This Guide provides details about developing and carrying out a community health needs assessment. The Guide is intended for planners working with Band Councils, Tribal Councils, other First Nations and Inuit organizations and associations.

The Guide was designed within the context of Health Services Transfer for communities planning for Transfer or updating their Community Health Plan.

Using This Guide

The steps outlined in this Guide do not need to be followed in every way. The Guide is intended to support a process to determine what health programs and services are needed and how they will work best in your community. The Guide promotes the integration of community beliefs and values into the design of your health programs. Read through the entire Guide before you begin the planning of your community health needs assessment.

Choose the suggestions and examples in this Guide which are most appropriate for meeting your community's particular needs and which reflect your community's values.

Keeping Up-to-Date

This Guide updates information formerly offered to First Nation and Inuit health authorities in the Health Canada publication:

A Guide for First Nations in Developing a Community Health Needs Assessment.

To ensure that you have the most current version of this Guide, contact the Regional Office of the First Nations and Inuit Health Branch (FNIHB).

This Guide and other useful information about Health Services Transfer can be downloaded from the FNIHB website.

Other Useful Resources

This Guide was written within the context of Health Services Transfer. For more information on planning for Transfer, refer to Transferring Control of Health Programs to First Nations, Handbook 1: An Introduction to Three Approaches. Additional information on Transfer is provided in Handbook 2: The Health Services Transfer and Handbook 3: After the Transfer - The New Environment. These three Handbooks are available from FNIHB Regional Offices and on the FNIHB website.

The First Nations and Inuit Regional Health Survey, National Report 1999, describes the process and the results of a set of surveys conducted by First Nations and Inuit communities in nine regions of Canada on topics relevant to community health needs assessments.The report is available from the Health Secretariat of the Assembly of First Nations (AFN) at (613) 241-6789. Fact sheets based on the report are also available from the AFN Resource Centre and are posted on the AFN website at:

www.afn.ca

For a helpful introduction on how your Community Health Needs Assessment fits into the wheel of health program management, see A Guide for First Nations on Evaluating Health Programs. Chapters 1 and 2 explain the importance of an effective health needs assessment as the basis for planning, operating and evaluating your community health programs and services. The guide is available from FNIHB Regional Offices and on the FNIHB website.

The First Nations and Inuit Home and Community Care: Planning Resource Kit covers all aspects of planning, setting up, and operating home and community care programs. The Kit consists of six handbooks. Handbook 2, Community Needs Assessment, leads the reader through the steps in conducting a needs assessment related to home and community care. Although its focus is this one aspect of health services, it has many helpful suggestions for any community health needs assessment.

Acknowledgement

The author would like to acknowledge that parts of this Guide have been adapted from sections of Handbook 2 of First Nations and Inuit Home and Community Care: Planning Resource Kit

Basic Information About Community Health Needs Assessment

The value of the Community Health Needs Assessment

Identifying your community's health needs in an organized way is an important activity in planning for Transfer. Your Community Health Needs Assessment (CHNA) will provide comprehensive and unbiased information about the health needs in the whole community. It will help you to identify your community health priorities.

This information will form the basis of your Community Health Plan (CHP) for delivering health programs and services under a Transfer Agreement. The CHP provides details about the community, its health needs, and all aspects of how the community will deliver health services and programs to meet those needs. You develop the CHP as you proceed through the phases of planning for Transfer. The CHP becomes the key document for discussions between the community and FNIHB in working toward a Transfer Agreement. (For details about the Community Health Plan, see Transferring Control of Health Programs to First Nations and Inuit Communities: Handbook 2 - The Health Services Transfer.)

The CHNA collects information from community members, from records on use of health services, and from other health-related sources. It provides the foundation for all community health planning. As such, it must be completed carefully to ensure that it is representative of the community (appropriate sample size), addresses the real needs of community members (the right questions), and involves proper and accurate analysis and summary (report).

The CHNA and CHP are also important components of program management after Transfer has been achieved. The relevance of the CHNA and the CHP in the wheel of program management is illustrated below.

