Community Assessment

Community Assessment

Frances A. Maurer and Claudia M. Smith

Focus Questions

Key Terms



Census tract


Community capacity

Community competence

Community resiliency



Healthy community



Population “at risk”

Target population

The community/public health nurse is concerned with the health of the individual, the family, populations, and the community (American Nurses Association [ANA], 2007). This unit focuses on applying the nursing process with the community as client. What is the role of the nurse in population-focused nursing? What does it mean to be a nurse who is responsible for the health of a community? Where does the nurse start in considering community? What is a healthy, competent community?

Healthy communities have “environmental, social, and economic conditions in which people can thrive” (Quad Council of Public Health Nursing Organizations, 1999, p. 3). A healthy community is one in which residents are happy with their choice of location and which exhibits characteristics that would draw others to the location. The majority of community residents are relatively functional for their age and health status. What are other characteristics of a healthy community? Kotchian (1995) suggested that a healthy community would be a safe community with little crime, supportive interaction between families and neighborhoods, a healthy environment (e.g., clean air, clean water, safe food), good schools, available and good quality health care services, and a sense of community cohesion. Green and Kreuter (2005) identified affordable housing and the availability of employment as prerequisites for healthy communities.

Besides these factors that immediately and obviously affect health, many social circumstances and other less tangible issues affect community living. For example, high crime rates and high levels of poverty in a neighborhood can seriously affect the health and welfare of residents. Ervin (2002) suggested that a healthy economy is key to a functional, healthy population. Although difficult to quantify, most people can identify characteristics of a healthy community that would influence their decision to reside there (Box 15-1).

Community assessment: application to community/public health nursing practice

Assessment, the first step of the nursing process, forms the foundation for determining the client’s health, regardless of whether the client is an individual, a family, or a community. Nurses gather information by using their senses, as well as their cognition, past experiences, and specific tools. These data are analyzed to make diagnoses about the community’s health status and allow the nurse to answer the question, “How healthy is this community, or what are its strengths, problems, and concerns?”

The assessment process affords nurses the opportunity to experience what it is like to be in the community, to get to know its people and their strengths and problems, and to work with them in planning and implementing programs to meet their unique needs. Just as all individuals and families are different, communities, too, are different. What makes one community different from another? To understand, nurses must get to know the community, its people, its purpose, and how it functions. Assessment tools provide a framework, a method of systematically gathering important information to help the nurse and other health care professionals know the community.

How does the nurse become acquainted and familiar with a community? One way is to read about a community through newspapers, community histories, and objective statistical reports. Another way is to visit the community, talk to the people, and attend meetings—that is, be with the people. A visit to or a walk or a drive through the community provides a feel for the community that cannot be obtained from just reading about it. The walk or drive-through is frequently referred to as a windshield survey. Being in the community allows the nurse to subjectively experience a community and to learn how community members experience their community.

Take a moment to reflect on this scene:

You are driving down a city street on a warm, sunny day. The row houses you see are in various physical states; some are painted and appear to be cared for, and others are in disrepair and dilapidated; no grass is growing in the yards, and the street is littered with trash. People are sitting on the steps and front porches, talking and watching the traffic pass by. Several young female adolescents are sitting on the steps holding infants. Children of different ages are playing on the sidewalk and in the streets. The neighborhood is alive with noise and activity. As you continue your drive, you enter an area in which the houses are detached. The houses have small yards with green grass that are carefully maintained, and the streets are lined with lovely flowering trees. A few adults are working in their yards; a few children are playing in a nearby park. The scene is very quiet.

What is it like for residents who live here? Would you like to live here? What kinds of things would lead you or others to want to live here?

In the preceding example of community, two neighborhoods are presented, geographically close but different. Who lives in the two neighborhoods? What would it be like to live in these communities? What would it be like to be a community health nurse responsible for the health of these communities? What type of nursing care do you think this community needs?

Before we go any further, we need to define community. What is the meaning of this term? Does community mean only the neighborhood in which one lives, or does it have other meanings?

