An Inclusive Community Health Assessment Process

Community health needs assessments (CHA) allow community agencies and service providers to discuss issues. However, this process lacked representation from people that utilize community services and experience health inequities. Staff were successful in applying an inclusive approach to engage residents and organizations that represented low-income and minority populations through CHA workgroup meetings, surveys and interviews.

During the previous 2014 CHA, the Missoula City-County Health Department (MCCHD) Leadership Team conducted a survey with past CHA participants to identify areas for improvement. Participants identified the need to include more data on disparities, information on health equity as an approach, and to bring more sectors to the table to inform discussion and help shape the final CHA report. CHA organizers at the MCCHD identified three areas to improve inclusion in the CHA process based on evaluation of the 2014 process: • Recruit across different sectors in the community: Housing and job training almost exclusively serves lower income residents and were not well represented in the 2014 CHA. • Develop an inclusive and engaging group process: The 2014 process focused heavily on collecting data as a group rather than seeking input and discussing issues, which limited contributions from individuals and non-traditional community partners. • Access to CHA meetings: 2014 CHA meetings always occurred at the MCCHD building, which has limited parking, and staff assumed everyone could and would attend all workgroup meetings. The process also left little ability for anyone to be involved if they couldn’t make regular daytime meetings.

To prepare for the 2017 Missoula County CHA, MCCHD worked with CHA partners including Providence St. Patrick Hospital, Planned Parenthood, and the Urban Indian Health Center to determine an approach for collecting data ahead of time to allow the process to focus on discussion of data rather than on collecting data from secondary sources. As a result, MCCHD staff produced and shared health equity reports on Native Americans, people with disabilities, and poverty prior to the CHA meetings. Other MCCHD efforts focused on areas identified through the participant survey. • Recruitment: The lead staff developed partnerships with groups that serve and represent people with disabilities and provide housing, job training, and other services for low-income residents. • Process development: The design supported discussion and shared decision-making. Groups and individuals were offered multiple ways to be involved in creating and making decisions about the CHA report. • Access to the process: We operated according to NACCHO’s Health and Disability 101 Training for Health Department Employees accessibility recommendations. CHA meetings occurred at different physically-accessible locations around town (such as at the food bank, which serves lower-income residents), all venues were located near a bus stop, and meetings occurred in the middle part of the day.

Efforts to improve inclusion of the CHA process paid off better than expected. • Recruitment efforts resulted in 35 regularly engaged community agencies, up from 15, including a disability advocate and representatives from housing, job training and disability services. The increase in diversity led to adding issues such as affordable child care that enriched discussions and the report. • Quantitative data and data maps focused on specific populations, such as low-income neighborhoods, outlying rural communities in the county, Native Americans, and people with disabilities. • The CHA group identified key informants to contribute rich information, especially for people living with mental health issues and substance abuse. • The CHA workgroup prioritized input from low-income residents, including development of a survey conducted at the food bank, homeless shelter, and housing authority. This rich, relevant primary data will be used to guide future targeted focus groups and surveys. Moving into the community health improvement plan (CHIP), we have commitments of continued participation from current CHA members, and selected priority areas will include a health equity approach. The CHIP will address infrastructure in low-income neighborhoods, affordable child care and rising rates of child abuse and neglect, and access to dental care for low-income, older, and disabled adults.

Our combined efforts to create a more inclusive CHA process were successful. We learned the importance of beginning the process with data that focuses on health indicators by populations (disability status, rural, socioeconomic, race, etc.) when available. Such data naturally led the workgroup to discuss health equity and inclusion during meetings. Because our CHA workgroup included a wider array of sectors and individuals and the process was open and accessible, the discussion on inclusion and health equity led to more substantial actions. The inclusive CHA membership made possible the surveying of lower-income residents and the identification of CHIP priorities focused on groups experiencing health inequities. Connecting with the mental health community remains a challenge. Based on our successful recruitment and engagement of diverse populations, we feel confident that we can build community capabilities the mental health community. Next steps for the CHA workgroup will be to assess a capacity-building project as one pillar of our CHIP work over the next five years. Designing an inclusive CHA workgroup and process requires demand and preparation, but the results are worth it! We now have a CHA that interests the community, creates discussion, and inspires collaboration.