The Wheel of Program Management

Wheel of Management

What the Community Health Needs Assessment includes

Through its health needs assessment, the community looks at:

physical health status including illnesses and physical impairments
mental and social problems of individuals and groups and
environmental problems which may affect community health or social welfare.

The CHNA usually includes analyses of statistics collected routinely by nursing stations, hospitals, and other facilities to establish levels of various health and social problems. However, the most important aspect of the CHNA is obtaining information and views from community members themselves. This involves surveying a certain percentage of the community to find out which health problems are most prevalent. The survey also explores the factors which will affect the design of programs and services to effectively address these health problems.

Communities have learned the importance of involving their members in the planning of programs and the need for good communication throughout all phases of the planning process. Community involvement during the health needs assessment can create and maintain the support of key community members which is necessary for successful programs.

The information gathered in the needs assessment process is confidential and remains within the community. Information about individuals is not reported. A summary report of the findings is used in preparing the Community Health Plan.

Funding and support for the Community Health Needs Assessment

Communities planning for Transfer have access to one-time funds for conducting the initial CHNA. The funding is based on the community population approved by FNIHB. The amount ranges from $38,000 to $96,000 per Transfer project. The time frame for conducting the CHNA ranges from five to nine months. A table showing the funding available to communities of different sizes is provided in Appendix A.

Getting Started

Set up a planning and management committee

The health authority in your community should form a committee to plan and manage the CHNA. The first task of this committee is to develop and obtain approval for its own terms of reference: what is the committee's role, who is responsible to whom, how often will they meet, etc.

Terms of reference should specify what the committee's responsibilities are for:

the study timeframe
the survey questions
the methods for collecting information
hiring members of the research team
attending selected community meetings
reviewing the findings of the study and
making recommendations to the community's leadership.

Decide if you have the skills to carry out the work

If your community has members with the skills to carry out the work, review this Guide and select and adapt the methods which are best for your community. Use the Guide to help develop your workplan for carrying out the needs assessment, setting reasonable timelines for each activity.

If your community does not have the necessary skills to carry out the needs assessment, you may want to consider:

partnering with another community, region or Band skilled in needs assessments. This could involve:
- sending a staff member from your community to participate in another community's needs assessment to learn from a skilled staff member doing the assessment; or
- arrange with another community or region or Band for a skilled staff member to come to your community so that he or she can work together with your staff to do the assessment and report.
contracting with a research consultant to discuss the objectives of the needs assessment and the type of data you want to collect. The consultant may then either carry out the work or provide technical support and training needed for the community to carry out the needs assessment.

An experienced community-based researcher can give you advice and support on key aspects of the needs assessment such as agreeing on manageable objectives, designing effective research tools, developing a reasonable workplan, training interviewers, analyzing data, and reaching conclusions.

If the decision is to contract a consultant, it is important to try to find one who is experienced in involving community members and training them to conduct the work of the needs assessment. In this way, the process of conducting the needs assessment will enhance community skills and knowledge. When the study is completed and the consultant leaves, the new skills and knowledge gained will remain in the community to support program planning and other community research.

Adopt or develop research ethical guidelines

Whether you conduct only one survey or several in your community, you must be able to assure people that the information they provide is going to be handled respectfully and that individual names or situations will not be used or reported. Respecting individual privacy is an important aspect of your needs assessment. Within research practice, this and similar topics come under the heading of research ethics.

Check whether your community already has ethical guidelines for research in place. If not, you should adopt or develop a set of guidelines before proceeding with your community health needs assessment. Examples of research ethical guidelines are provided in:

First Nations and Inuit Regional Health Survey, National Report 1999, Appendix 4, Code of Research Ethics
First Nations and Inuit Home and Community Care: Planning Resource Kit, Handbook 2, Community Needs Assessment, Appendix A, Sample Research Ethical Guidelines for Community Health and Social Development Research
Ethical Guidelines for Research published by the Royal Commission on Aboriginal Peoples.

The following tips can assist you in drafting research ethical guidelines for your community.

