Community Health Assessment and Improvement Planning

The fundamental purpose of public health is defined by three core functions: assessment, policy development, and assurance [1]. The community health improvement (CHI) process contributes to these functions by using data from a community health assessment (CHA) to identify priority issues and develop a community health improvement plan (CHIP) that outlines strategies for the local public health system to address the priorities [2]. These activities support all three functions of public health by identifying problems and assets, developing policies and action plans to address priorities, evaluating impact, and continuing to assure that the public health system provides high quality, accessible public health services [2].

A community health improvement process looks at the way in which activities of many organizations contribute to community health improvement, going beyond the performance of an individual organization serving a specific segment of a community [2,3]. A health department is often the “facilitator and supporter” of the local public health system and convenes community members and organizations who serve them to take collective action [4]. A successful community health improvement process requires relationship building across sectors, broad community engagement, comprehensive assessment of community needs and strengths, and collaborative action by the local public health system. 

Mobilizing for Action Through Planning and Partnerships (MAPP) 2.0 is NACCHO’s framework for community health improvement. MAPP helps communities apply strategic thinking to prioritize public health issues and identify resources to address them. Click the link above to learn about MAPP 2.0, access the MAPP 2.0 materials, join MAPP Network Virtual Community, and download supplemental resources.

Below you will find a description of the steps in a CHI process (including developing a CHA and CHIP), additional CHI frameworks, and suggested resources.  

These are the core steps of a CHI process, with suggested tools and resources from MAPP 2.0 listed for each. Visit the MAPP webpage above to access them.

Organize and Engage Partners

A CHA/CHIP process begins with two critical and interrelated activities: organizing the planning process and developing the planning partnership. The purpose of this step is to structure a planning process that builds commitment, engages community members and local organizations as active partners, uses participants' time well, and results in a realistic implementation plan. 

MAPP 2.0 Resources:

• Phase I, Step 1: Do a Stakeholder and Power Analysis

• Phase I, Step 3: Establish or Revisit CHI Leadership Structures 

Develop a Community Vision

Visioning guides the community through a collaborative process to develop a shared community vision and common values which provide focus, purpose, and direction to the CHI process. The shared community vision describes the ideal future of the community that will be achieved through CHI. Values are the fundamental principles and beliefs that guide the community-driven planning process. 

MAPP 2.0 Resource:

• Phase I, Step 5: Develop the Community Vision 

Collect and Analyze Data

It is essential to collect comprehensive data to understand the community’s health status and how the local environment, public health system, and root causes contribute to health outcomes. The community health assessment uses multiple tools and mixed methods to collectively identify the most pressing community issues and contributing factors. Different frameworks for CHI may offer their own community health assessment tools. See the list of frameworks below to explore examples.  

MAPP 2.0 Resources:

• Phase II, Step 3: Do the Three Assessments:
  • Community Partner Assessment
  • Community Status Assessment
  • Community Context Assessment 

Identify and Prioritize Strategic Issues

After conducting the community health assessment, the community develops and prioritizes a list of community health related strategic issues by analyzing how the status of the community revealed through the assessment compares to the shared vision or gets in the way of achieving the shared vision. 

MAPP 2.0 Resources:

• Phase II, Step 4: Triangulate Data, Identify Themes, and Develop Issue Statements

• Phase III, Step 1: Prioritize Issues for the CHIP 

Develop Goals, Strategies and an Action Plan

During this step, participants formulate goals, strategies and an action plan for addressing the strategic issues. The action plan includes activities, timeframes, responsible parties, and performance measures to achieve the goals.

MAPP 2.0 Resources

• Phase III, Step 2: Do a Power Analysis of Each Issue
• Phase III, Step 4: Create Community Partner Profiles
• Phase III, Step 5: Develop Shared Goals and Long-Term Measures
• Phase III, Step 7: Develop Continuous Quality Improvement Action Planning Cycles 

Take and Sustain Action

Community Health Improvement Frameworks and Tools

• CDC Assessment and planning frameworks: CDC identifies common elements of assessment and planning frameworks and provides information about commonly used frameworks.
• The Association for Community Health Improvement (ACHI) Community Health Assessment Toolkit: The ACHI Toolkit is a guide for planning, leading and using community health needs assessments to better understand -- and ultimately improve -- the health of communities. It presents a suggested assessment framework from beginning to end in six steps, and provides practical guidance drawn from experienced professionals and a variety of proven tools.
• The Association for Community Health Improvement (ACHI) Community Health Assessment Supplements: In addition to the Toolkit, the ACHI compiled supplemental resources to ensure equitable engagement for select populations throughout the CHA process, including caregivers, people with disabilities, and older adults.
• Community Tool Box, Chapter Three: Assessing Community Needs and Resources: The Community Tool Box, created by the Work Group for Community Health and Development at the University of Kansas, provides information on how to build healthier and more equitable communities. Chapter Three of the tool box ("Assessing Community Needs and Resources") provides practical, step-by-step guidance on how to embark on the community health assessment process.
• Local Assessment and Governance Tools: This page provides access to the National Public Health Performance Standards (NPHPS) framework to assess capacity and performance of the local public health system. These resources might be used as part of a comprehensive community health assessment, and were included as part of MAPP 1.0.

CHA/CHIP Examples, Tools and Training on the MAPP Network

Visit the MAPP Network to connect with communities implementing MAPP nationwide, view example community health improvement plans, Stories from the Field, recommended tools, and recorded trainings of the MAPP process for community health improvement.