Community Needs Assement Plan-Building a Team

PARTICIPANT WORKBOOK

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Community Needs Assessment

Created: 2013

Community Needs Assessment. Atlanta, GA: Centers for Disease Control and Prevention (CDC), 2013.

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Table of Contents INTRODUCTION ……………………………………………………………………… 4

LEARNING OBJECTIVES ………………………………………………………………………………………… 4 ESTIMATED COMPLETION TIME ………………………………………………………………………………. 4 TARGET AUDIENCE ……………………………………………………………………………………………… 4 PRE-WORK AND PREREQUISITES ……………………………………………………………………………. 4 ABOUT THE WORKBOOKS …………………………………………………………………………………….. 5 ICON GLOSSARY ………………………………………………………………………………………………… 5 ACKNOWLEDGEMENTS …………………………………………………………………………………………. 5

SECTION 1: OVERVIEW OF COMMUNITY NEEDS ASSESSMENT …………. 6 INTRODUCTION …………………………………………………………………………………………………… 6 CHANGE TOOL AND WORKBOOK …………………………………………………………………………….. 8 OVERVIEW OF COMMUNITY NEEDS ASSESSMENT STEPS ……………………………………………… 8 PRACTICE EXERCISE #1 (10 MINUTES) ………………………………………………………………….. 11

SECTION 2: PLAN FOR A COMMUNITY NEEDS ASSESSMENT …………. 12 INTRODUCTION …………………………………………………………………………………………………. 12 IDENTIFY AND ASSEMBLE A DIVERSE COMMUNITY TEAM …………………………………………….. 12 DEVELOP A TEAM STRATEGY ………………………………………………………………………………. 13 IDENTIFY THE SCOPE OF THE ASSESSMENT …………………………………………………………….. 14 DEVELOP QUESTIONS TO ASK ……………………………………………………………………………… 17 SELECT SITES ………………………………………………………………………………………………….. 18 DETERMINE DATA COLLECTION METHODS OR USE EXISTING DATA ………………………………. 18 IDENTIFY KEY INFORMANTS TO CONTACT ……………………………………………………………….. 23 DOCUMENTATION ……………………………………………………………………………………………… 23 PRACTICE EXERCISE #2 (30 MINUTES) ………………………………………………………………….. 24 SECTION 3: KEY POINTS …………………………………………………………………………………….. 26

SECTION 3: REVIEW AND RATE THE DATA ………………………………… 27 INTRODUCTION …………………………………………………………………………………………………. 27 POLICY AND ENVIRONMENTAL STRATEGIES …………………………………………………………….. 27 DEVELOP A RATING SCALE …………………………………………………………………………………. 28 MAKING A TEAM DECISION ON RATINGS …………………………………………………………………. 31 SECTION 4: KEY POINTS …………………………………………………………………………………….. 32

SECTION 4: RECORD AND SUMMARIZE DATA …………………………….. 33 INTRODUCTION …………………………………………………………………………………………………. 33 RECORD DATA …………………………………………………………………………………………………. 33 SUMMARIZE DATA …………………………………………………………………………………………….. 35 SECTOR DATA GRID ………………………………………………………………………………………….. 36

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SECTION 5: KEY POINTS …………………………………………………………………………………….. 39

SECTION 5: CREATE A COMMUNITY ACTION PLAN ……………………… 40 INTRODUCTION …………………………………………………………………………………………………. 40 IDENTIFY ASSETS AND NEEDS ……………………………………………………………………………… 40 PRIORITIZE NEEDS ……………………………………………………………………………………………. 42 DEVELOP STRATEGIES ………………………………………………………………………………………. 43 PRIORITIZE STRATEGIES …………………………………………………………………………………….. 44 COMMUNITY ACTION PLAN ………………………………………………………………………………….. 46 SECTION 6: KEY POINTS …………………………………………………………………………………….. 48

CONCLUSION ………………………………………………………………………. 49 IMPLEMENTING THE ACTION PLAN AND SHARING PROGRESS ………………………………………. 49 TAKE HOME POINTS ………………………………………………………………………………………….. 50 WORKBOOK REVIEW …………………………………………………………………………………………. 50

RESOURCES ……………………………………………………………………….. 51 APPENDICES ……………………………………………………………………….. 52

APPENDIX A …………………………………………………………………………………………………….. 52 APPENDIX B …………………………………………………………………………………………………….. 53 APPENDIX C ……………………………………………………………………………………………………. 76

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Introduction LEARNING OBJECTIVES

After completion of the workbook, participants will be able to: • Plan for a community needs assessment by:

o Identifying a community team o Describing the scope of the assessment o Listing the questions to ask o Selecting sites o Determining data collection methods or sources o Identifying key informants

• Review and rate data collected from a community needs assessment.

• Summarize data by creating sector data grids. • Develop and prioritize strategies for improvement. • Create a community action plan that includes:

o Project period objective o Annual objective(s) o Activities needed to complete the objectives o Persons responsible for completing the activities, and o Estimated completion time

ESTIMATED COMPLETION TIME The workbook should take approximately 10 hours to complete.

TARGET AUDIENCE The module is designed for Field Epidemiology Training Program (FETP) residents who specialize in NCDs; however, you can also complete the module if you are tasked to evaluate a communicable disease surveillance system.

PRE-WORK AND PREREQUISITES Before participating in this training module, you must complete training in:

• NCD Data Sources

• Program Planning

• Prioritizing public health problems

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ABOUT THE WORKBOOKS You will read information about conducting a community needs assessment in the Participant Workbook. To practice the skills and knowledge learned, you will refer to the Activity Workbook and complete 4 exercises.

ICON GLOSSARY The following icons are used in this workbook:

Image Type Image Meaning

Activity Icon

Activity, exercise, assessment or case study that you will complete

Stop Icon

Stop and consult with your facilitator/mentor for further instruction

Resource Icon

A resource or website that may provide further information on a given topic

Tip Icon

Supplemental information, or key idea to note and remember

ACKNOWLEDGEMENTS Thanks to Shannon Griffin-Blake, PhD (Division of Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention) for sharing and explaining the CHANGE tool.

Thanks to Indu Ahluwalia, MPH, PhD (Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention) for reviewing this module and providing feedback and guidance.

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Section 1: Overview of Community Needs Assessment INTRODUCTION

What is a “Community?”

Communities are typically defined by a geographic area; however, they can also be based on shared interests or characteristics such as religion, race, age, or occupation. People within a community come from different backgrounds and have unique cultures, customs, and values. Utilizing this wide range of ideas and wisdom is critical to assessing the community needs and strategizing areas for improvement. Before you conduct a community needs assessment you should have a clear understanding of the different cultural groups within a community and how to best work with them to solve the community issues.

What is a Community Needs Assessment?

A community needs assessment provides community leaders with a snapshot of local policy, systems, and environmental change strategies currently in place and helps to identify areas for improvement. With this data, communities can map out a course for health improvement by creating strategies to make positive and sustainable changes in their communities.

Components of a Needs Assessment

The main outcomes of a community needs assessment are in 3 main categories: Policy Change, Systems Change, and Environmental Change.

Policy Change

This involves laws, regulations, rules, protocols, and procedures that are designed to guide or influence behavior. Policies can be either legislative or organizational. Policies often mandate environmental changes and increase the likelihood that they will become institutionalized or sustainable. Examples of legislative policies include taxes on tobacco products, provision of county or city public land for green spaces or farmers’ markets, regulations governing a national school lunch program, and clean indoor air laws. Examples of organizational policies include

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schools requiring healthy food options for all students, menu labeling in restaurants, and required quality assurance protocols or practices (e.g., clinical care processes).

System Change

This involves change that affects all community components including social norms of an organization, institution or system. It may include a policy or environmental change strategy. Policies are often the driving force behind systems change. Examples are implementing a national school lunch program across a region or provincial school system or ensuring a hospital system becomes tobacco free.

Environmental Change

This type of change relates to the physical, social, or economic factors designed to influence people’s practices and behaviors. Examples of alterations or changes to the environment include:

Physical: Structural changes or the presence of programs or services, including the presence of healthy food choices in restaurants or cafeterias, improvements in the built environment to promote walking (e.g., walking paths), the availability of smoking cessation services to patients or workers, and the presence of comprehensive school health education curricula in schools.

Social: A positive change in attitudes or behavior about policies that promote health or an increase in supportive attitudes regarding a health practice, including an increase in favorable attitudes of community decision makers about the importance of nonsmoking policies or an increase in nonacceptance of exposure to second-hand smoke from the general public.

Economic: The presence of financial disincentives or incentives to encourage a desired behavior including charging higher prices for tobacco products to decrease their use or the provision of nonsmoker health insurance discounts.

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CHANGE TOOL AND WORKBOOK

Resource

The community needs assessment process taught in this module is based on the Community Health Assessment and Group Evaluation (CHANGE) data- collection tool developed by CDC’s Healthy Communities Program within the Division of Community Health at the National Center for Chronic Disease Prevention and Health Promotion.1 The CHANGE tool was written primarily for communities in the United States interested in creating environments that support healthy living.

This workbook teaches a similar approach to conducting community needs assessment as the CHANGE tool, but since this participant workbook is to be used globally we are providing some flexibility in the tool you choose to use. For example, after learning the process you may decide to create your own Excel spreadsheets to record and summarize data, or something similar in MS Word.

If you wish to use the CHANGE tool, you can download and modify (free of charge) the Excel spreadsheets at: http://www.cdc.gov/HealthyCommunitiesProgram

If you choose to order (free of charge) the CHANGE tool CD-ROM, you will also receive additional resources such as an Action Guide, an MS PowerPoint presentation template, and a policy brief or one-pager template. Please note that the Action Guide contains slightly different “action steps” than the ones in this workbook since the workbook is designed to be used with or without the CHANGE tool.

OVERVIEW OF COMMUNITY NEEDS ASSESSMENT STEPS There are different approaches to conducting community needs assessments. In this module you learn how to gather and assess data on community assets and determine areas for improvement. You will learn a process that involves these main steps:

1 Centers for Disease Control and Prevention. Community Health Assessment aNd Group Evaluation (CHANGE) Action Guide: Building a Foundation of Knowledge to Prioritize Community Needs. Atlanta: U.S. Department of Health and Human Services, 2010.

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This workbook explains steps 1, 3, 4 and 5 in detail.

Step 1: Plan for a community needs assessment • Identify and assemble a diverse community team

• Develop a team strategy

• Define community to assess (e.g., region, village)

• Identify community sectors to assess (e.g., health care, schools)

• Identify community components to assess (e.g., nutrition, tobacco)

• Develop questions to ask for each community component

• Select sites and number of sites to visit within each sector

• Determine existing data to use or methods for collecting new data Identify key informants to contact

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Resource

Step 2: Conduct the needs assessment For guidance on how to conduct a needs assessment (for example, how to prepare for and conduct interviews and focus groups), access the North Carolina Department of Health Community Assessment Guide Book at http://www.schs.state.nc.us/schs/data/databook/2002/GuideBook 2002.pdf.

Step 3: Review and rate the data • Develop a rating scale, and,

• Make a team decision on ratings.

Step 4: Record and review consolidated data • Enter the data,

• Total the data, and,

• Summarize the data.