Community defined

If you were to ask five people to define the word community, you would probably get five different answers: “a place where people dwell,” “a group of people with common interests,” “a place with specific boundaries.” Some people may speak about an academic community, a religious community, or a nursing community, and others may define community as the neighborhood or city in which they live. Depending on the circumstances, each definition is correct.

In this text, community is defined as an open social system that is characterized by people in a place who have common goals over time. The term is applicable to a variety of situations. A community includes a place and groups or aggregates. An aggregate is any number of individuals with at least one common characteristic (Williams, 1977). The terms population group and aggregate are synonyms for population (Williams, 1977). A population is a collection of individuals who share one or more personal or environmental characteristics, the most common of which is geographical location (Schultz, 1987). How a person defines community depends on the situation and that person’s purpose. To community health nurses working for a county health department, community might mean a geographical area and its residents (population) such as the county or health district to which they are assigned. This description is the classic definition of community. Nurses working with the homeless, older adults, or a special interest group (e.g., smokers) may define community as people with common characteristics (aggregate) within a specific place.

Literature Review

Community health literature offers a variety of definitions. Behringer and Richards (1996) described community as a web of people shaped by relationship, interdependence, mutual interests, and patterns of interaction. Shamansky and Pesznecker (1981) provided an operational definition of community considering the following three factors: (1) who (people factors), (2) where and when (space and time factors), and (3) why and how (for what purpose?). Ervin (2002) stressed that community assessments always occur at a particular time, for example, July 2011, or during the year 2012.

Anderson and McFarlane (2010) define community in terms of a core dimension (people) and eight subsystems: (1) physical environment, (2) education, (3) safety and transportation, (4) politics and government, (5) health and social services, (6) communication, (7) economics, and (8) recreation.

Other authors define community by describing types or categories. Communities may be geographically or socially bound (Hawe, 1994); categorized as emotional, structural, or functional (Archer, 1985); or defined in terms of relational and territorial bonds (Turner & Chavigny, 1988).

One of the most comprehensive definitions of the term community found in community health literature was formulated by Higgs and Gustafson (1985): “A community is a group of people with a common identity or perspective, occupying space during a given period of time, and functioning through a social system to meet its needs within a larger social environment.” This definition is most closely related to the concept of community discussed in this text.

Critical Components of a Community

For the purpose of this text, a community may be defined as a community if three critical components or defining characteristics are included: (1) people, (2) place, and (3) social interaction or common characteristics, interests, or goals. All communities contain all three of these components.


Population is the most obvious of the necessary community components. The number of people included in the community depends on the other two critical components. A population can be a relatively small number (a group of 20 pregnant adolescents enrolled in a clinic) or a large number of people (a city of one million). The ages, gender, race/ethnicity, religion, occupations, and socioeconomic status may be similar or diverse.


Traditionally, communities were described in relation to geographical area. However, population aggregates such as older adults, the poor, people with acquired immunodeficiency syndrome (AIDS), or any population in which the members share one or more common characteristics, goals, or interests are sometimes used to identify a community for assessment purposes. Therefore, communities may be defined by one of two designations: (1) geopolitical (spatial) or (2) phenomenological (relational). Figures 15-1 and 15-2 illustrate some geopolitical and phenomenological communities.


The geopolitical community is a spatial designation—a geographical or geopolitical area or place. This view is the most traditional in the study of community.

Geopolitical communities are formed by either natural or human-made boundaries. A river, a mountain range, or a valley may create a natural boundary; for example, the Chesapeake Bay separates Maryland into the eastern and western shores. Human-made boundaries may be structural, political, or legal. Streets, bridges, or railroad tracks may create structural boundaries. City, county, or state lines create legal boundaries. Political boundaries may be exemplified by congressional districts or school districts.

Why does a community/public health nurse need to be concerned about geopolitical boundaries? A geopolitical view of community focuses the nurse’s attention on the environment, housing, transportation, education, and political process subsystems. All of these elements are related to geographical locations as well as to the population composition and distribution, health services, and resources and facilities. Statistical and epidemiological studies are frequently based on data from specific geopolitical areas.


