LibGuides: PA 696 Clinical Graduate Project: Needs Assessment Process

Understanding Social Determinants of Health

What are social determinants of health?

Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.

SDOH can be grouped into 5 domains:

Economic Stability
Education Access & Quality
Health Care Access & Quality
Neighborhood & Built Environment
Social & Community Context

Read more about the goals and objectives in Healthy People 2030.

Source: Healthy People 2030 Social Determinants of Health

Social Determinants of Health in Rural Communities Toolkit
This toolkit compiles evidence-based and promising models and resources to support organizations implementing programs to address social determinants of health in rural communities across the United States.
PRAPARE: Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences
PRAPARE is a nationally recognized and standardized patient social risk assessment protocol, containing 21 measures on social determinants of health, used by health centers and other providers to collect the data needed to better understand and serve their patients.

Community Health Needs Assessment Process

Community Health Assessment Toolkit

Community Health Needs Assessment (CHNA) is a systematic process involving the community to identify and analyze community health needs and assets, prioritize those needs and then implement a plan to address significant unmet needs.

Basic Steps of a Community Needs Assessment

Step 1 Establish CHNA team

Form and organize a CHNA team
Establish mission, goals, roles, and actions
Identify needed resources and develop budget

Step 2 Data collection

Inventory health resources
Collect primary and secondary county data
Map community assets

Step 3 Assemble findings

Analyze and interpret primary and secondary county data
Compare county and state data
List important strengths and problems

Step 4 Determine health priorities

Report CHNA findings to community
Select priority health issues with community input

Step 5 Plan programs

Develop community health action plan
Promote active participation in program planning

Step 6 Report and implement plans

Implement community health action plan
Report on outcomes

Source: Community Health Assessment Guide Book, North Carolina Department of Health and Human Services Division of Public Health, June 2014

Community Needs Assessment Tools

Community Health Assessment Guide Book
Originally created by the North Carolina Division of Public Health, this guide book is a resource document or toolkit for local public health departments and other community agencies planning a county level community health needs assessment. It details the 8 phases in the community health assessment process.
Community Needs Assessment Resource Guide
A Community Needs Assessment is a process conducted by all Community Action Agencies every three years to determine the underlying causes and conditions of poverty within the community they serve and identify the available resources to address the unmet needs of the community’s most vulnerable residents. The Community Needs Assessment is the first phase of the Results Oriented Management and Accountability (ROMA) Cycle, grounding and guiding the work to develop and implement programs and services that lift families and communities out of poverty.