Step 5: Develop a community action plan • Identify community assets and needs,

• Prioritize needs,

• Develop and prioritize strategies for improvement, and,

• Create an action plan for top priority strategies.

Tip

The focus of this workbook is on assessing a community’s strengths and weaknesses through mainly qualitative collection methods; however, it is still important to support those findings with quantitative data collection methods (e.g., vital statistics, hospital records) to assess the health status of a community; for example, identifying prevalence and incidence of NCDs.

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PRACTICE EXERCISE #1 (10 MINUTES)

Activity

Instructions:

1. Complete this exercise individually.

The community needs assessment can yield information about different types of change strategies in the community: policy, systems or environmental. Systems changes can either be policy or environmental. Match the examples in the first column of the following table with the appropriate category. Mark your responses. The first one has been done for you as an example.

Example of types of strategies in a community- Law requiring schools to provide healthy food options for students

 Policy Environmental

Walking paths at a work site Policy Environmental

Higher prices for alcohol Policy Environmental

Smoking cessation programs for government employees

Policy Environmental

Food labeling Policy Environmental

2. Review your responses with a colleague. Then check the answers with those in Appendix A.

Stop

Let the facilitator or mentor know you are ready for the group discussion.

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Section 2: Plan for a Community Needs Assessment INTRODUCTION

Planning for a community needs assessment is just as critical as conducting the actual assessment. You need to ensure you have the right people to help out and that you have identified the logistics and content of the assessment, what data to collect, how to collect the data and from whom.

In this section you will learn how to plan for a community needs assessment, in particular how to:

• Identify and assemble a diverse community team

• Develop a team strategy

• Identify scope of assessment

• Develop questions to ask

• Select sites

• Determine data collection methods

• Identify key informants

IDENTIFY AND ASSEMBLE A DIVERSE COMMUNITY TEAM Representation from diverse sectors of the community is critical to successful team work and enables easy and accurate data collection and assessment. All members of the community team should have an active role in the assessment process from developing questions to identifying data collection methods to use. This process also ensures the community team has equitable access to and informed knowledge of the process, thereby solidifying their support.

Identifying 10-12 individuals is recommended to ensure the size is manageable, allow for adequate representation of different perspectives, and to account for attrition of members. Include representatives of different stakeholder groups.

Examples of types of stakeholders to include on the community team are: • Law enforcer

• Faith leader

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• Hospital administrator

• Community health worker

• School principal or headmaster (of primary school or university)

• Neighborhood council representative

• Civic leader

• Local advocates

• Local business leader

• Local health practitioner

When your community team is assembled you should clearly define the purpose of your community team, capacity of team members and their organizations, identify potential barriers to success, and plan for overcoming any obstacles. Ensuring adequate funding to support the community team’s efforts is critical to the success of the project.

DEVELOP A TEAM STRATEGY After you have assembled your team you will meet to develop a team strategy. This involves, at a minimum:

• Defining goals for the needs assessment

• Defining how the data collected will be used (e.g., to influence policy makers, to support new programs, to support new changes in service delivery or policies)

• Determining the timeline for the assessment (e.g., 3 months, 6 months)

• Determining roles and responsibilities of team members

• Assigning tasks based on skills and available resources

• Identifying how decisions will be made

• Selecting a method or tool for conducting the needs assessment (e.g., CHANGE tool, customized Excel spreadsheets, MS Word worksheets)

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IDENTIFY THE SCOPE OF THE ASSESSMENT In this step you will determine the scope of your community assessment. During this process, your team should define “community” and then keep this definition the same throughout the needs assessment.

A community needs assessment should focus on: • a selected community as defined by the team, such as a region or

neighborhood

• sectors within that area, such as health care and work sites

• community components to assess within each sector, such as nutrition, chronic disease management and tobacco use

Define the Community to Assess The community team will decide what community to assess. Previously established areas (e.g., school districts, city limits) may be helpful, but the community team will define its own community. As the community team decides on the area to assess, it should consider starting with a smaller geographic area or segment of the population. It might be easier to attain greater impact with a smaller sized community than a larger one within the first year.

Identify Community Sectors to Assess Within the community identified, your team will determine which distinct parts or sectors of the community to assess. Examples of community sectors are:

Community-At-Large Sector: includes community-wide efforts that impact the social and built environments such as food access, tobacco- free policies, walkability or bikeability, and personal safety.

Community Institution/Organization (CIO) Sector: includes entities within the community that provide a broad range of human services and access to facilities such as childcare settings, faith-based organizations, senior centers, health and wellness organizations, colleges and universities.

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Health Care Sector: includes places people go to receive preventive care or treatment, or emergency health care services such as hospitals, private doctors’ offices, community clinics, or health posts. Work Site Sector: includes places of employment such as agriculture, manufacturing, private offices, restaurants, retail establishments, and government offices. School Sector: includes all primary and secondary learning institutions.

Identify Community Components to Assess Within each sector, you should identify which components of the community to assess. Choose ones that the community team believes are most important and relevant to evaluate and that will lead to the most useful recommendations for improvement. For example, you may want to assess demographics, statistical data of a population such as age, income, education level, type of work site/health facility/school. For each sector, you will determine which demographic factors that you want to assess. For example, in some sectors, you might collect information on whether the population using the institution is from an urban or rural setting. You will also assess whether each sector has the policies and systems in place to evaluate risk and to help those in that system to engage in health promoting behavior. Part of this assessment may include who provides leadership and how and assessing who are the successful change agents.

Policies, Systems and Environments • Physical activity: the policy, systems or environmental change

strategies in place that support physical activity. For example, does the sector assess patients’ physical activity as part of a written checklist or screening used in all routine office visits? Does it provide access to public recreation facilities? Does it promote stairwell use?

• Nutrition: the policy, systems or environmental change strategies in place that support nutrition. For example, does the sector ensure that healthy food preparation practices (e.g., steaming, low fat, low salt, limited frying) are always used? Does it implement a referral

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system to help patients access community-based resources or services for nutrition?

• Tobacco Use: the tobacco control-related change strategies in place. For example, does the sector institute a tobacco-free policy 24/7 for indoor/outdoor public places? Does it ban tobacco vending machine sales? Does it provide access to a referral system for tobacco cessation resources and services?

• Chronic disease management: the policy, systems or environmental change strategies in place that support managing chronic diseases and its related risk factors. For example, does the sector provide chronic disease self-management education to individuals identified with chronic conditions or diseases? Does it implement a referral system to help patients access community- based resources or services for chronic disease? Does it promote chronic disease prevention?

• After school: the policy, systems or environmental change strategies in place that support after school activities. For example, does the school ensure appropriate active time during after-school programs or events? Does it institute healthy food and beverage options during after school programs?

• Leadership: the policy, systems or environmental change strategies in place that relate to the management of the community. For example, does the sector participate in community coalitions and partnerships? Does it reimburse employees for preventive health or wellness activities? Does it finance public parks/sports facilities?

• Legislative / Legal Environment

o District: the policy, systems or environment change strategies that are in place at the school district level. For example, does the district ban tobacco advertising on school property, at school events, and in written educational materials and publications? Does the school eliminate the sale and distribution of less than healthy foods and beverages during the school day?

o Additional governmental levels

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DEVELOP QUESTIONS TO ASK You will develop a list of questions to ask to learn about the strengths and weaknesses of specific community components within each sector. Ensure you determine how the responses will be measured (qualitative/quantitative) and include response options for quantitative questions. (See the Managing Data training module on developing data dictionaries with response options.)

For example, within the Health Care Sector, Physical Activity component, some questions you may want to include in the assessment are:

To what extent does the health care facility:

• Promote stairwell use (e.g., make stairs appealing, post motivational signs near stairs to encourage physical activity) to patients, visitors, and staff?

• Assess patients’ physical activity as part of a written checklist or screening used in all routine office visits?

• Provide regular counseling about the health value of physical activity during all routine office visits?

• Implement a referral system to help patients’ access community- based resources or services for physical activity?

Examples of questions to include if assessing the tobacco component of the health care sector are:

To what extent does the health care facility:

• Institute a smoke-free policy 24/7 for indoor public places?

• Institute a tobacco-free policy 24/7 for indoor public places?

• Institute a smoke-free policy 24/7 for outdoor public places?

• Institute a tobacco-free policy 24/7 for outdoor public places?

• Assess patients’ tobacco use as part of written checklist or screening used in all routine office visits?

• Assess patients’ exposure to tobacco smoke as part of written checklist or screening used in all routine office visits?

• Provide advice and counseling about the harm of tobacco use and exposure during all office visits?

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• Implement a referral system to help patients to access tobacco cessation resources and services?

Refer to Appendix B for a list of questions you may wish to include in your assessment.

SELECT SITES Sites are the locations within each sector your team will visit to conduct the needs assessment. At each site, the information gathered will provide answers to the questions you have identified.

Be sure to systematically choose a variety of sites within each sector to show the extent of work being done in the community. Some schools, for example, may be ready to pass a physical activity policy while others have not yet begun to consider the need. A diversity of policy implementation enhances your data-gathering process. If you only choose sites that are excelling, it will be more challenging to identify gaps and needs when you develop your Community Action Plan.

It is important to document the process for site selection. It is recommended that besides the community-at-large sector, you assess a minimum of 3 sites per sector. For example, if you are assessing each of the 5 sectors you would gather data from at least 13 sites as follows:

Sectors Community- At-Large

Community Institution/ Organization (CIO)

Health Care School Work site

Number of Sites

1 Minimum of 3 Minimum of 3 Minimum of 3 Minimum of 3

Tip

The more sites your team assesses, the greater the capacity of your team to understand the assets and needs of the community.

DETERMINE DATA COLLECTION METHODS OR USE EXISTING DATA Use a variety of data-gathering methods to access and collect information for each site. Data come in many forms; varying data-collection methods provides a more comprehensive assessment of your community. For example, direct observation enables you to better understand the environment in which people interact and to see the things of which others may not be aware. It may also produce useful information that may not be

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apparent from your other data-collection methods, such as a key informant interview or focus group. This type of data-collection allows you, the observer, to choose a location or event and watch what is happening.

A combination of 2 or more data-collection methods is recommended at each site to confirm or support initial findings. For example, photographs of walkable streets or congested intersections unfriendly to pedestrians may supplement the feedback from an independent survey.

The goal of this step is to reflect the voices of the community through a diverse set of data-collection methods and to mobilize support by demonstrating a detailed, thorough method of data-collection. Comprehensive data enable a more effective action plan for community improvements, so perform this task carefully to ensure the data needed to make decisions are available. Table 1 lists the advantages and disadvantages of various data-gathering methods. This is not a comprehensive list but a sample of methods you can use.

Also consider if your community has already gathered data for another purpose. To determine if you can use that information for the needs assessment, consider the following:

• How old are the data? If data are less than 6 months old they can be used. If not, it is time to gather new data.

• Do you have all the information?

• Is the information relevant?

• Can you use the data in the existing format?

• Do you need more data?

• Does anyone on your team have experience with analyzing data?