Most people initially think of community in terms of geographical location. Another way of thinking about community is in terms of the members’ feeling of belonging or sense of membership, rather than geographical or political boundaries. Such a community is a phenomenological community, a relational rather than a spatial designation. A sense of place emerges through the members’ awareness of their experiences together. This place is more abstract than a geopolitical place but is just as real to its members. People in a phenomenological community have a group perspective that differentiates them from other groups. A group consists of two or more people engaged in an interdependent relationship that includes repeated face-to-face communication. A group’s identity may be based on culture, beliefs, values, history, common interests, characteristics, or goals. Examples of phenomenological communities include populations of people with common interests such as a common religious conviction or professional or academic interest; with common beliefs such as beliefs about human rights including women’s rights or racial equality; or with a common goal such as Students Against Drunk Driving (SADD), whose common goal is to decrease alcohol-related accidents among students who drive.

Another example of a phenomenological community is a community of solution. This type of phenomenological community has special significance for health planning. The National Commission on Community Health Services (1966) suggests that when health services are considered, the boundaries of each community are established by the boundaries within which a problem can be identified, dealt with, and solved. A community of solution includes (1) a health problem shed (i.e., an area that has similar health problems) and (2) a health marketing area (i.e., an area that has similar solutions to the problem or an adequate supply of health resources to meet the problem).

For example, an oil spill in the Chesapeake Bay would affect more than one county. Parts of several counties in Maryland and Virginia may be affected. All of the communities affected become the health problem shed. All of the communities that join together and pool their resources to meet the need create a health marketing area. Figure 15-3 illustrates one city’s communities of solution. The concept of a community of solution is especially important in coordinating health care and decreasing duplication and fragmentation of services.

Social Interaction or Common Interests, Goals, and Characteristics

Communities, similar to families, have their own patterned interaction among individuals, families, groups, and organizations; this interaction varies from community to community depending on needs and values. In a geopolitical community, this interaction may go beyond talking to one’s neighbor and may include interactions with agencies and institutions within the community. In a phenomenological community, this attribute is inherent. A phenomenological community exists because of a common interest or feeling of belonging (Dreher & Skemp, 2011).

Each of us lives in a geopolitical community, but we may be members of several phenomenological communities. Figure 15-4 illustrates one individual’s community membership.

Basic community frameworks

Now that we have defined the concept of community, how do you approach or study the community as a client? There are many theoretical approaches to communities. Perspectives on community come from diverse fields of study, including anthropology, sociology, epidemiology, social psychology, social planning, and nursing. Community/public health nurses have adapted and used theories from other disciplines. Several frameworks that are especially helpful in community/public health nursing include developmental, epidemiological, structural–functional, and systems frameworks. Box 15-2 provides examples of frameworks used to study communities.

Box 15-2

Basic Frameworks Used to Assess Communities

Developmental Framework

Information about the community is collected from several points in time because communities change (McCool & Susman, 1990). Exploring the history of the community allows the community health nurse to consider the past. For example, even if a community has inadequate resources for treatment of substance abuse, it may currently have many more resources than it did 5 years ago.

Changes in a community are related to the needs of the population, changes in the societal context, changes in the physical environment, and the history of the community itself. For example, the U.S. population is currently aging; as the population ages, more health services are needed for older adults. Loss of population within a community may result in deterioration of existing buildings. An incorporated area may change its form of governance from a city manager and council to a city mayor and council.

Single events and trends should be considered. Events may be linked with the age of the community (e.g., the opening of the first local health department office), with changes in the environment (e.g., the closing of a business because of shifts in the national economy), and with unexpected situations (e.g., a flood) (McCool & Susman, 1990). Patterns of change may form trends. For example, trends in the health status of the community members are identified by analyzing epidemiological data from several points in time.

Epidemiological Framework

An epidemiological perspective focuses on the health of the population. In this approach to community assessment, the nurse identifies persons who are at greater risk of illness, injury, disability, and premature death so that targeted interventions aim at reducing the risk or preventing the problem (Merrill & Timmreck, 2006).

