Assess Community and Population

Population health assessments look at whole populations and groups within that whole. Collaborating partners look at indicators of health status, health equity, and factors and environments that influence health, often referred to as the social determinants of health.  

Below are some recommended steps to help ensure your assessment provides quality information.

  • Engage communities and partners
    • Maximize opportunities created by the way health care, public health, and community partners are working together in new ways to improve health outcomes and lower costs.
    • Engage diverse organizations and individuals at the assessment stage, and keep them engaged throughout the process.

Tools to help with community engagement are included in the Resources section below.

  • Gather and analyze data, including
    • Quantitative data - information that can be measured in numbers and may indicate prevalence and trends. 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.

The Resources section offers sources of quantitative data and tools for gathering qualitative data.

  • Review research, including scientific literature, related to health issues that surface
  • Identify community strengths and resources that can help address identified problems

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

Attention to health equity and the social determinants of health makes for a stronger plan. 

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 specific populations 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.

Addressing 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? Do people have access to adequate housing and 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 a prevalence of obesity and diabetes, are you also tracking access to healthy food and physical activity?

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