If your country uses the Behavioral Risk Factor Surveillance System (BRFSS) or a similar system to collect data on health and risk behaviors, this is an excellent data source that collects community information that would be helpful in your needs assessment. This is an example of a data source older than 6 months that is acceptable to use. However, note the frequency with which the data are collected. BRFSS alternates asking questions on certain key indicators (e.g., physical activity, nutrition) each year. As such, it is suggested that your team review a 2-year range of data to ensure a complete set of data.

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BRFSS as commonly implemented does not provide policy, systems, and environmental change strategies; however, it does document the health behaviors and health conditions common in a community. You can use data from this source in conjunction with the original data you collect from sites to gain a more comprehensive picture of the community needs.

As previously mentioned, the focus of this workbook is on qualitative data; however, it is important to use both qualitative and quantitative data collection methods to obtain a more in-depth, reliable assessment of the community. You will analyze data from each method separately. When both types of data suggest similar conclusions, the results are strengthened. If the data have different conclusions, then it is important to find out why they differ. Further study might be warranted.2

Table 1: Advantages and Disadvantages of Qualitative Data Collection Methods Method Definition Advantages Disadvantages

Individual Interviews

Conversation with a purpose that is conducted between two people either face- to-face or by telephone

• Interviewer can ask what he or she wants to know

• Can tell if questions are understood

• Can ensure questions are answered

• Interviewees might tell interview things he or she would not write on a survey

• Time-consuming • Must transcribe

notes after interview • Person being

interviewed may be biased

Focus Groups

Involve gathering information and opinions from a small group of people (8 to 10 per group) Group discussions often provide insights that might not emerge in interviews

• Can assess body language

• Observers can be present without distracting participants. If videotaped can share with others who couldn’t attend.

• Have participants’

• Responders lose anonymity

• Higher travel expenses when multiple locales are used

• Logistical challenge in rural areas or small towns

2 Community Assessment Guide Book, North Carolina Department of Health (2002); retrieved on October 19, 2012 from http://www.schs.state.nc.us/schs/data/databook/2002/GuideBook2002.pdf.

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Method Definition Advantages Disadvantages undivided attention

Observation

Data collection method that allows you to use the events around you to gather clues and generate conclusions about specific locales or experiences

• Relatively inexpensive

• Efficient • Can be conducted

on foot

• Provides only an overview of community

• Requires closer observation to identify previously unrecognized assets/issues

Postal Survey

Mailing self-completion questionnaires to a targeted group of people (e.g., a client’s customers or people living in a certain area)

• Relatively inexpensive

• Less potential for people to give answers they assume the interviewer wants to hear

• No interviewer training required

• Suitable only for short and straightforward surveys

• Data collection takes a long time

• Relatively low response rates

• Moderate literacy level required

Telephone Survey

Collection of data from a sample population using a standardized questionnaire by telephone

• Minimizes missing data

• Can use open-ended questions and more complex interviewing schedules

• Can record reasons and characteristics of nonconsenters

• Quick and inexpensive

• Does not require a high level of literacy

• Can be hard to prevent consultation with and/or interference from others

• Need to keep questions few and short

• Unable to ask questions requiring visual cues

• Some likelihood of socially desirable responses

Face-to-face Survey

A face-to-face survey is a telephone survey without the telephone. The interviewer physically travels to the respondent’s location to conduct a personal interview

• Allows flexibility in number and style of questions

• Minimizes missing data

• Allows physical measurements & direct observations

• Minimizes literacy level issues

• High likelihood of socially desirable responses

• Can be hard to prevent consultation with or interference from others

• Very expensive, especially if respondents are

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Method Definition Advantages Disadvantages widespread geographically

• Time-consuming

Web-based Surveys

A group of potential respondents is invited to participate in completing a web- based survey, and their responses are submitted electronically via the Internet

• Can be relatively inexpensive

• Relatively quick method of data- collection

• Minimizes social desirability biases

• High set-up costs • Useful only for

relatively large-scale surveys

• High level of literacy and basic computer skills required

• Requires access to good hardware, programming, and support services

• No information on non-respondents

• Best suited to pre- coded questions

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IDENTIFY KEY INFORMANTS TO CONTACT For each sector and site your team has identified for the assessment, contact people (or key informants) in the community who can provide the appropriate insight, knowledge, or documentation. Community team members can then reach out and contact people from the community (e.g., school principal, business leaders, city planners, police chief, hospital administrator) who should have access to the desired information or can point them in the right direction.

DOCUMENTATION Keep a comprehensive file of all sources of information, key contacts, and data to review at a later date or to share with coalition members. The file can be in multiple forms—notebooks or bound volumes, facilitator guides, field notes, meeting minutes, or an electronic data file. The purpose of cataloguing all the data files is to ensure that everything your team collects can be accessed and used.

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PRACTICE EXERCISE #2 (30 MINUTES)

Activity

Instructions:

1. Find a colleague with whom to complete this exercise. If you are from a different country/region/district, choose one person who will provide the responses for this exercise. The other person will contribute ideas and feedback.

2. Answer the following questions. Then check the answers with those in Appendix A.

Questions:

1. If you were planning a community needs assessment, what are some components of a team strategy that you would develop?

2. Describe the community you will assess including at least 4 community sectors.

3. For each community sector, list at least 5 community components to assess.

4. Select one community component and list at least 3 types of questions to ask to learn about strengths and weaknesses.

5. For one of the community sectors you will assess, list at least 2 sites to visit.

6. For 1 of the sites you will visit, list at least one data collection method you will use.

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7. For 1 of the sites you will visit, describe the key informants who your team will contact.

Stop

Let the facilitator or mentor know you are ready for the group discussion.

Activity

TAKE OUT THE ACTIVITY WORKBOOK AND COMPLETE SKILL ASSESSMENT – ACTIVITY#1.

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SECTION 3: KEY POINTS

Tip

Planning for a community needs assessment includes:

• Identify and assemble a diverse community team

• Develop a team strategy

• Define the community to assess (e.g., school districts, city limits)

• Identify community sectors to assess (e.g., health care, schools)

• Identify community components to assess (e.g., nutrition, tobacco use)

• Develop questions to ask for each component, including how the responses will be measured

• Select sites and number of sites to visit within each sector

• Determine existing data to use or methods for collecting new data

• Identify key informants to contact

Identifying 10-12 individuals maximum for your community team is recommended to ensure the size is manageable and to account for attrition of members.

A community needs assessment should focus on a particular geographic area, sectors within that area such as health care and work sites, and community components to assess within each sector such as nutrition, chronic disease management, and tobacco use.

A combination of 2 or more data-collection methods is recommended at each site to confirm or support initial findings.

Keep a comprehensive file of all sources of information, key contacts, and data to review at a later date or to share with coalition members.

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Section 3: Review and Rate the Data INTRODUCTION

Before recording the data collected from the needs assessment into a data capturing tool, such as the CHANGE tool, your team should review the information from each site to gain consensus on how to rate each item. Rating the data helps to identify strengths and weaknesses. The team should discuss the data, share what each person found, and identify evidence to support the team’s rating.

In this section, you will learn:

• The difference between policy and environmental change strategies,

• How to develop a rating scale, and

• How to reach consensus on rating data.

POLICY AND ENVIRONMENTAL STRATEGIES For each site visited, you will rate the data collected about policy and environmental change strategies. Remember that policy refers to laws, regulations, rules, protocols, and procedures that are designed to guide or influence behavior. They can be either legislative or organizational policies. Environmental change relates to the physical, social, or economic factors designed to influence people’s practices and behaviors.

Examples of Policy and Environmental Change Strategies: Policy Environmental

• Smoke-free policy for indoor public places

• Ban marketing of less than healthy foods and beverages at work sites and schools

• Ban using or withholding physical activity as a punishment in schools

• Institute a requirement that health staff measures weight and height and calculates BMI for every patient at each business

• Adopt a nutrition education curriculum in all primary schools

• Referral system to help employees access tobacco cessation resources or services

• Provide healthy food and beverage options in vending machines

• Ensure availability of proper equipment (e.g., playground) and facilities that meet safety standards

• Provide screening for chronic diseases in adults with risk factors

• Provide adequate time to eat school meals

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DEVELOP A RATING SCALE

Your team will develop a rating scale that can be used to assess the strengths and weaknesses of each site within a sector. You may wish to adapt a rating scale similar to the one that the CHANGE tool uses, which allocates a number between 1 and 5 for policy and environment changes in each of the five sectors. Table 2 shows the scale with definitions of scores 1–5. A response of ‘99’ can be used only when the item is not applicable at the site (e.g., stair promotion not suitable in a one-story building). If you do use the CHANGE tool a response of ‘99’ does not factor into the column total or percentage calculations. Table 2: Rating Scale Response

# Policy Environment

1 Not identified as problem Elements not in place

2 Problem identification/gaining agenda

status

Few elements in place

3 Policy formulation and adoption

Some elements are in place

4 Policy implementation Most elements are in place

5 Policy evaluation and enforcement

All elements in place

99 Not applicable Not applicable

The Environment column can be more subjective than the Policy column, distinguishing between the words “few”, “some” and “most”. For example, a team has assessed the following item under the Health Care Sector, Chronic Disease Management: Provide screening for chronic diseases in adults with risk factors. At the site the team members conducted focus groups and observations. Through observations within a 5-day period, 6 out of 10 adults who presented with risk factors were screened for chronic diseases. However, during focus group discussions with medical

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professionals, 75% of the staff said that they always conduct screenings and 50% of the staff said that they provide screenings inconsistently depending on time and resources. In this example, you could rate the environment element a ‘3’ (some of the elements are in place) or a ‘4’ (most of the elements are in place).

Table 3 provides a detailed example of the rating scale for the Health Care Sector, Chronic Disease Management and the item that was assessed: Does the facility provide screening for chronic diseases in adults with risk factors?

Table 3: Policy and Environment Scale for Health Care Sector and Chronic Disease Management

Item: Does the facility provide screening for chronic diseases in adults with risk factors?

Response #

Policy Environment

1 The issue has not yet been identified as a concern or a problem. For example, there has been no discussion on requiring screening for chronic diseases in adults with risk factors.

No elements are in place in the environment. For example, there are no screenings for chronic diseases in adults with risk factors

2 The issue or problem has received attention from the authoritative body that must deal with the issue. This is usually done when the issue or problem is categorized as a social or public problem. For example, the issue of chronic disease screening has been put on the agenda, but no formal policy has been formulated or adopted.

Only a few elements are in place in the environment. For example, a few health care professionals at the site are providing screenings for chronic disease.

3 Policy goals and solutions have been formulated but not implemented. For example, the health care facility developed

Some elements are in place in the environment. For example, one-third of the adult patients with risk factors are being

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Response #

Policy Environment

and approved the chronic disease screening policy, but it has not yet been implemented across the entire facility. It will be implemented in the next fiscal year.

screened for chronic disease at the health facility.

4 Administrators have made a decision about how to deploy necessary resources (human and financial) to actualize the policy. For example the chronic disease screening policy was established and passed last year, communicated to the health care professional, and implemented this year. The end of this year will be the review and comment period of the policy.

Most elements are in place in the environment. For example, more than half the adult patients with risk factors are being screened for chronic disease at the health facility.

