Community as client (or partner). In community health nursing, the "client" is the whole community or a population within it. Its health is judged by population measures (mortality, morbidity, risk behaviors, access to care) and by the community's ability to solve its own problems. Working with residents, not just for them, is the modern standard.

Types of community

• Geographic (geopolitical): defined by boundaries — a county, city, census tract, or school district.
• Community of interest (phenomenological): shared identity or interest — a faith group, people with diabetes, farmworkers.
• Community of solution: people and agencies that come together to solve a shared problem (for example, several towns sharing one watershed).

Community assessment is the systematic collection and analysis of data to identify a community's health needs (problems) and strengths (assets and resources). Its purpose is to provide the basis for community diagnosis and program planning.

Types of assessment

• Comprehensive: broad look at the whole community.
• Problem-oriented: focused on one known problem (for example, teen vaping).
• Familiarization: getting to know a community through existing data and observation.
• Subsystem or single-population: focused on one sector (schools) or group (older adults).

Data types

Data collection methods

• Windshield survey: driving or walking through the area to observe housing, businesses, transportation, services, people, and signs of decay or vitality.
• Key informant interview: talking with people who know the community (faith leaders, school principals, business owners, elected officials).
• Focus group: facilitated discussion with a small group (usually 6–12) sharing a characteristic.
• Participant observation: joining community events and activities.
• Surveys: questionnaires to a sample of residents for health status, behaviors, and perceptions (best for residents' own health levels and lifestyle).
• Asset mapping: listing and mapping skills of individuals, associations, and institutions.

Community-as-Partner model (Anderson and McFarlane). Based on Neuman's systems model. The community core is the people: history, demographics, ethnicity, and values and beliefs. It is surrounded by eight subsystems:

The model also considers lines of defense and resistance (the community's strengths) and stressors that threaten its balance, and it links assessment to the nursing process.

MAPP 2.0 (Mobilizing for Action through Planning and Partnerships), NACCHO, released 2023. A community-driven framework for community health assessment and improvement planning, with equity at the center.

• Phase 1 — Build the community health improvement foundation: convene partners, shared vision and mission.
• Phase 2 — Tell the community story: three assessments — Community Partner Assessment (the partners and their capacity), Community Status Assessment (quantitative data on health and its determinants), and Community Context Assessment (qualitative data on community strengths, assets, and lived experience).
• Phase 3 — Continuously improve the community: prioritize issues, develop and implement the community health improvement plan (CHIP), and monitor progress.

Related US requirements

• Local and state health departments seeking national accreditation from the Public Health Accreditation Board (PHAB) must complete a community health assessment (CHA) and community health improvement plan (CHIP).
• Nonprofit hospitals must conduct a Community Health Needs Assessment (CHNA) at least every 3 years and adopt an implementation strategy to keep federal tax-exempt status (Affordable Care Act, Internal Revenue Code section 501(r)).

Community diagnosis. A statement of the community health problem that guides planning. A common format:

Risk of [problem] among [population] related to [etiology or contributing factors] as demonstrated in [data or indicators].

Example: "High rate of fall-related hip fractures among adults 65 and older in the East District related to unsafe home environments and limited exercise programs, as demonstrated in a fracture rate twice the county average, in a district where 25% of residents are aged 65 or older."

Use "risk of" when the problem may develop; when the problem already exists, state it directly (for example, "Increased ..." or "High rate of ...").

Components: the population (client), the problem, the related factors (etiology), and supporting evidence (indicators) that prove the problem exists. Community diagnoses may also be wellness (strength-based) statements.

The Omaha System is a standardized classification used in community and home health, with a Problem Classification Scheme (four domains: environmental, psychosocial, physiological, health-related behaviors), an Intervention Scheme, and a Problem Rating Scale for Outcomes.

Setting priorities among problems

• Criteria commonly used: size (prevalence, incidence), seriousness (mortality, disability, cost, urgency), community concern, feasibility and available resources, effectiveness of possible interventions, and fit with policy. The nurse's personal interest is not a criterion.
• Hanlon method (Basic Priority Rating System, BPRS): Priority score = (A + 2B) × C, where A = size of the problem (0–10), B = seriousness (0–10, counted twice), and C = effectiveness of available interventions (0–10). A PEARL test (Propriety, Economics, Acceptability, Resources, Legality) screens out problems that cannot be addressed; a "no" on any item removes the problem from action for now.
• PATCH (CDC's Planning Approach to Community Health) ranks problems by importance and changeability; high-importance, high-changeability problems come first.