Essentially, the research ethical guidelines should:

Outline the general principles that you want to govern any research in your community such as the requirement that the research benefit the community in some way. The principles should apply both to research that you conduct yourself and to research that outside agencies, such as universities, may ask to conduct in your community.
Include the steps for approval of research projects. Your health authority should review and approve all research plans before the research proceeds.
Set out the assessment criteria that will be used to review and approve each research project, ensuring that each project meets an acceptable research standard.
Include a full description of informing procedures to ensure that people participating in the research have been informed about the purpose of the research and are participating willingly.
Address dissemination issues such as how the information will be sorted, who will have access to the data and to the results, and how the data will be protected from inappropriate use or distribution.

Review your research ethical guidelines with the community leadership to ensure they support and approve the guidelines.

Coordinate your needs assessment with other community research

Generally speaking, people in your community will appreciate not being asked the same kinds of questions repeatedly. Find out about previous or planned community-based research and coordinate with them. You may be able to make an arrangement for sharing information that others have already gathered or you may be able to add the questions you want to ask into another survey which will take place in the near future.

For example, the First Nations and Inuit Regional Health Survey is conducted periodically in some communities across Canada and may have been completed recently in your community. It could provide you with current data you need on a number of topics in your needs assessment. If the Regional Health Survey has not been conducted in your community, you may want to consider using some or all of the core questions that the survey asks community members. (See section 3, Designing and Carrying Out Your Needs Assessment, for more details on the Regional Health Survey.)

Check with the FNIHB Regional Office for information on other planned or completed surveys on which you can build.

Discuss the objectives of the health needs assessment

The findings of your needs assessment form an essential contribution to the preparation of your Community Health Plan. As well, the findings assist in your long-term planning and evaluation by providing a base line of information to measure the impact of your delivery of health programs and services.

The objectives of a community health needs assessment are to help you to document and understand the following:

community demographics (e.g., numbers and ages of community members) and the elements that make up your community health system
what kinds of health problems members of communities are experiencing (including physical, mental, social, environmental)
what causes these health problems
what resources are available to address these health problems (e.g., funding, community expertise, other strengths and assets)
what goals and objectives communities need to write to help solve these health problems
which community members have the most urgent needs
how best to meet the needs of community members, and
what training is needed by health care personnel to help them meet the health goals and objectives.

Your planning and management committee will want to discuss these objectives among themselves, and perhaps with a hired research coordinator or consultant. Discussion with an experienced research consultant can help the committee to decide whether to adopt or modify the objectives to reflect your community's particular situation.

Form the research team

Now is the time to form the research team: a research coordinator, an interview coordinator, and interviewers for the survey. Before going out of your community for research expertise, look first for the needed knowledge and skills within your community. Community members trained as interviewers work well in many communities except in some instances in smaller communities where community members are unwilling to share certain sensitive information with people who might know them.

Develop a management plan for your needs assessment

The planning and management committee, together with the research team, should draft a management plan which includes activities, timeframes, responsible persons, and others involved. The preliminary management plan is an overview of the needs assessment to guide the work of the research coordinator or consultant carrying it out. Additional details of the management plan will be added by the research coordinator as decisions are made later on in the process.

Designing and Carrying Out Your Needs Assessment

Decide on the type of information you want

Your planning and management committee and research team may want to brainstorm the type of information you want to gather in your needs assessment. Examples of data collected in community health needs assessments conducted in other communities include:

general background information on the community including a description of the population, location, community health programs and services and staff, other relevant services (e.g., social services, environmental programs, housing programs, economic development initiatives, crime prevention), and access to off-reserve health facilities and services, and
descriptions of priority health needs, gaps in services, barriers to access, and training needs.

Decide on the data collection methods you will use

The study can include several methods to obtain different kinds of information from different perspectives such as a review of documents, interviews with health care and other staff, a survey of community members, and focus group discussions with various groups of community members or service providers.