5 This stage involves determining to what extent the policy has been enforced and what occurred as a result of the policy. Based on the evaluation results, adjustments can be made to the current policy to ensure effectiveness. For example, the chronic disease policy was implemented last year and evaluated. The policy was revised and is now implemented with revisions.

All elements are in place in the environment. For example, all the adult patients with risk factors are being screen for chronic disease at the health facility.

99 This type of policy is not appropriate for this community.

This type of environmental change strategy is not appropriate for this community.

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The following is an example of how you might rate an item for Health Care Sector, Tobacco component: Does the facility assess patients’ tobacco use as part of written checklist or screening used in all routine office visits?

Data Collected Policy Environment

Use of checklists or screenings has been discussed at staff meetings, but no formal policy exists. One- third of the doctors and one-quarter of the nurses use a written checklist or screening to assess patients’ tobacco use consistently at every office visit.

2 3

A rating of ‘2’ was given to policy because although the issue of assessing patient’s tobacco use has been discussed, it has not yet been formulated as a policy. A rating of ‘3’ was given to environment, meaning some elements are in place at this site, because one-half of the doctors and one-third of the nurses assess patient’s tobacco use. Another community team might rate this item as a ‘2’, deciding that only a few elements are in place.

Tip

One or two members of your team should take note of what type of data was collected from the site being discussed, where it came from, and add it

to the comprehensive data file. This information will provide valuable, historical documentation.

MAKING A TEAM DECISION ON RATINGS When you assembled your team, you should have agreed upon a decision-making strategy. Some examples are the Delphi method (voting is at first anonymous, scores are shown to the group, voting is done repeatedly until a consensus is reached), simple voting, or a discussion among members that indicates all or most are in agreement. Choose a method based on your team’s preference, but you should use that same method consistently throughout the process.

As a team, decide what these data mean in terms of the parameters of the rating scale you developed. Be sure to record comments for each rating to document why the decision was made. Ensure that the information represents the site you assessed so information can be used from year to year.

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Rating the data should be based on a comprehensive review of all sources and the agreement of the individuals on your team.

Stop

Let the facilitator or mentor know you are ready for the group discussion.

Activity

TAKE OUT THE ACTIVITY WORKBOOK AND COMPLETE SKILL ASSESSMENT – ACTIVITY#2.

SECTION 4: KEY POINTS

Tip

• When your team reviews the information from each site, be sure to reach consensus on how to rate each item.

• Rating the data should be based on a comprehensive review of all sources and the agreement of the individuals on your team.

• The rating scale presented in this workbook is as follows:

Response #

Policy Environment

1 Not identified as problem Elements not in place

2 Problem identification/ gaining agenda status

Few elements in place

3 Policy formulation and adoption

Some elements are in place

4 Policy implementation Most elements are in place

5 Policy evaluation and enforcement

All elements in place

99 Not applicable Not applicable

• One or two members of your team should document the type of data that was collected from each site and where it came from.

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Section 4: Record and Summarize Data INTRODUCTION

Designate one person as the data manager within your community team. This person should be responsible for entering the data for each of the sites into the specific tool you are using. If your team is using the CHANGE tool, the data manager should have a basic working knowledge of MS Excel, such as opening and closing files, entering macros, and entering data in fields.

In this section you will learn how to record and summarize data.

RECORD DATA After your team has reached consensus on the most appropriate rating for each item within a site, the data should be recorded in a table or spreadsheet along with any supporting comments.

If you are using the CHANGE tool or another customized Excel spreadsheet, your team should use 1 Excel file for each site assessed as shown below in figure 1.

Figure 1: CHANGE tool: Example of an Excel file for one site of the School Sector

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Enter Comments Data managers are encouraged to enter comments on the Excel spreadsheets to provide detailed records of how and from where the data were collected.

In the CHANGE tool, you click on the red corner of the cell to enter a comment, as shown in figure 2 below.

Figure 2: CHANGE tool: Entering a Comment

Total the Data To understand a sector’s strengths and weaknesses you will need to compile and then compare all the scores for each community component, e.g., nutrition, tobacco use. To compare the scores you will first total all the ratings and then give it a percentage score as shown on Table 4.

One of many advantages to using the CHANGE tool is that it automatically completes all data calculations within each sector. If you choose to create your own tool you will need to create a formula or do manual calculations for totaling the data.

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Table 4: Sample of Competed Entries and Totals and Percentages Scores (for one site): Community Institution/Organization: Chronic Disease Management

To what extent does the community institution/organization:

Policy Response #

Environment Response #

Provide access to chronic disease self- management programs?

1 2

Provide routine screening, follow-up counseling and education to patrons to help address chronic diseases and related risk factors?

2 3

Adopt curricula or training to raise awareness of the signs and symptoms of heart attacks and strokes

1 1

Promote chronic disease prevention to patrons (e.g., post signs reminding patrons to get blood pressure checked, to quit smoking, and avoid secondhand smoke)?

3 3

COLUMN TOTAL: 7 9 CHRONIC DISEASE MANAGMENT SCORE: 35% 45%

Follow these steps to calculate the percentage score manually: 1. Determine the highest possible score for the column, based on the

highest rating of ‘5’ and the number of questions.

For example, in Table 4, since there are 4 questions, the highest possible score for the column is 20 (‘5’ rating x 4 questions).

2. Divide the column total into the highest possible score.

For example, in Table 4, the column total for Policy is 7, so the calculation is as follows: 7 ÷ 20 = .35

3. Multiply the result from step 2 by 100 to get a percentage.

For example, .35 x 100 = 35%

SUMMARIZE DATA After you have totaled and scored the item responses for all sectors and community components, create a summary of all the percentage scores for each site. For example, if you assessed 3 community institutions/organizations, you will have 3 summary pages (1 for each site)

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that show all the percentage scores for the Community Institution/Organization sector, as in Table 5. Notice the percentage scores of 35% Policy and 45% Environment from Table 4 are carried over to the summary worksheet in Table 5.

Table 5: Sample Summary of Community Component Scores for a Community Institution/Organization Policy Environment Community Component

62% 70% Physical Activity 50% 60% Nutrition 75% 82% Tobacco Use 35% 45% Chronic Disease Management 25% 30% Leadership

SECTOR DATA GRID To provide a quick data reference across all sectors, you can use the Summary Scores to create a Sector Data Grid as shown in Table 6. This grid helps communities easily review and determine areas for improvement. Identifying sectors and related community components with low scores is useful for informing priority areas for improvement and determining what specific strategies to incorporate into the action plan.

This action step supports a comprehensive view of all the data and reveals how the sites compare to each other. It builds a spectrum against which your community team can begin thinking about gaps, needs, assets, and areas of change.

To create a Sector Data Grid you will refer to all Summary of Community Component Percentage Score sheets. For each sector (Community-At- Large, Community Institution/Organization, etc.), you will indicate where each site’s community component (row) percentages fall in the appropriate column.

In the Sector Data Grid you will indicate the sector’s policy community component scores (by using a “P”) and environment community component scores (by using an “E) for each site (denoted by a “1”, “2”, etc.). For Community-At-Large, place a ‘CALP1’ (remember there is only one site assessed for this sector) in each row to denote this site’s policy community element percentages across the scale (low [0–20%] to high [81–100%]). Use ‘CALE1’ to denote the site’s environment community component percentages.

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Notice that in Table 6, The Community Institution/Organization (CIO) sector shows the percentages for the three sites that were assessed, indicated by the “1”, “2” and “3” at the end of each code.

Table 6: Example of a Sector Data Grid (for 2 sectors only) Community-At-Large (CAL) Community Component

Low: 0-20%

Low: 21-40%

Medium: 41-60%

Medium: 61-80%

High: 81-100%

Physical Activity

CALP1, CALE13

Nutrition CALP1, CALE1

Tobacco CALP1, CALE1

Chronic Disease Mgt CALE1 CALP1

Leadership CALP1 CALP1

3 CALE1: ‘CAL’ = Community-At-Large Sector ‘E’ = Environment ‘1’= Site number (If you have multiple sites, number them consecutively, 1, 2, 3 and so forth.)

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Community Institution/Organization (CIO) Community Component

Low: 0-20%

Low: 21-40%

Medium: 41-60%

Medium: 61-80%

High: 81-100%

Physical Activity CIOP1 CIOE1

CIOP2, CIOE2, CIOP3

CIOE3

Nutrition CIOE1, CIOP1, CIOE2

CIPO2, CIOE3 CIOP3

Tobacco CIOP2, CIOE3, CIOP3

CIOP1, CIOE1, CIOE2

Chronic Disease Mgt CIOP1,

CIOE1 CIOP2 CIOE2, CIOP3, CIOE3

Leadership CIOE2, CIOP2

CIOE3 CIOP3, CIOE1 CIOP1

Your mentor or facilitator will review in greater detail how to complete this grid.

Stop

Let the facilitator or mentor know you are ready for the group discussion.

Activity

TAKE OUT THE ACTIVITY WORKBOOK AND COMPLETE SKILL ASSESSMENT – ACTIVITY#3.

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SECTION 5: KEY POINTS

Tip

• To ensure proper data management, there should be only one data manager, such as the community team’s evaluator; all data should be forwarded to this individual.

• After your team has reached consensus on rating each item within a site, the data should be recorded in a table or spreadsheet along with supporting comments.

• After recording the data and entering comments, the data manager should total all the ratings and assign a percentage score.

• After totaling and scoring the item responses for all sectors and community components, the data manager should create a summary of all the percentage scores for each site.

• To provide a quick data reference across all sectors you can use the Summary Scores to create a Sector Data Grid.

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Section 5: Create a Community Action Plan INTRODUCTION

At this stage of the community needs assessment, you should have summarized the data the team has collected and are ready to identify the community assets and needs. In this final section of the workbook you will learn how to use your summary information to identify areas for improvement and then transform them into measurable action items.

The outcome of this step is a Community Action Plan which will contain Specific, Measurable, Attainable, Realistic and Timely (SMART) objectives and the activities to support those objectives.

You should present your needs assessment findings and obtain approval from stakeholders and/or community leaders on the strategies before developing an action plan.

IDENTIFY ASSETS AND NEEDS You will use the Sector Data Grids to identify focal policy, systems, and environmental change strategies that are both in place, (i.e., assets), and missing, (i.e., needs).

Your team should designate a cut-off point–the scores to the right of the line would be considered assets; those to the left would be the needs, as shown in Table 7.

Table 7: Sample Needs and Assets: Needs=0-60%, Assets=61-100%

Community-At-Large (CAL) Community Component

Low: 0-20%

Low: 21-40%

Medium: 41-60%

Medium: 61-80%

High: 81-100%

Physical Activity

CALP1, CALE14

Nutrition CALP1, CALE1

Tobacco CALP1, CALE1

Chronic Disease Mgt CALE1 CALP1

4 CALE1: ‘CAL’ = Community-At-Large Sector ‘E’ = Environment ‘1’= Site number (If you have multiple sites, number them consecutively, 1, 2, 3 and so forth.)

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Community Component

Low: 0-20%

Low: 21-40%

Medium: 41-60%

Medium: 61-80%

High: 81-100%

Leadership CALP1 CALP1

Now that you have a visual depiction of each sector’s needs and assets across all the community components, you can then create a list of all the policy, systems, and environmental change strategies across sectors that are assets or needs. Table 8 shows an example of a Policy, Systems and Environmental Change Strategies Worksheet you can use to record this information.

