessment Paper

Alfano-Sobsey, E., Ledford, S. L., Decosimo, K., & Horney, J. A. (2014). Community Health Needs Assessment in Wake County, North Carolina: Partnership of Public Health, Hospitals, Academia, and Other Stakeholders. North Carolina Medical Journal , 75(6), 376-383.

Becker, K. (2014). Conducting Community Health Needs Assessments in Rural Communities: Lessons Learned. Health Promotion Practice, 16(1), 15-19.

County Health Rankings & Roadmaps . (2018). IBM Watson Health . (n.d.).

Pennel, C. L., James, B. N., McLeroy, K. R., & Matarrita-Cascante, D. (2015). Nonprofit Hospitals? Approach to Community Health Needs Assessment. American Journal of Public Health; Washington, 105(3), E103-E113. Retrieved from

Pennel, C. L., McLeroy, K. R., Burdine, J. N., Matarrita-Cascante, D., & Wang, J. (2016). Community Health Needs Assessment: Potential for Population Health Improvement. Population Health Management, 19(3), 178-186.

U.S. Department of Agriculture. (n.d.).

Identify a Community Health Assessment Model. (This document from the CDC lists commonly used community assessment models: ) What are some benefits of using a specific model to assess a community? What agencies should be included with the assessment? What is a reasonable time frame in which to complete a community-wide assessment? What is the role of the public nurse in the implementation of the chosen model?

N492 Community Health Assessment Paper Instructions

In this module, you will complete a full assessment of your own community. 

Defining the Community

Your community can be any geographically defined county, city, or town. Clearly delineate the following dimensions before starting the process of community assessment:

  • Describe the population that is being assessed?
  • What is/are the race(s) of this population within the community?
  • Are there boundaries of this group? If so, what are they?
  • Does this community exist within a certain city or county?
  • Are there general characteristics that separate this group from others?
  • Education levels, birth/death rates, age of deaths, insured/uninsured?
  • Where is this group located geographically…? Urban/rural?
  • Why is a community assessment being performed? What purpose will it serve?
  • How will information for the community assessment be collected?


After the community has been defined, the next phase is assessment. The following items describe several resources and methods that can be used to gather and generate data. These items serve as a starting point for data collection. This is not an all-inclusive list of resources and methods that may be used when a community assessment is conducted.

The time frame for completion of the assessment may influence which methods are used. Nonetheless, these items should be reviewed to determine what information will be useful to collect about the community that is being assessed. It is not necessary to use all of these resources and methods; however, use of a variety of methods is helpful when one is exploring the needs of a community.

Data Gathering (collecting information that already exists)

Demographics of the Community

When demographic data are collected, it is useful to collect data from a variety of levels so comparisons can be made.

If the population that is being assessed is located within a specific setting, it may be best to contact that agency to retrieve specific information about that population.

The following resources provide a broad overview of the demographics of a city, county, or state:

State and County Quick Facts “Easy access to facts about population, housing, economics, geographic data, business, based on U.S. Census data

Obtain information about a specific city or county on these useful websites and 

Information from Government Agencies

  • Healthy People 2020 – this resource is published by the U.S. Department of Health and Human Services. It identifies health improvement goals and objectives for the country to be reached by the year 2020
  • National Center for Health Statistics – this agency is part of the Centers for Disease Control and Prevention; this website provides statistical information about the health of Americans
  • National Vital Statistics System
  • Centers for Disease Control and Prevention (CDC) – The CDC website contains a large amount of information related to the health of the American population. The search engine within this website can be used to find relevant information
  • Federal agencies with statistical programs

Every state in the United States has its own specific health improvement plan and goals that are based on the Healthy People 2020 document. This information may be available on the state health department website.

State and local health departments provide information related to vital statistics for the community.

Other Data Sources

America’s Health Rankings – this website provides information about various health indicators for each state:

Other relevant data sources may be found by conducting an Internet search related to the topic that is being examined through the community assessment.

After data are collected from various sources, it is important to review the information and to identify assets and areas for improvement in the community by comparing local data (if available) versus state and national data. This will facilitate organization of the information that has already been obtained and will provide direction for the next step of the process.

Data Generation (data are developed that do not already exist):

Windshield Surveys

With the use of public transportation or by driving a vehicle around the community, one can observe common characteristics of the community.

Examples of key observations to make when one is assessing the community through a windshield survey include the following:

  • Age of the homes in the community
  • Location of parks and other recreational areas
  • Amount of space between homes and businesses
  • Neighborhood hangouts
  • Transportation in the community
  • Quality and safety of streets and sidewalks
  • Stores and other businesses
  • People out in the community
  • Cleanliness of the community
  • Billboards or other media displays
  • Places of worship
  • Healthcare facilities 

Participant Observation

Spend time observing the population that is being assessed. Through observation of interactions among group members, much can be learned about the community, including the following:

  • Developmental level of the population
  • Effectiveness of peer-to-peer interactions
  • Respect for peers and others
  • Safety in the environment
  • Economic status

Informant Interviews

Informants could be people who are familiar with and interact with the population on a regular basis.

