Population health

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1st stage – Identify and define the population that will be the focus of your DNP project or a population of interest. 

2nd stage – Explain how you conduct a preliminary needs assessment using the course materials you have read in Modules 1-3. 

2-3 paragraphs


Health Needs Assessment

Pamela J. Biernacki, DNP, FNP – C

Master’s Program Director, Assistant Professor

Department of Family and Community Health


Needs assessment: evaluation that answers
questions about the conditions your program
addresses, used to determine whether there is a
need for a new program, and to prioritize needs
within and across program areas

Key informant: Persons whose personal or
professional position gives them a perspective
on the nature and scope of a social problem


Survey: systematic collection of information from a
defined population, usually interviews or
questionnaires from a sample

Focus group: small panel of people chosen for their
knowledge or perspective on a topic of interest

Social indicator: Periodic measurements designed to
track the course of a social indicator over time



Incidence: Number of new cases over a specified

Prevalence: Number of existing cases in a specific
area at a given time

Population at risk: Individuals or units in a specified
area with characteristics judged to indicate that they
have a significant probability of having or developing
a particular condition



  Likelihood of correctly selecting the target who
should be in a program in contrast to those who
may be selected by the criterion but aren’t


  Correctly excluding people or units that don’t have
the condition of concern


Population in need: Individuals or units in a
specific area that have a particular problematic

Rate: Occurrence or existence of a particular
condition expressed as a proportion of units in
the population (eg deaths per 1,000)

Stakeholders: Have something to gain or lose
from the program



Citizen participation: mobilization of citizens to
take action to change or improve a community

Community development: creating conditions of
economic and social progress for the whole
community with its active participation and


Community participation: involving people in the
institutions or decisions that affect their lives

Empowered community: one where individuals and
organizations apply their skills and resources in an
effort to meet their needs

Grass-roots participation: Bottom-up efforts of
people taking action on their own behalf, blending
confrontation and cooperation to meet their needs

Gathering Data

Getting Started

Primary, Secondary and Combined Data


Sources of Primary Data

 From individuals

  Single step (cross-sectional, one time)

  Multi-step (contact on more than one occasion)

 Significant others

 Opinion leaders

 Key informants

Sources of Primary Data

 From groups

 Community forum

  Focus group
 Nominal group process

Few knowledgeable representatives of the target
population (5-7) qualify and quantify needs

 Self-directed assessments (health assessments)

Sources of Primary Data

 From Governmental Agencies

 US Department of Commerce
 Centers for Disease Control

  Non-governmental agencies

  Existing records



Conducting a

Needs Assessment

Purpose and Scope

Conducting a
Needs Assessment
 Decide the purpose and scope of the

 What do you want to collect?

 How extensive do you want to be?

 Gather Data

 Decide if you will use primary or secondary data, or

Conducting a
Needs Assessment
 Analyze your data

Formal or informal

“Eyeballing” your data

 Set priorities
Most critical need  

Adequate resources to manage

Is the best approach to the problem a health promotion

Can you solve the problem in a reasonable amount of time


Conducting a
Needs Assessment

In setting priorities consider:
  A: Size of the problem

Epidemiological rates


  B: Seriousness of the problem
Economic loss to the community, families, individuals

Involvement of others not initially affected (infectious disease, drugs)

Severity of the problem (morbidity, mortality, disability)

Urgency of solving problem before causes other problems

   C: Effectiveness of the intervention

  D: Determine whether an intervention can be carried out at all

Conducting a
Needs Assessment

Identify the factors linked to the health problem

 Economic factors

 Cultural factors



Conducting a
Needs Assessment

Identify the program focus

 What predisposing, enabling, and reinforcing factors exist?

What programs are available?

What programs are being used? Not used? Why?

How were those program needs determined?

Are the programs accessible?

Are needs being met?


Conducting a
Needs Assessment

Validate your prioritized needs

  Confirm that you’re doing the right thing

  Double checking

  Make sure needs assessment wasn’t biased

  Conduct a focus group with your population to confirm
your assessment

  Get a second opinion from other health care providers


Define the Elements


A locale or domain that is characterized by the following

  a sense of identity and belonging

Common symbol systems

Shared values/norms
Mutual influence
Shared needs
Shared emotional connections


Community Organizing

Recognizing the concern

  May happen inside or outside the community

Local or state health department

  VCU SON DNP Nursing Student

Grass roots, citizen initiated, bottom-up


Health System

Community Organizing

Gaining entry

  Approach on their terms, play their game

  Know the politics

  Know the power players

  May enter through an established organization



Community Organizing

Organizing the people –
  “Executive participants”

  Fairly small group

  Choose appropriate leaders

  Choose supportive people

  Choose people affected by the problem

  Identify a leader from the core group


Community Organizing

 Skills of organizers
 Change vision attributes

  Can see a need for change and are committed to
making that change

 Technical skills

  Interactional or experience skills
 Play well with others

Community Organizing

Assess the community
  Identify primary building blocks
  Most accessible assets

  Located in the neighborhood/Employment Setting

  Controlled by the neighborhood/Employment Setting

  Small businesses or $$ source

  If outside the employment setting
Local expertise

Religious organizations

Citizens’ Associations

Community Organizing

Identify secondary building blocks

  Located in the workplace (?)

  Located in the neighborhood

  Controlled outside the neighborhood

  Higher education institutions


  Public schools



Community Organizing

  Identify potential building blocks
  Resources outside the neighborhood

  Controlled by outside people

  Welfare expenditure

 Final steps
  Implement the plan

  Evaluate the outcomes

  Maintain the outcomes

  Change as needed

Needs Services

What are the nature and magnitude of the problem?

What are the characteristics of the population in

What are the needs of the population?

How much service is needed, over what time frame?

What service delivery arrangements are needed?

Program Design

What clientele should be served?

What services should be provided?

What are the best delivery systems?

How can the program identify, recruit, and sustain the
intended clientele?

How should the program be organized?

What resources are necessary and appropriate for the


Operations and Delivery

Are administrative and service objectives being met?

Are the intended people getting the intended services?

Are there needy but un-served persons the program isn’t

Do sufficient numbers use/complete services?

Are clients satisfied with services?

Are administrative, organizational, and personnel
functions handled well?


Are goals and objectives being achieved?

Do the services have beneficial effects on the

Are some recipients affected more by the service
than others?

Is the problem or situation the services address

Cost and Efficiency

Are resources used efficiently?

Is the cost reasonable in relation to benefits?

Would alternative approaches yield equivalent
benefits at less cost?


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