Table 8: Sample Policy, Systems, and Environmental Change Strategies Worksheet: Assets and Needs

ASSETS NEEDS Community-At-Large Sector: • Smoke-free and tobacco-free

policies implemented for indoor and outdoor places.

• Strategies adopted to educate residents on importance of controlling high blood pressure and cholesterol.

Community Institution/Organization (CIO) Sector: • All sites instituted healthy food

and beverage options in vending machines.

• 3 out of 4 sites provide routine screening for cholesterol and provide counseling and education about tobacco use and exposure.

• 3 out of 4 sites participated in the last three years in community coalitions and partnerships related to tobacco use and physical inactivity.

Community-At-Large Sector: • No policies in place that ban

local restaurants and retail food establishments from cooking with trans fats.

• Recent budget cuts for public shared-used paths or trails.

Community Institution/Organization (CIO) Sector: • 1 site did not provide any

routine screenings for chronic diseases management.

• No sites promoted stairwell use. • 1 site has never participated in

community coalitions and partnerships related to tobacco use or physical inactivity.

Health Care Sector: • Health care centers and private

physician’s office do not take routine body mass index readings (BMIs) for routine office exams.

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ASSETS NEEDS

Health Care Sector: • Two facilities promoted stairwell

use to patients, visitors, and staff

• Patients referred to smoking cessation programs at all sites

School Sector: • 1 of the schools was initiating a

plan to ensure the playground equipment meets safety standards

Work Site Sector:

• Employee wellness coalition developed by local small business

• All sites have designated, safe walking paths on building property

• 4 out of 5 sites implemented a referral system for tobacco cessation services

• 75% of the health care professionals do not provide patient education on nutrition or physical activity

School Sector: • No requirements for physical

activity during school day • 2 of the 3 schools offered no

healthy food or beverage options

Work Site Sector:

• No sites promoted stairwell use • No sites offered healthy food or

beverage options in vending machines

Strategies:

PRIORITIZE NEEDS If you have identified many community needs, your team should prioritize those needs. Some criteria you may consider when prioritizing needs are: • Size of problem • Seriousness of problem • Availability of current interventions • Economic or social impact • Public health concern • Availability of resources

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Tip

Please refer to the Prioritize Public Health Problems module for more information about how to prioritize needs.

DEVELOP STRATEGIES Using your priority list of community needs, identify a specific community strategy to address each key need. You do not have to address every weakness.

When identifying strategies, consider the community’s strengths. For example, in the sample needs assessment in Table 8 all the community institution/organization sites offered healthy food and beverage options in vending machines; however, none of the sites promoted stairwell use. Since the institutions already have a healthy nutritional environment they might be more acceptable of incorporating physical activity initiatives.

Your team can also combine similar strategies to streamline activities. For example, in the sample needs assessment, work sites also did not promote stairwell use. The community team can formulate a strategy that encourages stairwell use at work sites and community institutions/organizations. The team members responsible for this strategy can use the same promotional materials (e.g., posters on the benefits of using stairwells) for both sectors.

After developing the strategies, record them on the bottom section of the Policy, Systems and Environmental Change Strategies Worksheet. An example is shown below in Table 9.

Table 9: Sample Strategies (bottom of Policy, Systems, and Environmental Change Strategies Worksheet)

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Strategies:

• Work with key stakeholders to formulate and implement a policy that bans local restaurants and retail food establishments from cooking with trans fats.

• Encourage community institutions/ organizations and work sites to promote stairwell use.

• Encourage health care professionals to provide patient education on nutrition and physical activity to adults with chronic disease risk factor.

• Require schools to incorporate a minimum of 30 minutes of physical activity during school day.

• Require schools to offer healthy food and beverage options.

PRIORITIZE STRATEGIES Once you have identified the strategies, your team will need to prioritize what can be implemented, given the time, resources, and other competing community priorities. Use any method to prioritize that your team has agreed upon. One way is to rank each strategy according to each criterion from 1 to 5 as follows: Table 10: Example Scale for Ranking Strategy Time Resources Competing Priorities 1= Large amount of time needed to implement strategy 2 = Substantial amount of time needed to implement strategy 3 = Some amount of time needed to implement strategy 4 = A little amount of time needed to implement strategy 5 = Very little amount of time needed to implement strategy

1= Large amount of resources needed to implement strategy 2 = Substantial amount of resources needed to implement strategy 3 = Some amount of resources needed to implement strategy 4 = A little amount of resources needed to implement strategy 5 = Very little amount of resources needed to implement strategy

1= Large amount of competing priorities 2 = Substantial amount of competing priorities 3 = Some competing priorities 4 = A few competing priorities 5 = No competing priorities

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After ranking each strategy according to time, resources, and competing priorities, total the scores to determine the highest ranking strategies to implement. See Table 11 for an example of how to use this ranking method.

Table 11: Sample Prioritize Worksheet Strategy Time

(1-5) Resources

(1-5) Competing Priorities

(1-5)

Total (T x R x C)

Rank

Work with key stakeholders to formulate and implement a policy that bans local restaurants and retail food establishments from cooking with trans fats.

1 2 2 4 5

Encourage community institutions/organizations and work sites to promote stairwell use.

4 4 3 48 1

Encourage health care professionals to provide patient education on nutrition and physical activity to adults with chronic disease risk factor.

4 3 3 36 2

Require schools to incorporate a minimum of 30 minutes of physical activity during school day.

3 2 3 18 3

Require schools to offer healthy food and beverage options.

2 2 2 8 4

In the above example the top 2 strategies are: 1. Encourage community institutions/organizations and work sites to

promote stairwell use.

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2. Encourage health care professionals to provide patient education on nutrition and physical activity to adults with chronic disease risk factors.

COMMUNITY ACTION PLAN Your team will develop an action plan for each priority strategy. A quality plan contains sufficient details to map a clear course of action. Table 12 shows an example of a Community Action Plan.

Notice there are two types of objectives listed in the Community Action Plan: Project Period Objective and Annual Objective. The project period objective allows your team to look at a long term perspective of what can be accomplished over a multiyear period. For example, in Table 11 the project period objective states: In 5 years, all ministry of health providers will include NCD counseling to all patients, that includes lifestyle counseling on physical activity, nutrition and smoking.. There is also space on the worksheet to record the community component that is the area of focus, such as nutrition or physical activity.

Annual objectives cover a 12-month timeframe and show incremental progress toward completion of the project period objective. In Table 12 there is one annual objective: At 12 months, all clinics in district Y will provide lifestyle NCD counseling to all patients.

Table 12: Example of a Community Action Plan

Policy/Environmental Change Strategy

Encourage health care professionals to provide patient education on nutrition and physical activity to adults with chronic disease risk factors.

Project Period Objective Community Component(s)

In 5 years, all ministry of health providers will include NCD counseling to all patients that includes lifestyle counseling on physical activity, nutrition, and smoking.

Physical Activity Nutrition

Annual Objective(s): Sector(s) No. of People Reached

At 12 months all clinics in district Y will provide lifestyle NCD counseling to all patients.

Health Care 250,000

Activities Person Responsible Timeline

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NCD counseling protocols developed J. Thomas Month 0-3

NCD counseling monitoring system developed

W. Lee Month 0-3

Health provider reward/recognition system established

Month 0-3

NCD physicians/health providers trained on protocol

W. Lee Month 3

Community interventions including establishment of exercise locations for women and the general public, and cooking classes

J. Thomas Months 6-9

A district-wide, multisectoral NCD plan will be developed and implemented

W. Lee Months 6-9

All physicians/health providers trained W. Lee Months 6-9

All clinics begin counseling J. Thomas Month 125

It is important to associate each annual objective with a particular sector. You may develop multiple annual objectives that cut across more than one sector for a project period objective. In this example, the sector impacted is health care.

For each annual objective, indicate the approximate number of people who will be affected by the strategy through its successful completion.

Tip

As you craft the objectives, be sure they are SMART—specific, measurable, achievable, realistic, and time-phased.

The last section of the Community Action Plan template is where you list the activities that support the accomplishment of the annual objective. When listing activities be sure to provide clear descriptions of key milestones. For each annual objective it is recommended that you list no

5 In reality, more activities would be listed which would include activities for years 2 through 5 (project objective).

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more than 10 activities, which may limit these activities to key actions for completing the annual objective.

Next to each activity that is listed identify the lead or primary contact person, and estimate the timeline for strategy completion. Be specific and realistic. If the strategy’s completion depends on actions by several individuals or organizations, allow time for stakeholder coordination.

Stop

Let the facilitator or mentor know you are ready for the group discussion.

Activity

TAKE OUT THE ACTIVITY WORKBOOK AND COMPLETE SKILL ASSESSMENT – ACTIVITY#4.

SECTION 6: KEY POINTS

Tip

• Create a list of all the policy, systems, and environmental change strategies across sectors that are community assets or needs.

• Use your list of community needs to identify a specific community strategy to address each key need. You do not have to address every weakness.

• After identifying strategies, your team will prioritize what can be implemented given the time, resources, and other competing community priorities.

• On the action plan a project period objective allows your team to look at a long-term perspective of what can be accomplished over a multiyear period. Annual objectives cover a 12-month timeframe with incremental progress toward completion of the project period objective.

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Conclusion IMPLEMENTING THE ACTION PLAN AND SHARING PROGRESS

Although this workbook does not cover implementing the community action plan or sharing results, it is worthwhile to briefly mention those here. After completing the community needs assessment and developing a communication action plan, coordinate your resources to make sure the activities you have identified are completed on time. Track your progress, note key successes, and document any obstacles to implementing the action plan. You will also want to share the data and accomplishments with community leaders and other people and organizations that contributed their time and expertise to the needs assessment. Identify the best venue for sharing the results. You can organize a community meeting and/or write a policy brief or one-pager. Anonymity is important to protect the interests of those who participated in the assessment. Community teams should not list who they talked with or provide specific details about data that could specifically link to an individual or organization. Share data in aggregate for a sector. For example, when providing results of assessing work sites you may state that “across the 6 work sites examined by the community team, 2 had policies requiring healthy food choices in vending machines, 1 was in the process of formulating a policy, and 3 had no formal policy regarding vending machine healthy food choices.”

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TAKE HOME POINTS

Tip

• A community needs assessment should focus on a particular geographic area, sectors within that area such as health care and work sites, and community components to assess within each sector such as nutrition, chronic disease management, and tobacco use.

• A combination of 2 or more data-collection methods is recommended at each site to confirm or support initial findings.

• Keep a comprehensive file of all sources of information, key contacts, and data to review at a later date or to share with coalition members.

• Rating the data should be based on a comprehensive review of all sources and the agreement of the individuals on your team.

• To ensure proper data management there should be only one data manager, such as the community team’s evaluator, and all data should be forwarded to this individual.

• After your team has reached consensus on the most appropriate rating for each item within a site, the data should be recorded in a table or spreadsheet along with any supporting comments. The data manager should total all the ratings, assign a percentage score, and then create a summary of all the percentage scores for each site.