Examples of questions that may be asked of key informants include the following:

  • Strengths/assets of the community
  • Areas of improvement for the community
  • Concerns of community members
  • Access to health care
  • Emergency plans for natural or man-made disasters

Focus Groups

Focus groups (usually small groups of 6-12 people) can be helpful when one is gathering information about specific areas of concern within the population. Use of a focus group involves open dialogue about the population, whereas an interview or survey yields only individual responses.

Focus groups may be effective for assessing the following:

  • Satisfaction with services provided
  • Community resources used
  • Transportation issues within the community
  • Safety within the community
  • General concerns of members of the population


Surveys may be used to collect data from the community. Selecting a sample of the target population may prove helpful in the collection of data that are easier to analyze. It is important to ensure that the sample is representative of the target population.

A survey should be developed that takes into consideration the developmental level of the group that is being assessed. Questions should be written at the appropriate developmental level, so they are answered in a way that makes the data useful. Surveys might include closed-ended (yes/no), multiple choice (several responses to choose from), Likert scale (Strongly Agree/Agree/Neutral/Disagree/Strongly Disagree), or open-ended (why/how) questions.

Topics that may be addressed in a survey include the following:

  • Demographic information
  • Status of employment
  • Safety within community
  • Safety in environment
  • Personal safety (seatbelts, helmets, etc.)
  • Stressors/stress management patterns
  • Risky behaviors
  • Support systems
  • Volunteer/community activities
  • Rest patterns
  • Nutrition
  • Dental hygiene
  • Health promotion activities

Module Goals

Complete and finalize a community assessment and describe the tools utilized to accurately define your community

Goals Alignment:

  • University Mission Based Outcomes 1, 2, 4
  • Program Learning Goals  2, 5, 6
  • Course Learning Objectives 1, 2, 3, 4, 5, 6

Professional Standards:

  • Essential II: Basic Organizational and Systems Leadership for Quality Care and Patient Safety 
  • Essential III: Scholarship for Evidence-Based Practice 
  • Essential VII: Clinical Prevention and Population Health  
  • Essential VIII: Professionalism and Professional Values

Community Health Assessment Paper Sample Answer

Community health assessment entails comprehensive data collection and analysis to reveal the community’s health needs, issues, status, and priorities. According to the Centers for Disease Control and Prevention (CDC, 2018), holistic community health needs assessment results in various benefits, including improving organizational and community collaboration and coordination, increasing knowledge and awareness of public health needs, facilitating the identification of the underlying community strengths and weaknesses, and establishing baselines for public health performance. 

It is essential to note that communities exhibit varying strengths and weaknesses consistent with health needs, priorities, and issues. Therefore, conducting community health needs assessment is a profound strategy for unearthing discrepancies, population-centered health issues, and social determinants of health that contribute to disproportionately of healthcare utilization. While community health needs assessment is a vital process, this paper focuses on health statistics of the Seattle community and other social determinants, including quality of life, socio-economic status, and demographics. Also, it provides an analysis of health issues based on information gathered from a windshield survey.

Background of the Community

Seattle is the largest city in the state of Washington and the Pacific Northwest region of North America in terms of population. According to the World Population Review (2022), Seattle has an estimated population of about 762,687, making it the 15th largest city in the United States. In the same breath, the Seattle Metropolitan area has about 4 million inhabitants, making it one of the largest metropolitan areas and the fastest-growing regions in the country. It is essential to note that the urban population accounts for the largest section of the total population in Seattle.

History of the City

Native Americans inhabited the Seattle area for about 4000 years before the arrival of the first European settlers. In 1853, the name Seattle officially appeared in Washington Territory following the filing of the village’s first plats. By 1865, the Legislature of Territorial Washington had incorporated the Town of Seattle, where a Board of Trustees managed the town. Historical events that facilitated the growth of Seattle town include the Klondike Gold Rush, where the town became one of the major transportation centers and a supply point for minors in Yukon and Alaska.

Shipbuilding and commercial activities during the Klondike Gold Rush replaced logging as Seattle’s major economic activity. After World War II, Seattle emerged as a center of aircraft manufacturing, providing opportunities for further development in the second half of the 20th century. Today, Seattle City thrives on multiple economic and commercial activities, including as a technological center and as the home for the largest and most influential companies such as Amazon and Microsoft Inc.