Document review

A document review collects relevant information about the community, health status, where health services are obtained, other related services, and gaps in services. This information may be found in reports and records of facilities such as the following:

data from facilities, i.e., hospitals, nursing stations, clinics, etc., and government records for the past ten years on population numbers each year for the whole community, by age groups, and by sex.
reports from earlier needs assessments conducted for health, environment, social services, economic development, crime prevention, etc.
community planning documents in similar areas
environment reports, e.g., the results of monitoring of water, air or soil conditions for the purposes of waste management
regular reports or special analyses of data on use of health services by various age groups to determine information about rates and causes of death, acute illnesses or injuries (e.g., respiratory infections, broken arm), chronic diseases (e.g., asthma, diabetes, arthritis, cancer), disabilities, use of prenatal services, pregnancy outcomes, use of dental services, use of substance abuse services, use of prescription drugs, etc.
reports about specific health programs or services
reports on culture and recreation, children's services, police services (e.g., accident reports).

Interviews with key individuals

The document review will give demographic information and an idea of the prominent health concerns, gaps in services, and any other community issues related to health. Interviews can then be conducted with key individuals if more information is needed to help the researchers to identify unique characteristics of the community as well as potential health problems. Who is interviewed will vary depending on the community and the information required. You may want to interview staff of facilities, members of community organizations, elders, community leaders, health professionals, health care workers, informal caregivers, child and family services workers, police, providers of transportation, etc. These people could offer their perspective on the health problems and gaps in services in the community.

Survey of community members

A survey involves asking a set of questions of a number of people in the entire community. Face-to-face interviews by trained interviewers often work best for community health needs assessments. Enough people must be surveyed to allow you to make general statements about the health concerns of community members. For example, about 30% of everyone 14 years of age or older could be surveyed. People should be selected randomly so that they represent a good cross- section of opinions. An experienced researcher knows how to ensure that you involve a representative sample of your community so the survey results are meaningful and useful.

Focus groups

A survey of the community is often followed by interviews or focus groups with people who can provide greater insights into the key issues which the survey identified. For example, if results of a survey suggested that home and community care services were lacking for many community members, you could learn more about the specific needs, gaps in services, and barriers to access by talking to possible users of the services and to key people knowledgeable about the issues. Focus groups might include elders, people with chronic illnesses or disabilities, family service workers, community health representatives (CHRs), family members, other informal caregivers, and so on.

Focus groups pull together a number of people to discuss concerns they have in common. Organizing focus groups on the basis of similarity of people's situations is a good approach to take. For example, related to home and community care, the needs of younger adults with disabilities are usually quite different from those of children or elders so separate focus groups might be needed for each if numbers permit. An additional focus group made up of health care and social service providers may also be helpful.

It is recommended that a focus group session have no more than 12 participants to ensure that everyone has a better chance of expressing their views. An experienced researcher knows about the other important considerations for how to organize and conduct a focus group, and how to record the information the focus group participants provide.

Develop or adapt data collection tools

Regardless of which data collection methods you use, the quality of the information you get will depend on what you ask and how you ask it. Data collection tools (e.g., survey questionnaires, interview forms, questions for focus groups) are necessary for consistency in what is asked. In addition, they must be worded carefully so that it is easy for the person being interviewed to give the information you need.

Before developing or adapting your data collection tools, you need to decide whether you will analyze the data you collect manually (with pencil and paper) or by computer. Your choice for analyzing the data influences the design of the tools. Your choice will be affected by the size of your community, the length of the questionnaire, and your access to computers and data analysis software. The larger the number of respondents and the longer the questionnaire, the more difficult it is to analyze the data manually.

Once you have made the decisions about the research methodology and how you will analyze the data, you need to develop or adapt the tools for data collection for each method. Try to use existing questions which have been tested in similar communities and are known to obtain the information you need. Whether you use existing questions or develop your own, the questions should be pre-tested before they are used for the needs assessment. The pre-test helps to find problem questions before you go out into the community, such as questions that people find confusing because the wording is unclear or refuse to answer because the wording is insensitive to their situation.