• Create Sector Data Grids to provide a quick data reference across all sectors.

• Use your list of community needs and identify a specific community strategy to address each key need. You do not have to address every weakness.

• After identifying strategies your team will prioritize what can be implemented, given the time, resources, and other competing community priorities.

• On the action plan, a project period objective allows your team to look at a long term perspective of what can be accomplished over a multiyear period. Annual objectives cover a 12-month timeframe with incremental progress toward completion of the project period objective.

WORKBOOK REVIEW After completing this workbook, you should be able to:

� Plan for a community needs assessment, � Review and rate data collected from a community needs assessment, � Summarize data, � Identify areas for improvement, and, � Develop a community action plan.

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Resources For more information on topics found within this workbook:

• Community Health Assessment and Group Evaluation (CHANGE) data-collection tool developed by CDC’s Healthy Communities Program in the Division of Community Health at the National Center for Chronic Disease Prevention and Health Promotion. Available at: http://www.cdc.gov/HealthyCommunitiesProgram

• Centers for Disease Control and Prevention. Healthier Worksite Initiative, Environmental Audits. Available at: http://www.cdc.gov/nccdphp/dnpao/hwi/programdesign/enviro nmental_audits.htm

• Community Assessment Guide Book, North Carolina Department of Health (2002); retrieved on October 19, 2012 from http://www.schs.state.nc.us/schs/data/databook/2002/GuideBo ok2002.pdf

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Appendices APPENDIX A

The community needs assessment can yield information about different types of change strategies in the community: policy, systems or environmental. Systems changes can either be policy or environmental. Match the examples on the left side of the following table with the appropriate category. Mark your responses.

Example of types of strategies in a community- Law requiring schools to provide healthy food options for students

 Policy Environmental

Walking paths at a work site Policy  Environmental

Higher prices for alcohol Policy  Environmental

Smoking cessation programs for government employees

Policy  Environmental

Food labeling  Policy Environmental

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APPENDIX B The following is a list of sample questions you can ask for each sector and community component. Please note that these were developed for a U.S. audience and should be adapted accordingly:

Community-At-Large Sector Demographic 1. Approximate number of people who reside in the community

(population).

2. Approximate size of the area (square kilometers).

3. Best description of the community setting: rural, suburban, urban.

4. The median household income of the community: provide 4 choices.

5. Approximate percentage of people in the community with no high school diploma.

6. Approximate percentage of people in the community who are living in poverty: < 5%, 5 – 9%, 10 – 14%, 15 – 19%, ≥ 20%.

7. Approximate percentage of people in the community who are currently unemployed: < 5%, 5 – 9%, 10 – 14%, 15 – 19%, ≥ 20%.

Physical Activity To what extent does the community:

1. Require sidewalks to be built for all developments (e.g., housing, schools, commercial)?

2. Adopt a land use plan?

3. Require bike facilities (e.g., bike boulevards, bike lanes, bike ways, multi-use paths) to be built for all developments (e.g., housing, schools, commercial)?

4. Adopt a complete streets plan to support walking and biking infrastructure?

5. Maintain a network of walking routes (e.g., institute a sidewalk program to fill gaps in the sidewalk)?

6. Maintain a network of biking routes (e.g., institute a bike lane program to repave bike lanes when necessary)?

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7. Maintain a network of parks (e.g., establish a program to repair and upgrade existing parks and playgrounds)?

8. Provide access to parks, shared-use paths and trails, or open spaces within reasonable walking distance of most homes?

9. Institute mixed land use?

10. Provide access to public recreation facilities (e.g., parks, play areas, community and wellness centers) for people of all abilities?

11. Enhance access to public transportation (e.g., bus stops, light rail stops, van pool services, subway stations) within reasonable walking distance?

12. Provide street traffic calming measures (e.g., road narrowing, central islands, roundabouts, speed bumps) to make areas (e.g., neighborhoods, major intersections) where people are or could be physically active (e.g., walk, bike) safer?

13. Adopt strategies (e.g., neighborhood crime watch, lights) to enhance personal safety in areas (e.g., playgrounds, parks, bike lanes, walking paths, neighborhoods) where people are or could be physically active (e.g., walk, bike)?

Nutrition To what extent does the community:

1. Adopt strategies to encourage food retailers (e.g., grocery, corner or convenience stores; bodegas) to provide healthy food and beverage options (e.g., fresh produce) in underserved areas?

2. Encourage community garden initiatives?

3. Enhance access to public transportation (e.g., bus stops, light rail stops, van pool services, subway stations) to supermarkets and large grocery stores?

4. Connect locally grown foods to local restaurants and food venues?

5. Promote (e.g., signage, product placement, pricing strategies) the purchase of fruits and vegetables at local restaurants and food venues?

6. Institute healthy food and beverage options at local restaurants and food venues?

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7. Institute nutritional labeling (e.g., ‘low fat,’ ‘light,’ ‘heart healthy,’ ‘no trans fat’) at local restaurants and food venues?

8. Provide smaller portion sizes at local restaurants and food venues?

9. Ban local restaurants and retail food establishments from cooking with trans fats?

10. Adopt strategies to recruit supermarkets and large grocery stores in underserved areas (e.g., provide financial incentives, lower operating costs, provide job training services)?

11. Provide comfortable, private spaces for women to nurse or use a breast pump in public places (e.g., government buildings, restaurants, retail establishments) to support and encourage residents’ ability to breastfeed?

12. Protect a woman’s right to breastfeed in public places?

Tobacco

To what extent does the community:

1. Institute a smoke-free policy 24/7 for indoor public places?

2. Institute a tobacco-free policy 24/7 for indoor public places?

3. Institute a smoke-free policy 24/7 for outdoor public places?

4. Institute a tobacco-free policy 24/7 for outdoor public places?

5. Ban tobacco advertisement (e.g., restrict point-of-purchase advertising or product placement)?

6. Ban tobacco promotions, promotional offers, and prizes?

7. Regulate the number, location, and density of tobacco retail outlets?

8. Restrict the placement of tobacco vending machines (including self- service displays)?

9. Enforce the ban of selling single cigarettes?

10. Increase the price of tobacco products and generate revenue with a portion of the revenue earmarked for tobacco control efforts (e.g., taxes, mitigation fees)?

11. Provide access to a referral system for tobacco cessation resources and services?

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Chronic Disease Management To what extent does the community:

1. Enhance access to chronic disease self-management programs (e.g., Weight Watchers for overweight/obesity)?

2. Adopt strategies to educate its residents on the importance of obesity prevention?

3. Adopt strategies to educate its residents on the importance of controlling high blood pressure?

4. Adopt strategies to educate its residents on the importance of controlling cholesterol?

5. Adopt strategies to educate its residents on the importance of controlling blood sugar or insulin levels?

6. Adopt strategies to educate its residents on heart attack and stroke symptoms and when to call 9-1-1?

7. Adopt strategies to educate its residents on the importance of preventive care?

8. Provide emergency medical services (e.g., 9-1-1, transport system)?

9. Adopt strategies to address chronic disease health disparities?

Leadership

To what extent does the community:

1. Participate in community coalitions and partnerships (e.g., food policy council, tobacco-free partnership, neighborhood safety coalition) to address chronic diseases and associated risk factors?

2. Participate in the public policy process to highlight the need for community changes to prevent and reduce chronic disease risk factors (e.g., poor nutrition, physical inactivity, tobacco use and exposure)?

3. Finance public shared-use paths or trails (by passing bonds, passing mileages, levying taxes or getting grants)?

4. Finance public recreation facilities (by passing bonds, passing mileages, levying taxes or getting grants)?

5. Finance public parks or greenways (by passing bonds, passing mileages, levying taxes or getting grants)?

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6. Finance public sports facilities (by passing bonds, passing mileages, levying taxes or getting grants)?

7. Finance pedestrian enhancements (e.g., sidewalks, street crossing enhancements)?

8. Finance bicycle enhancements (e.g., bike lanes, bike parking, road diets)?

9. Address the community’s operating budget to make walking, bicycling, or other physical activities a priority?

10. Promote mixed land use through regulation or other incentives?

11. Institute a management program to improve safety within the transportation system?

Community Institution/Organization Sector Demographic 1. Best description of the community setting: rural, suburban, urban

2. Median household income in the community: insert range here

3. Sector type: private, public

4. Profit type: for-profit, not-for-profit

5. Target population: children/youth* (ages: <18), adults (ages: 18-64), seniors/older adults (ages: 65+), other. *If serving children/youth, what grades are being served: preschool, elementary school, middle school, high school

6. Type of institution/organization: senior center, faith-based organization, daycare center, boys and girls club, health and wellness center, university/college, other

Physical Activity

To what extent does the community institution/organization: 1. Promote stairwell use (e.g., make stairs appealing, post motivational

signs near stairs to encourage physical activity)?

2. Provide a safe area outside (e.g., through lighting, signage, crime watch) to walk or be physically active?

3. Designate a walking path on or near building property?

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4. Encourage nonmotorized commutes (e.g., active transportation such as walk or bike) to the facility?

5. Enhance access to public transportation (e.g., bus stops, light rail stops, van pool services, subway stations) within reasonable walking distance?

6. Provide access to onsite fitness center, gymnasium, or physical activity classes?

7. Provide a changing room or locker room with showers?

8. Provide bicycle parking (e.g., bike rack, shelter) for patrons?

9. Provide access to a broad range of competitive and noncompetitive physical activities that help to develop the skills needed to participate in lifetime physical activities?

10. Provide opportunity for unstructured play or leisure-time physical activity?

11. Prohibit using physical activity as a punishment?

12. Restrict screen time to less than 2 hours per day for children over 2 years of age?

13. Provide direct support (e.g., money, land, pavilion, recreational facilities, sponsorship, advertising) for supporting community-wide physical activity opportunities (e.g., sports teams, walking clubs)?

Nutrition

To what extent does the community institution/organization:

1. Institute health food and beverage options in vending machines?

2. Institute healthy food and beverage options at institution-sponsored meetings and events?

3. Institute healthy food and beverage options in onsite cafeteria and food venues?

4. Institute healthy food purchasing (e.g., to reduce the caloric, sodium, and fat content of foods offered) for cafeteria and onsite food venues?

5. Institute healthy food preparation practices (e.g., steaming, low fat, low salt, limiting frying) in onsite cafeteria and food venues?

6. Institute pricing strategies that encourage the purchase of healthy food and beverage options?

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7. Ban marketing (e.g. counter advertisements, posters, other print materials) of less than healthy foods and beverages onsite?

8. Provide smaller portion sizes in onsite cafeteria and food venues?

9. Institute nutritional labeling (e.g., ‘low fat,’ ‘light,’ ‘heart healthy,’ ‘no trans fat’) at onsite cafeteria and food venues?

10. Provide safe, unflavored, cool drinking water at no cost to patrons?

11. Prohibit using food as a reward or punishment?

12. Provide direct support (e.g., money, land, pavilion, sponsorship, advertising) for supporting community-wide nutrition opportunities (e.g., farmers’ markets, community gardens)?

13. Provide a comfortable, private space for women to nurse or pump to support and encourage patrons’ ability to breastfeed?