A recipe does not exist for identifying which epidemiological data should be collected about a community. As discussed in Chapter 7, more data exist regarding mortality and the use of hospital services in the United States than exist about morbidity and the use of primary care services. However, we do know that health problems are not distributed evenly among all persons but, instead, vary with human characteristics such as age, gender, and socioeconomic status. Additionally, human behavior, quality of social support, and degree of environmental hazards are important factors that contribute to the distribution of health and the well-being among populations. Because of this fact, nurses who work with communities must consider the different health needs among various aggregates (e.g., older persons, pregnant women, workers in a specific occupation, poor individuals). The concept of aggregate/population is essential when using an epidemiological approach to community assessment.

Health Disparities and At-Risk/Vulnerable Populations

Epidemiological data can identify which populations in a community are at higher statistical risk for experiencing illness, injury, or premature death. All populations have some risk, but risks for multiple illness conditions and premature death are much higher for specific populations (Adler & Rehkoph, 2011). Community health nurses need to explore the multiple factors that contribute to health disparities among vulnerable portions of the population. Vulnerability is the predisposition or susceptibility to injury, illness, or premature death. To improve health status and reduce risk in high-risk populations, nurses must work with communities to identify and change, where possible, the factors that contribute to the populations’ vulnerability (ANA, 2007).

Health programs and health policies aimed at reducing vulnerability to poor health must address a broad range of factors. Refer to other chapters for more in-depth discussions of risk factors: demographic factors in Chapter 7, socioeconomic and cultural factors in Chapter 10, human behavior in Chapter 18, high-risk populations in Chapter 21, and environmental factors in Chapter 9. Unit VII addresses the subject of community support for three vulnerable populations: persons with disabilities, children, and older adults.

Structural–Functional Framework

Structural–functional approaches to community emerged from anthropology and sociology. As social systems, communities have structures, processes, and functions. Structures are the parts of the community, and their organization and processes are the interactional patterns that change with time. Functions are the purposes and actual outcomes that result from community structures and processes. This approach asks: What structures and patterns of human interaction foster community goal achievement?

The following functions of the community can be identified:

These social functions of the community may be achieved through a variety of social structures and processes. In other words, the same or similar results can be achieved in different ways. Communities differ by degree of autonomy, presence of service areas, psychological identification, and pattern of relationships (Warren, 1987).

A large urban area would generally be more autonomous and provide employment, a varied production of basic goods and services, its own police authority, and a network of formal groups that socialize and support the people. A suburban community might supply a strong social network and support of its members but be less autonomous with fewer opportunities for employment and no formal production of goods. A rural community might have a strong social network and also provide some employment. Both suburban and rural communities may be dependent on a larger urban area for the functions of production and distribution. A community may have multiple service areas. For example, the suburban community may consist of two school districts, one election district, and the market area of two hospitals. The degree to which members identify with the locale may be strong or weak.

A community’s relationship with other communities and the larger society affects the community. For example, many of the structures within a community, such as a hospital, nursing home, or home health agency, may be owned by corporations outside the community. Communities must be concerned with their internal functioning and their relationships to their social environments.

Nursing Theories Applicable to Community Assessment

Most nursing theories were developed for individual clients, not communities (Alligood & Marriner-Tomey, 2010; Hanchett, 1988). Many nursing theories view the community as the environmental system influencing individuals and families.

Only a few nursing theories view the community as client (Hamilton & Bush, 1988). Goeppinger and colleagues (1982) proposed the development of a community assessment tool using Cottrell’s characteristics (1976) of a competent community as a framework. Community competence is based on eight variables: (1) commitment, (2) self and other awareness and clarity of situation definitions, (3) articulateness, (4) communication, (5) conflict containment and accommodation, (6) participation, (7) management of relations with the larger society, and (8) machinery for facilitating participant interaction and decision making (Cottrell, 1976; Moorhead et al., 2008). Most of these characteristics of a competent community are community processes that can contribute to the inclusion and participation of community members.

