Background and Context for Conducting Literature Review

Many of the challenging health problems facing the United States in the 21st century require an understanding of the health not just of individuals but also of communities. Problems such as providing immunizations to all children, controlling epidemics, addressing the causes and consequences of obesity, and dealing with environmental health risks all demand comprehensive rather than disease-specific solutions, and solutions that take into account the needs of entire populations. While individual access to good health care is a necessity, medical care alone is not sufficient to address problems related to personal behavior (e.g., diet, exercise, smoking, alcohol abuse) and social problems (e.g., violence, drugs) or caused by environmental threats. Moreover, while the control of emerging infections and preparations against the threat of bioterrorism require a substantial medical response, such problems also require population-based solutions such as risk assessment and risk communication, quarantine, and mass immunization. Due to the complexity of these multi-faceted challenges, a community's health problems can be addressed most effectively through collaboration among health care systems, community groups, government, and business.

The challenge of maintaining and improving community health has led to the development of a "population health" perspective (Friedman and Starfield, 2003). Population health can be defined as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group" (Kindig and Stoddart, 2003). A focus on population health implies a concern for the determinants of health for both individuals and communities; the health of a population grows out the community's social and economic conditions as well as the quality of its medical care. Thus, a community's health is determined by interactions among multiple factors, including the social environment, the physical environment, genetic endowment, an individual's behavioral and biological responses, disease, health care, health and function, and well-being. The population health perspective includes a focus on resource allocation and accountability, implying the need for measures of health outcomes and evidence linking interventions to those outcomes.

This broader understanding of health and its determinants suggests that many public and private entities have a stake in or can affect the community's health. These stakeholders can include health care providers (clinicians, health plans, hospitals, and so on), public health agencies, and community organizations explicitly concerned with health. They can also include entities that may not see themselves as having an explicit health role, such as schools, sports clubs, employers, faith communities, and agencies providing social and housing services, transportation, education, and justice.

In this context, community health assessments (CHA) are a means of identifying and describing community health problems, gaps and strengths in services, and interventions to improve the health of the community. A CHA is intended to help a community maintain a broad, strategic view of its population's health status and the risk factors that can influence it. CHAs are also central to the Institute of Medicine (IOM) call for "public health agencies to regularly and systematically collect, assemble, analyze, and make available information on the health of the community, including statistics on health status, community health needs and epidemiologic and other studies of health problems."

The term Community Health Assessment or CHA is used in the literature to indicate both a written product (which may be available on paper or online) and the process that produces it. Where possible, we distinguish between these two uses as follows. CHA documents include various statistical indicators of health status, risk factors, and so on. Measures of community resources and organizational performance relating to the county health department or other entities in the county may also be included. These indicators may refer to an entire county population or to subgroups defined by geography, race and ethnicity, or in other ways. Time trends in these indicators may be presented, and the indicators can be presented in tabular and graphical formats. CHA documents may also include information about the causes and consequences of health problems, as well as possible solutions or agreed upon action plans. The CHA process, on the other hand, refers to the activities in which the county engages to develop the CHA document. A local health department may produce the CHA on its own, or a coalition of stakeholders in the community may be involved. The role of the stakeholders may be limited to guidance on the choice of indicators to be included in the CHA. In other cases stakeholders may make commitments to carry out parts of a community health improvement action plan specified in the CHA. The CHA process may also include a process for monitoring progress towards the CHA goals and objectives and making midcourse corrections if necessary.