Tobacco

To what extent does the community institution/organization:

1. Institute a smoke-free policy 24/7 for indoor public places?

2. Institute a tobacco-free policy 24/7 for indoor public places?

3. Institute a smoke-free policy 24/7 for outdoor public places?

4. Institute a tobacco-free policy 24/7 for outdoor public places?

5. Ban tobacco vending machine sales (including self-service displays)?

6. Ban tobacco promotions, promotional offers, and prizes?

7. Ban tobacco advertisement (e.g., restrict point-of-purchase advertising or product placement)?

8. Implement a referral system to help patrons to access tobacco cessation resources and services

Chronic Disease Management:

To what extent does the community institution/organization:

1. Provide access to chronic disease self-management programs (e.g., Weight Watchers for overweight/obesity)?

2. Provide access to an onsite nurse?

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3. Provide an onsite medical clinic to monitor and address chronic diseases and related risk factors (e.g., high blood pressure, high cholesterol, elevated blood sugar levels)?

4. Provide routine screening, follow-up counseling and education to patrons to help address chronic diseases and related risk factors (e.g., poor nutrition, physical inactivity, hypertension, high cholesterol, elevated blood sugar levels, tobacco use and exposure)?

5. Adopt curricula or training to raise awareness of the signs and symptoms of heart attacks and strokes?

6. Adopt curricula or training to raise awareness of the importance of calling 9-1-1 immediately when someone is having a heart attack or stroke?

7. Promote chronic disease prevention to patrons (e.g., post signs reminding patrons to get blood pressure checked, quit smoking, or avoid secondhand smoke)?

8. Have an emergency response plan (e.g., appropriate equipment such as Automatic External Defibrillator, instructions for action) in place?

Leadership

To what extent does the community institution/organization:

1. Provide incentives to patrons participating in chronic disease prevention measures (e.g., quit smoking, log miles walked, obtain blood pressure or cholesterol screening)?

2. Participate in the public policy process to highlight the need for community changes to address chronic diseases and related risk factors (e.g., poor nutrition, physical inactivity, tobacco use and exposure)?

3. Have a wellness coordinator?

4. Have a wellness committee?

5. Have a health promotion budget?

6. Have a mission statement (or a written policy statement) that includes the support of or commitment to patron health and well-being?

7. Implement a needs assessment when planning a health promotion program?

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8. Evaluate health promotion programs?

9. Provide opportunities for patron feedback (e.g., interest, satisfaction, adherence) about health promotion programs?

10. Participate in community coalitions and partnerships (e.g., food policy council, tobacco-free partnership, neighborhood safety coalition) to address chronic diseases and related risk factors (e.g., poor nutrition, physical inactivity, tobacco use and exposure)?

Health Care Sector

Demographic

1. Number of staff: fewer than 20, 20 – 99, 100 – 249, 250 – 499, 500 – 999, 1,000 – 1,499, 1,500+

2. Type of health care organization: medical/physician office, clinic, hospital, ambulatory care, home health agency, Health Maintenance Organization (HMO), local health department, Federally Qualified Health Center (FQHC), other

3. Number of patients:

a. average number of patients on monthly basis

4. Sector type:

a. private, b. public

5. Profit type:

a. for-profit, b. not-for-profit

Physical Activity

To what extent does the health care facility:

1. Promote stairwell use (e.g., make stairs appealing, post motivational signs near stairs to encourage physical activity) to patients, visitors, and staff?

2. Assess patients’ physical activity as part of a written checklist or screening used in all routine office visits?

3. Provide regular counseling about the health value of physical activity during all routine office visits?

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4. Implement a referral system to help patients’ access community-based resources or services for physical activity?

Nutrition

To what extent does the health care facility:

1. Implement breastfeeding initiative for future or current moms?

2. Assess patients’ nutrition as part of a written checklist or screening used in all routine office visits?

3. Provide free or low cost weight management or nutrition programs?

4. Provide regular counseling about the health value of good nutrition during all routine office visits?

5. Provide free or low cost weight management or nutrition programs?

6. Implement a referral system to help patients to access community- based resources or services for nutrition?

7. Institute healthy food and beverage options in vending machines?

8. Institute healthy food and beverage options served to their patients?

9. Institute healthy food and beverage options in the onsite cafeteria and food venues?

10. Institute pricing strategies that encourage the purchase of healthy food and beverage options?

11. Institute healthy food purchasing (e.g., to reduce the caloric, sodium, and fat content of foods offered) for cafeteria and onsite food venues?

12. Institute healthy food preparation practices (e.g., steaming, low fat, low salt, limiting frying) in onsite cafeteria and food venues?

13. Institute nutritional labeling (e.g., ‘low fat,’ ‘light,’ ‘heart healthy,’ ‘no trans fat’) at the onsite cafeteria and food venues?

14. Ban marketing (e.g., counter advertisements, posters, other print materials) of less than healthy foods and beverages onsite?

15. Provide smaller portion sizes in onsite cafeteria and food venues?

Tobacco

To what extent does the health care facility:

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1. Institute a smoke-free policy 24/7 for indoor public places?

2. Institute a tobacco-free policy 24/7 for indoor public places?

3. Institute a smoke-free policy 24/7 for outdoor public places?

4. Institute a tobacco-free policy 24/7 for outdoor public places?

5. Assess patients’ tobacco use as part of written checklist or screening used in all routine office visits?

6. Assess patients’ exposure to tobacco smoke as part of written checklist or screening used in all routine office visits?

7. Provide advice and counseling about the harm of tobacco use and exposure during all office visits?

8. Implement a referral system to help patients to access tobacco cessation resources and services?

9. Provide access to free or low cost pharmacological quitting aids for their patients?

10. Implement a provider-reminder system to assess, advise, track, and monitor tobacco use?

Chronic Disease Management

To what extent does the health care facility:

1. Implement a referral system to help patients to access community- based resources or services for chronic disease management?

2. Provide routine follow-up counseling and education to patients to help address chronic diseases and related risk factors (e.g., poor nutrition, physical inactivity, hypertension, high cholesterol, elevated blood sugar levels, tobacco use and exposure)?

3. Provide screening for chronic diseases in adults with risk factors (e.g., poor nutrition, physical inactivity, hypertension, high cholesterol, elevated blood sugar levels, tobacco use and exposure)?

4. Measure weight and height, and calculate appropriate body mass index (BMI) for every patient at each visit?

5. Adopt a plan or process to increase patient adherence to chronic disease (e.g., cardiovascular disease, diabetes) treatment?

6. Institute a systematic approach to the processes of diabetes care?

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7. Institute the latest emergency heart disease and stroke treatment guidelines (e.g., Joint National Committee 7, American Heart Association)?

8. Provide access to resources and training for using a stroke rating scale?

9. Provide specialized stroke care units?

10. Provide specialized heart disease units?

Leadership

To what extent does the health care facility:

1. Participate in community coalitions and partnerships (e.g., food policy council, tobacco-free partnership, neighborhood safety coalition) to address chronic diseases and related risk factors (e.g., poor nutrition, physical inactivity, tobacco use and exposure)?

2. Participate in the public policy process to highlight the need for community changes to address chronic diseases and related risk factors (e.g., poor nutrition, physical inactivity, tobacco use and exposure)?

3. Enhance access to childhood overweight prevention and treatment services to reduce health disparities?

4. Promote high standards of modifiable risk factor (e.g., poor nutrition, physical inactivity, tobacco use and exposure) practice to healthcare and provider associations?

5. Institute standardized treatment and prevention protocols that are consistent with national evidence-based guidelines to prevent heart disease, stroke, and related risk factors?

6. Institute an electronic medical records system and patient data registries to provide immediate feedback on a patient’s condition and compliance with the treatment regimen?

7. Adopt the Chronic Care Model in hospitals?

8. Provide patient services using provider care teams that cross specialties (e.g., physician/ pharmacist teams)?

9. Provide access to medical services outside of regular working hours (e.g., late evenings, weekends)?

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10. Promote collaboration between health care professionals (e.g., physicians and specialists) for managing chronic diseases (e.g., cardiovascular disease, diabetes)?

11. Partner with community agencies to provide free or low cost chronic disease health screenings, follow-up counseling, and education for those at risk?

12. Institute annual cultural competence training for all health workers for optimal care of all patients (regardless of their race/ethnicity, culture, or background)?

School Sector

Demographic

1. Total # of students served

2. School level: elementary, middle, high (specify grades)

3. Type of school: private, public, parochial

4. Best description of the setting of the school: rural, suburban, urban

5. Percentage (%) of students receiving free or reduced price lunch

6. Median household income of the students in this school: insert amount here

District

To what extent does the district:

1. Require 225 minutes per week of physical education for all middle school and high school students?

2. Require 150 minutes per week of physical education for all elementary school students?

3. Provide 20 minutes of recess daily for students in elementary school?

4. Ensure that students are not provided waivers or exemptions from participation in physical education for other school and community activities such as band, chorus, Reserve Officers’ Training Corps (ROTC), sports participation, or community volunteering?

5. Require that either fruits or vegetables or both are available wherever foods and beverages are offered?

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6. Eliminate the sale and distribution of less than healthy foods and beverages during the school day?

7. Prohibit the sale of sugar-sweetened beverages (can exclude flavored, fat-free milk) during the school day?

8. Institute a tobacco-free policy 24/7?

9. Ban tobacco advertising on school property, at school events, and in written educational materials and publications?

10. Ban tobacco promotions, promotional offers, and prizes on school property, at school events, and in written educational materials and publications?

11. Ensure access to a full-time, qualified health care provider (e.g., registered school nurse) in every school?

12. Establish a case management plan for students with identified chronic diseases or conditions (e.g., asthma, diabetes, epilepsy) in consultation with their families, medical providers, and school staff?

13. Ensure immediate and reliable access to prescribed medications (e.g., inhaler, insulin, epinephrine pen) for chronic disease management throughout school day?

14. Have a district health group (e.g., school health council) composed of school personnel, parents, students, and community partners that help plan and implement district health activities?

15. Have a designated school health coordinator who is responsible for overseeing school health activities across the district?

16. Monitor schools’ compliance with the implementation of the district school wellness policy enacted as a result of the Child Nutrition and WIC Reauthorization Act of 2004 (i.e., requires that all school districts that participate in the National School Lunch Program have local wellness policies)?

17. Allow the use of school buildings and facilities by the public during nonschool hours (e.g., joint use agreement)?

18. Adopt a physical education curriculum for all students in grades pre-K to grade 12 as part of a sequential physical education course of study consistent with state or National Physical Education Standards?

19. Adopt a nutrition education curriculum, designed to help students adopt healthy eating behaviors for all students in grades pre-K to grade

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12 as part of a sequential health education course of study, consistent with state or National Health Education Standards?

20. Adopt a tobacco-use prevention curriculum for all students in grades pre-K to grade 12 as part of a sequential health education course of study consistent with state or National Health Education Standards?

21. Require that students are physically active during the majority of time in physical education class?

Physical Activity

To what extent does the school:

1. Ban using or withholding physical activity as a punishment?

2. Require that students are physically active during the majority of time in physical education class?

3. Ban using or withholding physical activity as a punishment?

4. Require that students are physically active during the majority of time in physical education class?

5. Provide access to a broad range of competitive and noncompetitive physical activities that help to develop the skills needed to participate in lifetime physical activities?

