Assess the Health of the Population

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A population health improvement initiative typically begins with a thorough assessment. Partners identify needs and resources for specific populations by gathering and analyzing two kinds of data:

  • Quantitative data - information that can be measured in numbers and may indicate prevalence and trends. Because it can be measured in numbers, this type of data lends credibility to your assessment.
  • Qualitative data - information that is non-numeric. It can help with understanding the “why and how” of a population’s health status. Qualitative data can be gathered from surveys, focus groups, key informant interviews, environmental scans, and asset mapping.

Data and tools are included in the Resources at the end of this webpage, including the Washington State Health Assessment and an evidence based Guide to Effective Focus Groups.

Health Equity and the Social Determinants of Health

It’s essential to pay attention to health equity and the social determinants of health. Learn more by expanding the options below.

Health Equity

What is health equity and why is it important to population health?

Health equity means equal access to health (not just health care) for all members of our population. Partners will need to be alert to the unique strengths and vulnerabilities of subpopulations within a patient panel or geographic region.

The Guide offers data and resources on health equity concerns specific to several priority health issues. In addition, the resources below offer guidance on applying a health equity lens to population health:

Department of Health’s website provides health equity definitions, literature and a Tool for Policy Planning.

Washington Health Alliance 2016 Disparities in Care Report offers information on disparities in care among minority populations in Washington State.

American Indian Health Commission (AIHC). A unique aspect to working with tribal partners is the sovereignty of American Indian and Alaska Native (AIAN) nations, and operating within the government-to-government relationship. Other important considerations include the overlap of tribal boundaries with health system regions, and the needs of the urban Indian population as Assess the Health of the Population contrasted with those living on reservations. New AIHC resource: Tribal Services Profile, providing geographic and demographic details along with information about health care and community services.

Foundation for Healthier Generations provides information on some of the nuances of health equity, including how it intersects with social determinants of health such as housing and employment.

The Centers for Disease Control and Prevention offers health equity resources about chronic disease prevention and health promotion. The site includes links to health equity information on specific physical and behavioral health issues.

Social Determinants of Health

According to Healthy People 2020, social determinants of health are conditions in which people live their lives that impact health and quality of life. These conditions are both physical and social.

How clean is the air? How safe are the streets? What about housing? Employment? These are all factors in population health and are important to consider when conducting an assessment. For example, if your community is focusing on prevalence of obesity and diabetes, are you also tracking access to healthy food and physical activity?

The Washington State Health Assessment includes a section and Social and Economic Determinants of Health, and social determinants data is included in data gathered by the Washington Tracking Network.


Challenge: National or state data may not reflect your community, and local data may not be available.

Try: Engage community partners in local surveys, key informant interviews, and focus groups. If you have a nearby community college or university, contact a health occupations or sociology instructor to see if gathering local data could be a class or individual student project. For tools on gathering good qualitative data, see the Assessment Tools at the bottom of this page.


Challenge: Available data, even when local, may not provide enough data for a subpopulation.

Try: Reach out to local schools and nonprofit organizations. They may have data available and/or be able to help gather it. Explore grant and philanthropic funding to support the data gathering. Also, let your local health jurisdictions and tribal governments know what your data needs are. Your input can help their data teams plan future state and local assessments. 

Give us your feedback and we will share with appropriate local and state data stewards. Send comments to


Challenge: Data may not adequately reflect social determinants.

Try: Resources such as the Washington Tracking Network (link below) can help. Also, local government and community partners may have qualitative data to provide. Some communities have engaged partners and volunteers in Photovoice (described in Assessment Tools below) projects, to capture social determinant information in a way that can drive policy change.


Data Sources

Health-related data at the state and county level, primarily quantitative

Assessment Tools

Tools to help you gather information, including qualitative data