Geography and Boundaries

Seattle City is an oceanic port located between Saltwater Puget Sound and Lake Washington. The city borders the Kitsap Peninsula and the Olympic Mountains to the west and Lake Washington and the Eastside suburbs to the east. Further, Seattle is proximal to seven hills: First Hill, Capitol Hill, Beacon Hill, Queen Anne, Magnolia, and the former Denny Hill. The City’s location in the Pacific Ring of Fire makes it a major earthquake zone. For instance, the city suffered the consequences of the earthquake in 2001. The 6.8-magnitude earthquake led to significant architectural damage, especially in the Pioneer Square area, and led to one fatality. The history of earthquakes in the proximal areas of Seattle city prompts profound preparedness, response, and recovery strategies.

Demographic Aspects of Seattle City

Seattle is a highly diverse city because the urban population exhibits diversities in age, gender, and ethnicity. As a metropolitan area, Seattle is the 15th largest metropolitan area because it has about 4 million inhabitants. Seattle, as a city, has a population of around 762,687 and is the county seat of King County (World Population Review, 2022). The city has grown from just over 1100 people in 1870 to an estimated population of 762,687 in 2022. When compared to other cities in the state of Washington, the Seattle metropolitan area accounts for more than half of the state’s population (World Population Review, 2022). The presence of a high population makes Seattle an ideal target for community health needs assessment.

Seattle is predominantly a “white city,” meaning white people account for the largest population section. According to the US Census Bureau (n.d.), white people make up about 65.8% of the total population. On the other hand, African Americans account for 7.1% of the population, while Asian Americans emerge as the second largest ethnic community in the city with 16.3% of the total population. The minority groups in Seattle city are American Indian and Alaska Native (0.5%) and Native Hawaiian and Other Pacific Islanders (0.3%) (US Census Bureau, n.d.).

According to the 2021 population estimates, Latinos and African Americans accounted for an almost equal section of the total population. In the same breath, people of two or more races are about 7.6% of the total population in Seattle. Based on the ethnic aspects of the city’s demography, it is valid to argue that the city is highly diverse, although white people are the majority community.

Age and sex are essential demographic aspects of Seattle’s demography. According to the US Census Bureau (n.d), people under 5 years account for 4.6%, while those people aged 6 to 17 years are about 14.5%. Most of the people in Seattle fall under the age category of 19 to 64 years since the age bracket accounts for more than 68% of the population. In the same breath, people aged 65 years and older make up 12.5% of the total population. Regarding gender distribution, about 49.4% of the total population are female persons, while male persons account for about 50% of the city’s population.

Education Attainment and Other Social Determinants of Health (SDOH)

Education attainment is one of the most profound social determinants of health because it correlates with individual awareness of health issues and self-management. According to the US Census Bureau (n.d.), about 95.2% of persons aged 25 years and older are high school graduates or higher. In the same breath, about 65% of the people aged 25 years and over have attained a bachelor’s degree or post-graduate degree. Regarding poverty and income, about 10.2% of the total population in Seattle lives in poverty. The par capital income as of 2020 was $63,610. About 73.9% of people aged 16 years and older are in the civil labor force, whereas 70.2% of female persons aged 16 years and older are in the civil labor force. The unemployment rate in Seattle is about 4.1% (World Population Review, 2022). The city’s unemployment rate is slightly below King County’s rate which stands at 7.5%.

Another essential aspect of social determinants of health in Seattle is underinsurance and uninsurance. According to County Health Ranking and Roadmaps (n.d.), King County’s rate of uninsured is 6%, which is slightly lower than the state’s rate (8%). A relatively lower rate of uninsurance in Seattle and King County contributes to Improved access to quality and timely care and the subsequent improvement in life expectancy. For instance, the average life expectancy in King County is about 82.3 years, which is better than the state’s average (County Ranking and Roadmaps, n.d.). It is essential to note that King County is one of the healthiest counties in Washington and one of the top performers in the country in terms of healthcare.

Birth/Death Rates and Age-adjusted Mortality

Premature deaths and age-adjusted mortality are essential measures of community health and well-being. According to the County Rankings and Roadmaps (n.d.), the rate of premature deaths in King County is around 4700 per 100000 people. The leading causes of premature deaths include heart disease, accidents, intentional self-harm or suicide, and chronic liver disease and cirrhosis. The childhood mortality rate in the county is 40 per 100000 children, while premature age-adjusted mortality is 240 per 100000. It is essential to note that the age-adjusted mortality rate refers to the number of deaths among residents under 75 years per 100000 population.

Healthcare Issues in Seattle

Although Seattle city is one of the top-performing counties in Washington and the US, it is susceptible to various healthcare issues that compromise people’s health and well-being. According to the US Census Bureau (n.d.), uninsured people under 65 years are about 4.9%, while people aged 65 years and below with disabilities are approximately 6.2%. The two sections of the population are susceptible to challenges that compromise their ability to access and utilize healthcare services.