The theories of Johnson (1980), Roy (Roy & Andrews, 1999), King (1981), Neuman (Neuman & Fawcett, 2002), and Watson (Rafael, 2000) may be used to view the community as client. All theories are based, in part, on general systems theory. As discussed in Chapter 1, general systems theory can be applied to any social system, including a community. Table 15-1 presents views of the health of a community from the perspectives of these nursing theories.

Nursing Frameworks for Community Assessment and Practice

Several frameworks have emerged that are either nurse developed or used in public health practice. Two such frameworks view the community as partner. Anderson and McFarlane’s (2010) Community as Partner model and Helvie’s (1998) Energy Theory are nurse-developed frameworks. Both views consider community as a network of interrelating relationships, characteristics, and supports. Using these models, community/public health nurses act in partnership with others (health care professionals and community members) to address the community’s health concerns (ANA, 2007). Several models are based on the epidemiological framework. Two of these models have particular value to community health nurses: the GENESIS and MAPP models. All four models are influenced, to some degree, by systems theory and are briefly summarized in Box 15-3.

Box 15-3

Sample Nursing Frameworks for Community Assessment and Practices

Community-as-Partner Model

The community-as-partner model evolved at the University of Texas School of Nursing at Galveston. Based on Betty Neuman’s system model of a total-person, the community-as-partner model focuses on two central factors: the community as partner and the nursing process (Anderson & McFarlane, 2010). The community is composed of a core population and eight subsystems. These are depicted visually as a wheel with the population at the hub surrounded by the subsystems. The subsystems are physical environment, education, safety and transportation, politics and government, health and social services, communication, economics, and recreation. The core population and each subsystem may be influenced by other segments, as well as by stressors, beyond the community (external factors). The community/public health nurse works in partnership with the community to plan, implement, and evaluate strategies to reduce stressors, reestablish equilibrium, and prevent future problems. Interventions address primary, secondary, and tertiary prevention.

Helvie Energy Framework

The community (population) is an energy field that is ever changing (Helvie, 1998). The community influences and is influenced by other energy fields or subsystems in the environment such as health, education, and economics. Changes in the community environment may come from internal (between community components) or external (outside the community) influences. The nurse works to identify stressors and to plan strategies to bring stressors into balance and improve health.

Epidemiological Framework Models


General Ethnographic and Nursing Evaluation Studies in the State (GENESIS) was developed by the University of Colorado School of Nursing. This model integrates epidemiological and ethnographic data to develop a comprehensive view of a community’s health status and health needs (Stoner et al., 1992). Areas of assessment include history, politics, services, economies, employment, education, environment, and a community’s sense of belonging. Community members’ feelings about health, health needs, and values are incorporated in the assessment process.


Mobilization for Action through Planning and Partnerships (MAPP) is a tool designed for use by local health departments in planning with geopolitical communities to create and implement a community health improvement plan (National Association of County and City Health Officials [NACCHO], 2008). The tool emphasizes community ownership of the process. It also helps instruct nurses and other public health personnel in the most effective ways to use collected data to develop effective intervention plans.

From National Association of County and City Health Officials. (2008). A community approach to health improvement. Washington, DC: Author. Retrieved May 21, 2011 from; Stoner, M., Magilvy, J., & Schultz, P. (1992). Community analysis in community health nursing practice: The GENESIS Model. Public Health Nursing, 9(4), 223-227.

Systems-based framework for community assessment

Although many useful strategies and frameworks are available for community assessment, the assessment tool used in this text is based on systems theory. A systems framework ensures that the dynamics within and external to each system, or community, are identified and explored. In addition, the tool incorporates aspects of the structural–functional framework (which identifies community goals and analyzes internal community functioning) and the epidemiological framework (which analyzes the health status of the people, or populations, within the community).

The advantage of this systems-based community assessment tool is that it incorporates multiple frameworks simultaneously. If considered useful, a developmental framework can be incorporated to explore the history of the community.

Overview of Systems Theory

A systems framework views the community as a dynamic model in which the community is constantly in the process of responding and adapting to internal and external stimuli. The responses are aimed at developing and maintaining a sense of balance or equilibrium. The systems model (Figure 15-5) serves as a tool to help the nurse identify, collect, and organize appropriate data, including the critical components and their relationship to each other.