To find sample questionnaires that you can adapt to your needs, ask the director of your health authority or the Regional Offices of FNIHB for information about planned or completed surveys. The First Nations and Inuit Regional Health Survey developed a questionnaire for use in interviews with community members. You could adapt the Regional Health Survey questionnaire or a similar one so that it is customized for your community. For example, you may want to add specific health or environmental issues which are not included but which are of concern in your community.

The First Nations and Inuit Regional Health Survey

The First Nations and Inuit Regional Health Survey was first conducted in 1997. It was a collaboration among researchers, 183 First Nations, 5 Inuit communities, Regional Advisory Committees, First Nations and Inuit Health Branch of Health Canada, Statistics Canada, and a National Steering Committee. Common core questions were asked in the areas of:

children's health
belder health
medical conditions including diabetes
tobacco use
disabilities and activity limitation
wellness
health services
dental health.

Other questions for community members were added for each community to suit their unique needs. Additional data recorded included information about population size; Health Transfer status; degree of isolation; adequacy of housing in terms of repair, plumbing, and crowding; sewage and solid waste management; and fire protection.

For more information about the Regional Health Survey, to obtain a copy of the report, or to find your regional representative on the Regional Health Survey National Steering Committee, contact the Health Secretariat of the Assembly of First Nations (AFN) at (613) 241-6789.

Review the process with community leadership

It is important to ensure that the community leadership is kept informed about the plans for the community health needs assessment. This is a good time to go back to the community leadership to ensure that they support and approve the needs assessment process. Present to them the objectives of the needs assessment, the type of data you plan to collect, and the methods you propose to use.

Organize and carry out the data collection

Organize and carry out the data collection by deciding who will be responsible for each component of the work and setting reasonable timelines.

Tips for Organizing and Carrying Out the Data Collection

Partner with other communities who have already conducted a community health needs assessment to learn from their experiences.
Ask the Chief for a letter of introduction to be sent to everyone selected for an interview. (Appendix B provides a sample introductory letter which you can adapt for your needs.)
Be sure that the people who interview community members or workers for the needs assessment, or who conduct focus groups, are properly trained.

You may find people in your own or a neighbouring community who already have experience conducting interviews. Interviewers selected for the survey need to learn how to conduct the interview so that all interviewers administer the questionnaire in the same way. Inexperienced interviewers will need additional training in interview techniques.

Topics to Include in Training of Interviewers

the purpose of the survey, where respondents can get additional information about it, how respondents were chosen, and who will get the results
interview techniques including ways of speaking, general behaviour during the interview, ways of probing for more information and clarifying responses, so that the interviewer does not influence the respondent's answers
confidentiality of responses
practice interviews to become familiar with the questions and how to complete the questionnaire accurately
typical respondent statements and the appropriate interviewer response
role playing to practice working with respondents who refuse to be interviewed; are suspicious, aggressive, confused or uncooperative; are sad or embarrassed about a specific question; are elderly or handicapped persons who need someone else's help to answer
role playing to learn how to deal with distractions such as telephone calls, television, radio, children, other family members, animals, etc.

Analyzing the Information You Collected

Analyzing all the data you collected is an important part of your needs assessment process. The analyses you select will help to highlight your conclusions about the needs and assets of the community in the final needs assessment report.

An experienced researcher has simple tools and techniques for analyzing and interpreting your data for your report.

The first part of data analysis can be done manually or by computer. Analyze numbers obtained from the document review on use of health services by calculating rates of illnesses, deaths, or use of services for various age groups and by identifying the priority areas.

Analyzing the answers provided on the survey questionnaires involves:

recording and counting the number of people who gave each response in multiple choice questions (quantitative data)
writing out the comments (qualitative data), identifying themes and then grouping and labelling the similar comments.

Analyzing the focus group discussions is similar to analyzing the comments sections of the questionnaires.

The second stage of the analysis involves reviewing this information and discussing your understanding of it. It is important to remain objective at this stage and to reach conclusions that are supported by the data you have.