Besides people with disabilities and the uninsured population, Seattle and King County grapple with risky behaviors that increase the susceptibility to lifestyle-related challenges. For instance, about 10% of adults in the county are smokers, while 22% of adults struggle with obesity and overweight issues. Approximately 16% of the total population are physically inactive and have sedentary lifestyles.

However, about 95% of the total population in King County has access to exercise opportunities (County Rankings and Roadmaps, n.d.). It is essential to note that risky behaviors and lifestyle issues like smoking, physical inactivity, and alcoholism have led to premature deaths, age-adjusted mortalities, and a high prevalence of chronic diseases, such as heart disease, obesity, diabetes, and cancer. Also, alcoholism and other forms of drug and substance abuse contribute to crimes, teen pregnancy, and susceptibility to sexually transmitted infections like gonorrhea, HIV/AIDS, and genital herpes.

Windshield Survey

A windshield survey of Seattle involved a series of activities to observe the community’s common characteristics. According to Kaczynski et al. (2018), windshield surveys are profound tools for observing and assessing a community’s health characteristics, including the presence or absence of social support systems, learning institutions, physical activity opportunities, healthcare infrastructure, recreational facilities, and street quality deliverables, including traffic volumes and pedestrian amenities. Examples of activities involved in the windshield survey of Seattle City included driving a vehicle around designated areas like the International District/Chinatown and Rainer Vista, holding informant interviews, and focus groups of 6-12 people who provided information about specific issues and priorities in within the urban population.

During interviews with informants, the questions focused on essential aspects, including the community’s strengths and weaknesses, areas of improvement for the community, access to health care, disaster management plans, and the overall quality of life of residents.

The windshield survey revealed essential aspects of the Seattle residents. Regarding housing, there is a variety of modern apartments around the city. However, areas like Chinatown and Rainer Vista have older townhomes that are less developed and congested. The city has some of the best learning institutions across all education levels. For example, Seattle boasts of the University of Washington, Seattle University, and Seattle Pacific University. Further, Seattle has many religious institutions, including the Downtown Muslim Association, Plymouth Church United Church of Christ, St James Cathedral, Mount Zion Baptist Church, and St. Mark’s Episcopal Cathedral. These institutions are vital for providing spiritual nourishment and offering much sought-after social support to residents.

Equally, Seattle city has healthcare institutions that provide multiple healthcare services to the residents. Examples of these institutions are Husky Senior Care, the Public County Hospital, Harborview Medical Center, Seattle’s Children’s in Laurelhurst, the University of Washington Medical Center, and a Veterans Affairs hospital in Beacon Hill. Regarding recreation, parks, and physical exercise opportunities, the city boasts of gymnasia across neighborhoods, and outdoor recreation activities like walking, cycling, skiing, snowboarding, motorboating, team sports, and swimming.

The Discovery Park, Seward Park, and Gas Works Park provide a panoramic view of the Seattle skyline and provide opportunities for relaxation. The streets and sidewalks are in good condition, meaning people have ideal opportunities for cycling, jogging, and healthy walks. Finally, Seattle has various food programs, including Seattle’s Fresh Bucks, local farmland, and Seattle’s P-Patch programs. These programs avail healthy foods such as fruits and vegetables to residents.


The community needs assessment for Seattle, Washington, reveals various community aspects consistent with health needs and priorities. For example, it is valid to deduct the contention that most people in the city have access to insurance coverage, physical activity opportunities, and healthcare facilities. However, there are multiple healthcare issues that prompt interventions. For instance, congested houses in the Downtown area and Chinatown are issues of concern to policymakers.

In the same breath, risky behaviors like alcoholism, physical inactivity, and smoking are the leading causes of premature deaths and a high prevalence of chronic conditions, such as diabetes, heart disease, and cancer. The windshield survey provided opportunities for assessing the community’s characteristics from the lenses of observing neighborhood aspects and mapping strengths, weaknesses, and areas of improvement. The information gathered during the windshield survey requires comprehensive analysis and team-based assessment to extract meanings and themes regarding the community’s health needs and priorities.


Centers for Disease Control and Prevention. (2018, July 24). CDC – assessment and plans – community health assessment – STLT gateway.

County Health Rankings & Roadmaps. (n.d.). Washington.

Kaczynski, A. T., Besenyi, G. M., Child, S., Morgan Hughey, S., Colabianchi, N., McIver, K. L., Dowda, M., & Pate, R. R. (2018). Relationship of objective street quality attributes with youth physical activity: Findings from the healthy community’s study. Pediatric Obesity, 13, 7–13.

U.S. Census Bureau. (n.d.). QuickFacts: King County, Washington.

World Population Review. (2022). Seattle, Washington population 2020 (demographics, maps, graphs).