The components of the systems model for both geopolitical and phenomenological communities are the same and consist of the following:

• Boundaries: factors that separate a community from its environment and maintain the integrity of the community

• Goals: purpose or reason for which the community exists

• Characteristics: physical and psychosocial characteristics of the community that affect behavior

• External influences: resources or stressors from the suprasystem

• Internal functioning: structures and processes of the community, divided into four functional subsystems: economy, polity, communication, and values (University of Maryland School of Nursing, 1975)

• Outcomes: products, energy, and information created within the community, including health behavior and health status of the population(s) and degree of community competence

• Feedback: information that is returned to the system regarding its functioning

Although the components of geopolitical and phenomenological communities are the same, the types of data collected and the resources for those data vary. The environment external to the community in Helvie’s model (1998) is referred to as the suprasystem in our model (von Bertalanffy, 1968). For the discussion on the holistic assumptions and review of general systems theory, refer to Chapter 1.

Components to Assess

Box 15-4 presents the basic systems model for community assessment, identifies important data to collect, and suggests possible data sources. Website Resource 15A image expands the information on the tool in Box 15-4. The tool differentiates how the model would be used for both geopolitical and phenomenological community assessments, and suggests some of the questions nurses would need to ask. The following discussion examines the important features in each component in the assessment process.

Box 15-4

Community Assessment Tool: A Systems-Based Approach

1. Identify the boundaries of this community.

a. People

b. Place

c. Social interaction—common goals, interests, or characteristics

Sources of data: Geopolitical: maps, census tract maps, libraries, city clerks, health departments, printed material describing the community. Phenomenological: interviews, printed material describing the community (e.g., pamphlets), philosophic and membership statements.

2. Identify the goals of this community.
Sources of data: Geopolitical: charter of incorporation, printed material about the community, interviews of key informants (e.g., community leaders). Phenomenological: printed material about the community, statement of philosophy and goals, interviews of key informants (e.g., community leaders, community members).

3. Describe the community’s physical and psychosocial characteristics.

a. Physical characteristics

(1) How long has the community existed?

(2) Obtain demographic data about the community’s members (age, race, gender, ethnicity, housing, density of population).

(3) Identify physical features of the community that influence behavior.

b. Psychosocial characteristics

(1) Religion

(2) Socioeconomic class
Sources of data: Geopolitical: census tract data, geographical information system (GIS) databases, health planning agencies, libraries, city/county clerks, Chamber of Commerce, printed matter about the community, telephone books listing places of worship and schools, a visit to the neighborhood (for information on set factors of the community), written surveys, local realtors (for information on housing). Phenomenological: a visit to the community, health and membership records, surveys, interviews with key informants.

4. Identify the suprasystem and explain the importance of looking at the suprasystem during a community assessment.

5. Which external influences from the environment (suprasystem) are resources? Which are demands?

  Resources Demands
Human services:    
Health information:    
Values of suprasystem (i.e., what external values affect this community?):    

Sources of data: Geopolitical: windshield survey, census tract data, GIS databases, health planning agencies, libraries, city/county clerks, Chamber of Commerce, printed matter about the community, telephone books listing places of worship and schools, a visit to the neighborhood (for information on set factors of the suprasystem), written surveys, local realtors (for information on housing). Phenomenological: a visit to the suprasystem, health and membership records, surveys, interviews with key informants.

6. Internal functions: identify resources and demands within the community that influence its level of health. (See pp. 405-407 and Website Resource 15A image for additional details.)

a. Economy
Areas of assessment include formal and informal human services; money; facilities, equipment, and goods; education; analysis of economy subsystem functioning. Are the services, facilities, finances, and education in this community accessible, adequate, and appropriate?
Sources of data: Geopolitical: budget, interviews, drive or walk through the community, telephone book, and service directories. Phenomenological: budget, interview, surveys.