6. Implement a walk or bike to school initiative?

7. Ensure the availability of proper equipment and facilities (including playground equipment, physical activity equipment, and athletic or fitness facilities) that meet safety standards?

Nutrition

To what extent does the school:

1. Ensure that students are provided only healthy food and beverage options beyond the school food services (e.g., all vending machines, school stores, and food brought for celebrations)?

2. Institute school breakfast and lunch programs that meet the U.S. Department of Agriculture School Meal Nutrition Standards?

3. Ensure that healthy food preparation practices (e.g., steaming, low fat, low salt, limited frying) are always used in the school cafeteria or onsite food services?

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4. Ban marketing (e.g., counter advertisements, posters, other print materials) of less than healthy foods and beverages onsite?

5. Promote and market (e.g., through counter advertisements, posters, or other print materials) only healthy food and beverage options?

6. Provide adequate time to eat school meals (10 minutes for breakfast/20 minutes for lunch, from the time students are seated)?

7. Ban using food as a reward or punishment for academic performance or behavior?

8. Provide safe, unflavored, cool drinking water throughout the school day at no cost to students?

9. Provide school garden (e.g., access to land, container gardens, or raised beds) and related resources (e.g., staff volunteer time, financial incentives)?

10. Ensure that multiple channels including classroom, cafeteria, and communications with parents are used to promote healthy eating behaviors?

Tobacco

To what extent does the school:

1. Implement a referral system to help students to access tobacco cessation resources or services?

Chronic Disease Management

To what extent does the school:

1. Provide access to chronic disease self-management education programs to individuals identified with chronic diseases or conditions (e.g., diabetes, asthma)?

2. Meet the nutritional needs of students with special health care or dietary requirements (e.g., allergies, diabetes, physical disabilities)?

3. Provide access to chronic disease self-management education programs to individuals identified with chronic diseases or conditions (e.g., diabetes, asthma)?

4. Meet the nutritional needs of students with special health care or dietary requirements (e.g., allergies, diabetes, physical disabilities)

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5. Provide opportunities to raise awareness among students of the signs and symptoms of heart attack and stroke?

6. Ensure students are aware of the importance of calling 9-1-1 for emergencies?

7. Ensure cardiopulmonary resuscitation (CPR) training is made available to students?

8. Engage families in the development of school plans (e.g., school diabetes management plans) to effectively manage students with chronic diseases or conditions?

Leadership

To what extent does the school:

1. Participate in community coalitions and partnerships (e.g., food policy council, tobacco-free partnership, neighborhood safety coalition) to address chronic diseases and related risk factors (e.g., poor nutrition, physical inactivity, tobacco use and exposure)?

2. Participate in the public policy process to highlight the need for community changes to address chronic diseases and related risk factors (e.g., poor nutrition, physical inactivity, tobacco use and exposure)?

3. Have a school building health group (e.g., school health committee) composed of school personnel, parents, students, and community partners that help plan and implement the health activities at the school building?

4. Have an individual who is responsible for leading school health activities within the school building?

5. Have a health promotion budget?

6. Have a written mission or position statement that includes the commitment to student health and well-being?

7. Recruit teachers (e.g., physical education, health) with appropriate training, education, and background?

8. Provide training and support to food service and other relevant staff to meet nutrition standards for preparing healthy meals?

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9. Provide access to opportunities for professional development or continued education to staff (e.g., physical education, health, school nurse, food service manager)?

10. Provide training for all teachers and staff on school physical activity, nutrition, and tobacco prevention policies?

11. Permit only health-promoting fund raising efforts such as non-food options or only healthy food and beverage options, physical activity- related options (e.g., fun-run), or community service options (e.g., car wash, directing parking at school events)?

After School

To what extent does the after school program:

1. Ban using or withholding physical activity as a punishment?

2. Ban using food as a reward or punishment for academic performance or behavior?

3. Provide access to physical activity programs (e.g., intramural, extracurricular, interscholastic)?

4. Ensure appropriate active time during after school programs or events?

5. Institute healthy food and beverage options during after school programs or events?

6. Prohibit the sale of sugar-sweetened beverages outside of school hours?

Work Site Sector

Demographic

1. Number of employees: fewer than 20, 20 – 99, 100 – 249, 250 – 499, 500 – 999, 1,000 – 1,499, 1,500+

2. Type of work site: retail sales, bank or credit union, restaurant/food service, hotel/motel, auto/repair shop, gas station or convenience store, pharmacy or drug store, grocery store/food market, manufacturing, factory, warehouse, construction, school/educational institution, faith-based institution, health care (e.g., clinic, hospital, medical practice), government, other

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3. Sector type: private, public

4. Profit type: for-profit, not-for-profit

Physical Activity

To what extent does the work site:

1. Promote stairwell use (e.g., make stairs appealing, post motivational signs near stairs to encourage physical activity)?

2. Provide flexible work arrangements or break times for employees to engage in physical activity?

3. Encourage nonmotorized commutes (e.g., active transportation such as walk or bike) to work?

4. Enhance access to public transportation (e.g., bus stops, light rail stops, van pool services, subway stations) within reasonable walking distance?

5. Support clubs or groups (e.g., walking, biking, hiking) to encourage physical activity among employees?

6. Provide a safe area outside (e.g., through lighting, signage, crime watch) to walk or be physically active?

7. Designate a walking path on or near building property?

8. Provide access to onsite fitness center, gymnasium, or physical activity classes?

9. Provide a changing room or locker room with showers?

10. Provide access to offsite workout facility or subsidized membership to local fitness facility?

11. Provide bicycle parking (e.g., bike rack, shelter) for employees?

12. Implement activity breaks for meetings that are longer than one hour?

13. Provide direct support (e.g., money, land, pavilion, recreational facilities, sponsorship, advertising) for supporting community-wide physical activity opportunities (e.g., sports teams, walking clubs)?

Nutrition

To what extent does the work site:

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1. Institute healthy food and beverage options at company-sponsored meetings and events?

2. Institute healthy food and beverage options in vending machines?

3. Institute healthy food and beverage options in onsite cafeteria and food venues?

4. Institute healthy food purchasing practices (e.g., to reduce the caloric, sodium, and fat content of foods offered) for onsite cafeteria and food venues?

5. Institute healthy food preparation practices (e.g., steaming, low fat, low salt, limiting frying) in onsite cafeteria and food venues?

6. Ban marketing (e.g., counter advertisements, posters, other print materials) of less than healthy foods and beverages onsite?

7. Provide smaller portion sizes in onsite cafeteria and food venues?

8. Provide safe, unflavored, cool drinking water at no cost to employees?

9. Institute nutritional labeling (e.g., ‘low fat,’ ‘light,’ ‘heart healthy,’ ‘no trans fat’) at the work site’s cafeteria and onsite food service?

10. Institute pricing strategies that encourage the purchase of healthy food and beverage options?

11. Institute a smoke-free policy 24/7 for indoor public places?

12. Provide refrigerator access for employees?

13. Provide microwave access for employees?

14. Provide a sink with water faucet access for employees?

15. Provide direct support (e.g., money, land, a pavilion, sponsorship, donated advertising) for community-wide nutrition opportunities (e.g., farmers’ markets, community gardens)?

16. Support breastfeeding by having maternity care practices, including providing a comfortable, private space for employees to nurse or pump?

Tobacco

To what extent does the work site:

1. Institute a smoke-free policy 24/7 for indoor public places?

2. Institute a tobacco-free policy 24/7 for indoor public places?

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3. Institute a smoke-free policy 24/7 for outdoor public places?

4. Institute a tobacco-free policy 24/7 for outdoor public places?

5. Ban tobacco vending machine sales (including self-service displays)?

6. Provide insurance coverage for tobacco cessation services?

7. Provide insurance coverage for tobacco cessation products (e.g., pharmacological quitting aids, medicines)?

8. Ban tobacco promotions, promotional offers, and prizes?

9. Ban tobacco advertisement (e.g., restrict point-of-purchase advertising or product placement)?

10. Implement a referral system to help employees to access tobacco cessation resources or services, such as a quitline (e.g., 1-800-QUIT- NOW)?

Chronic Disease Management

To what extent does the work site:

1. Provide routine screening, follow-up counseling and education to employees to help address chronic diseases and related risk factors (e.g., poor nutrition, physical inactivity, hypertension, high cholesterol, elevated blood sugar levels, tobacco use and exposure)?

2. Provide access to an onsite occupational health nurse?

3. Provide an onsite medical clinic to monitor and address chronic diseases and related risk factors (e.g., high blood pressure, high cholesterol, elevated blood sugar levels)?

4. Provide paid time off to attend health promotion programs or classes?

5. Provide employee insurance coverage for preventive services and quality medical care?

6. Provide access to a free or low cost employee health risk appraisal or health screenings?

7. Provide access to chronic disease self-management programs (e.g., Weight Watchers for overweight/obesity)?

8. Adopt curricula or training to raise awareness of the signs and symptoms of heart attacks and strokes?

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9. Adopt curricula or training to raise awareness of the importance of calling 9-1-1 immediately when someone is having a heart attack or stroke?

10. Promote chronic disease prevention (e.g., post signs reminding employees to get blood pressure checked, quit smoking, or avoid secondhand smoke) to employees?

11. Adopt an emergency response plan (e.g., appropriate equipment such as Automatic External Defibrillator, instructions for employee action)?

Leadership

To what extent does the work site:

1. Reimburse employees for preventive health or wellness activities?

2. Participate in the public policy process to highlight the need for community changes to address chronic diseases and related risk factors (e.g., poor nutrition, physical inactivity, tobacco use and exposure)?

3. Have a wellness coordinator?

4. Have a wellness committee?

5. Have a health promotion budget?

6. Have a mission statement (or a written policy statement) that includes the support of or commitment to employee health and well-being?

7. Adopt organizational or performance objectives pertaining to employee health and well-being?

8. Provide employees with a health insurance plan?

9. Provide office-based incentives (e.g., discounted insurance premium, gift certificates) to employees participating in health risk assessments, initiatives, or support groups that promote chronic disease prevention measures (e.g., quit smoking, log miles walked, obtained blood pressure or cholesterol screening)?

10. Implement a needs assessment when planning a health promotion program?

11. Evaluate company-sponsored health promotion programs?

12. Provide opportunities for employee feedback (e.g., employee interest, satisfaction, adherence) about health promotion programs?

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13. Participate in community coalitions and partnerships (e.g., food policy council, tobacco-free partnership, neighborhood safety coalition) to address chronic diseases and related risk factors (e.g., poor nutrition, physical inactivity, tobacco use and exposure)?

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APPENDIX C The following are the worksheets used in this workbook. Policy, Systems and Environmental Change Strategies Worksheet

ASSETS NEEDS

Strategies:

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Prioritizing Strategies Worksheet Strategy Time

(1-5) Resources

(1-5) Competing Priorities

(1-5)

Total (T x R x C)

Rank

Community Action Plan

Policy/Environmental Change Strategy

Project Period Objective Community Component(s)

Annual Objective(s): Sector(s) No. of People Reached

Activities Person Responsible Timeline