Preparing and Sharing Your Report

Prepare your needs assessment report by summarizing the information you collected and your conclusions about the community's needs. Use a draft as the basis for reviewing the information with the community leadership to ensure that they understand and agree with the findings. In the CHNA report you should:

Describe the needs assessment process

Identify the purpose of this needs assessment.
Explain the methods used and how they were carried out.
Describe who participated.
Include the tools used for collecting the information.
Note any limitations in the process or with the tools used.

Describe the community and its health resources

Describe the community and demographics.
Summarize the community-based and other resources including local facilities, staff, and visiting health professionals, as well as other locations where community members receive health and other related services.

Summarize the information collected

Summarize the health needs in the community based on the information collected. Describe where the information came from and what was found according to the specifics of the data collection tools:

For quantitative data, report the statistics using charts and graphs.
For qualitative data, group the information by themes, objectives, sections of your report, etc.
For multiple choice (closed) questions, provide the percentage or number of people who chose each response.

Identify and describe the health priorities

Identify the community's health priorities based on all of the information collected. To decide on health priorities, consider:

the importance placed on the health issue (the number of respondents who identified it)
the impact of the health issue on the population and the functioning of the community
the feasibility of being able to provide programs or services which will change the situation in the community and improve health status relative to this health issue.

Identify and describe the existing and the needed services

Identify the priority health needs in the community based on the current situation.
Describe the services which you have now to meet those health needs and note what additional services are needed.
Identify whether training could help the community to provide the needed services.

Identify and summarize training needs

Summarize the most critical training needs relative to the health priorities and list them in order of priority including:

the type of training needed
the number of workers requiring the training.

Share the findings with Community Members

Your draft report can serve as the basis for presenting the results of the needs assessment to community leadership. In this way, you ensure that they understand the findings and agree with the conclusions and recommendations before you share the report with community members.

Community members need an opportunity to provide comments on the findings. They may have valuable additional interpretations of the results or questions about the priority health needs you have identified.

If you do not have an existing way of sharing this type of information with community members, communicate the results of the needs assessment to them by:

announcing the results in a community newsletter and providing contact information for comments and/or
inviting the public to a community meeting in conjunction with a social event.

Revise the report, if necessary, based on the feedback of community members.

Appendix A Funding for the Community Health Needs Assessment

Population	Funds Available for Planning	Preparation	Implemen-tation	Analysis	TOTAL
0-500	$4,000	$7,000	$10,000	$17,000	$38,000
501-1,000	$5,000	$9,500	$19,000	$18,000	$51,500
1,001-2,000	$5,000	$14,000	$31,000	$23,000	$73,000
Greater than 2,001	$5,000	$19,000	$49,000	$23,000	$96,000

Appendix B Sample Letter of Introduction

A letter of introduction should be sent by the Chief to each respondent chosen to be in the survey about two weeks before the Community Members Survey is to take place.

Dear ____________________:

The (1) _____________________ and the Band Council will conduct a Community Health Needs Assessment Study on our reserve in about two weeks time. You have been selected as one of the reserve residents to take part in it.

For this study, (2) ____________________, a specially trained interviewer, will visit you at your home on (3) Thursday, June 15, 2000, at 11:00 a.m.

The answers you give to the questions asked by the interviewer are very important to the Community Health Needs Assessment Study and will help us in developing plans for our own community health services. Your name will not be used and any information you give will be kept confidential.

If you have any questions, or if you cannot be available at the time set for your interview, please contact (4) _______________________, the Interviewing Coordinator, at (5) ______________, or telephone (6) ________________________ between 9 a.m. and 5 p.m. week days, and another time can be arranged.

Thank you for your help.
Sincerely,

Chief

(1) Name of the organization undertaking the survey
(2) Interviewer's name
(3) Date and time (those shown above are examples)
(4) Name of Interviewing Coordinator
(5) Office name, address and telephone number
(6) Alternate contact telephone number


	Last Updated: 2005-03-22		Important Notices

Community Health Needs Assessment: A Guide for First Nations and Inuit Health Authorities, 2000

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