b. Polity: Describe the political system within the community used to attain community goals.
Areas of assessment include basic organizational structure, formal and informal leaders, pattern of decision making, methods of social control, and analysis of polity subsystem. What is the ratio of demands to resources?
Sources of data: Geopolitical: organizational chart and charter, interviews and meetings with the community, laws. Phenomenological: by-laws, procedure and policy books, attending meetings, being with the group.

c. Communication: Describe the communication within the community that fosters a sense of belonging and provides identity and support to its members.
Areas of assessment include nonverbal communications, verbal communications, and analysis of communication subsystem. How well does the community communicate a sense of identity or belonging to its members? How adequate is the communication?
Sources of data: Geopolitical: interviews, newspapers, kiosks, meetings, visit to the community. Phenomenological: interviews, newsletters, meetings, classes, committees, being with the community.

d. Values: Identify the ideas, attitudes, and beliefs of community members that serve as general guides to behavior.
Areas of assessment include tradition, subgroups, environment, health attitudes and values, homogeneity versus heterogeneity of values and beliefs, and analysis of values subsystem. How well does the community provide guidelines for the behaviors of its members?
Sources of data: Geopolitical: surveys of agencies to determine utilization, surveys of community members, newspapers, and community announcements. Phenomenological: observation and interaction with members, charts or records, surveys of members.

7. Health behavior and health status (outcomes).
(Be sure to refer to the community assessment tool in Website Resource 15A image for this portion of the assessment, because some differences exist between the geopolitical community and the phenomenological community.)

a. People factors:

(1) Describe the general trends regarding size of community.

(2) What are the trends in mortality and morbidity?

(a) What is the mortality rate?

(b) What are the major causes of death?

(c) What major diseases and illnesses are present?

(d) Who are the vulnerable groups? What are the risky behaviors?

(e) What presymptomatic illness or problems might be expected?

(f) What is the level of social functioning in this community?

(g) What types of disabilities or impairments, or both, are present or might be found in this community?
Sources of data: Geopolitical: local and state vital statistics (available through local and state health departments); Morbidity and Mortality Weekly Reports (MMWR), published by the Centers for Disease Control and Prevention (available at libraries and health departments); reports of screening programs; interviews with key informants. Phenomenological: agency or community records, interviews with key informants, review of the literature pertaining to aggregates (e.g., literature about older individuals will provide information about most morbidity and mortality).

b. Environmental factors

(1) Physical environmental factors: What is the quality of the physical environment (air, water, land, housing, work or home environment)?

(2) Social environmental factors: What is the emotional tone and stability of the population?
Sources of data: Geopolitical: visit to community; reports such as Air Quality Index (AQI). Phenomenological: visit to community.

8. Describe feedback from the environment about the community’s functioning.

9. Make inferences about the level of health of this community.

 a. What are some actual health problems or needs?

b. What are some potential health problems or needs?

 c. How well is the community working to meet its health needs? What is its proposed action to meet its health needs?

d. How has the community solved similar problems in the past?

 e. What are the strengths of the community?

10. Identify one actual or potential health need for which you, as a nurse, could plan an intervention.

Adapted from Community Health Faculty, Undergraduate Program, University of Maryland School of Nursing. (1975). Community assessment tool. Baltimore: University of Maryland School of Nursing.


The essential first step in community assessment is identifying the boundaries or parameters of the community. Remember that a community is defined in terms of the three critical components: people, place, and social interaction or common interests. The definition of a community determines its boundaries. Consider the boundary as the skin or outside limit of the community. Establishing the boundary helps the nurse determine what data will be collected and considered internal to the community, in other words, community information. Defining the boundary also identifies the suprasystem, the environment outside the community. Data collected from the suprasystem are considered external influences, or inputs, and may impact or influence the community.

Boundaries, similar to the skin of an individual, maintain the integrity of the system and regulate the exchange between a community and its external environment, the suprasystem. Boundaries of a geopolitical community are spatial and concrete; they can be natural or human made, as discussed earlier. Because the boundaries of geopolitical communities are real and concrete, they are often visible on maps. For example, the Potomac River and the Maryland state line can be visualized on a map as indicators of the boundaries of Washington, DC. The Rocky Mountains divide the western part of the United States from the Great Plains. The river and mountains are natural boundaries and the state line a human-made boundary.