Steps

1. Define the community and engage partners and residents from the start.
2. Gather secondary data first (census, vital statistics, BRFSS, County Health Rankings), then fill gaps with primary data.
3. Conduct a windshield survey and key informant interviews; hold focus groups with groups that are often unheard.
4. Analyze: compare local rates with state and national data and Healthy People 2030 targets; identify disparities, trends, needs, and assets.
5. Validate findings with the community.
6. Write community diagnoses and set priorities.

Worked example — Hanlon (BPRS) scores (calculated twice)

Falls rank first: moderate size but high seriousness and effective interventions. Obesity, though largest, ranks last because interventions scored low in effectiveness. Both remaining problems still need a PEARL check before action.

• Lead or join assessment teams; ensure data are accurate, current, and include underrepresented groups.
• Build trust with residents, key informants, and partner agencies.
• Analyze data for disparities and root causes (social determinants).
• Write clear, evidence-based community diagnoses and facilitate fair priority-setting.
• Share results in accessible formats (community meetings, plain-language summaries, translated materials).

• Confidentiality: survey and interview data must be de-identified; small-area data may need suppression to avoid identifying individuals.
• Informed and voluntary participation in surveys and focus groups; if results will be published as research, IRB review may be needed.
• Respect and justice: avoid deficit-only portrayals; include assets; involve the community in interpreting and owning findings.
• Language access: federal civil rights law (Title VI of the Civil Rights Act) requires recipients of federal funds to provide meaningful access to people with limited English proficiency.
• Accountability: accredited health departments and nonprofit hospitals have formal requirements for CHA/CHIP or CHNA; documentation must be accurate.

Case 1 — Best data source. A nurse wants to know residents' exercise habits and how they perceive their own health.

Correct action: collect primary data by survey or interview. Why: behaviors and perceptions are best obtained directly from residents; secondary data may be absent or outdated at the local level.

Case 2 — First step. A nurse notices that the local youth smoking rate is above the national average and wants to write a diagnosis.

Correct action: first gather more assessment data on contributing factors (access, school policies, peer norms, retail density). Why: a diagnosis needs etiology and evidence; assessment comes before diagnosis.

Case 3 — Diagnosis after a water event. After a village water source is contaminated, diarrheal illness increases sharply.

Correct diagnosis: "Increased diarrheal disease among village residents related to a contaminated drinking water supply, as demonstrated in a sharp rise in diarrhea cases after the contamination event." Why: it links a specific cause with a specific problem and evidence.

• Listing only problems and ignoring community strengths and assets.
• Relying on secondary data alone; residents' perspectives are essential.
• Treating the windshield survey as a complete assessment — it is a starting point.
• Treating screening participation rates as demographic data — they are health service or behavior indicators; demographic data are age structure, births, deaths, and migration.
• Writing "risk of" for a problem that is already occurring.
• Placing per-capita income under health status — it belongs to the economy subsystem.
• Writing diagnoses without a target population or supporting data.
• Choosing priorities based on the nurse's interest instead of objective criteria.
• Forgetting that in the Hanlon formula seriousness (B) is doubled.

• Community as client/partner: the population is the focus; residents are partners.
• Primary data (windshield survey, key informants, focus groups, surveys) vs. secondary data (census, vital statistics, BRFSS) — secondary data save time and cost.
• Community-as-Partner: core (history, demographics, ethnicity, values and beliefs) + 8 subsystems.
• MAPP 2.0: three phases; three assessments — Community Partner, Community Status, Community Context.
• Nonprofit hospitals: CHNA every 3 years; PHAB-accredited health departments: CHA and CHIP.
• Diagnosis: [problem, or "risk of" problem if not yet present] among [population] related to [factors] as demonstrated in [data].
• Hanlon/BPRS = (A + 2B) × C with PEARL screening; PATCH = importance × changeability.
• Assessment identifies needs and strengths; it leads to diagnosis and planning.