Another type of human-made boundary is a census tract. The U.S. Census Bureau divides the United States into census tracts for the purpose of reporting demographic data about the U.S. population every 10 years. Census tract data are valuable for health planning. Census tract maps are available in libraries and health departments. Figure 15-6 illustrates how an area is incorporated into a census tract. Website Resource 15B image provides additional information on census tracts.

The boundaries of phenomenological communities are more relational or conceptual than are geopolitical boundaries and usually relate to the reason the community exists or to the criteria for membership. To determine the boundary of a phenomenological community, the following questions would be asked:

For example, the boundary of the nursing community would be its criterion for membership—that is, the person must be a nurse to belong. The boundary of a Cub Scout pack would be the criteria of age (7 to 10 years old) and gender (boys)

The Morgan Center is a nutrition center for frail older persons. The center consists of 25 senior participants, 1 site manager, and 3 staff members. To attend Morgan Center, the participants must be 65 years of age or older, live in Allen County, be classified as frail (having difficulty with at least one activity of daily living [ADL]), and be continent. The goals of the Morgan Center are to provide socialization, encourage ADLs, and ensure adequate nutrition for its clients.

A nurse assessing the community might determine some characteristics from the data provided. This community is a phenomenological community; it is an aggregate of frail older adults attending Morgan Center. The criteria for membership (65 years of age and older, residents of Allen County, frail, and continent) determine the boundaries. Another way to define the community would be to view the Morgan Center in its entirety, including frail older adults, the site manager, and the staff. In this case, the criteria for membership change to persons who work at or attend the center. Either definition is correct, depending on the reason or purpose for the assessment.

As you can see, the parameters of the community must be defined because they determine what data will be collected. In the first situation, the nurse will collect data about frail older persons only, and the site manager and the staff will be external influences to the community; in the second example, the nurse will collect data about frail older persons, the site manager, and the staff as part of the community. Boundary definition is especially important when examining the external influences and the internal functioning of a community.

Permeability of Boundaries

The boundaries of any system may be relatively permeable (open) or impermeable (closed). For example, entrance or membership into a religious community may be contingent on accepting certain beliefs and rituals, making the boundary impermeable to someone who does not hold these beliefs. In a phenomenological community, the criteria for membership often define the boundary’s permeability or openness. A geographical community that has a gated entrance and homes that cost $350,000 or more is impermeable to people with an annual income of $25,000 to $30,000. Communities with greater variety of housing prices and rental units would be open to more people; thus the boundaries would be permeable.

The openness or closeness of a community has implications for health planning. A closed, rigid system is resistant to change, whereas an open, flexible system is more receptive to change and to help from the health care delivery system.


Once you have determined the boundary of the community, anything outside the boundary becomes the suprasystem. No system (individual, family, or community) can exist in isolation. Therefore, every client system operates within a larger system. The larger system, the suprasystem, is defined as the environment external to, or outside of, the community that affects the community system. The suprasystem of a geopolitical community is concrete. For example, the immediate suprasystem of Ridgely’s Delight, a neighborhood in Baltimore, is the city of Baltimore. The suprasystem of Baltimore is the state of Maryland. Identifying a specific suprasystem for a geopolitical community is usually easier than it is in a phenomenological community.

In a phenomenological community, the suprasystem becomes anything outside of the community that affects or is affected by the community. Identifying a single suprasystem for a phenomenological community is sometimes difficult; many suprasystems may be found. For example, what is the suprasystem for an aggregate such as the older individuals in Orange County? It might be the Orange County Office on Aging, the entire Orange County government, the American Association of Retired Persons, or the Orange County Social Security Office, all four of these entities, or these four entities and still others. The sources of external influences from the larger society must be examined, such as legislation, services, and money that influence (positively or negatively) the older adult community. For some phenomenological communities, however, identifying a specific suprasystem may be possible. For example, Girl Scout Troop No. 201 is a phenomenological community; its suprasystem is the Girl Scouts of Central Ohio.


Goals of communities vary with the type of community, but in general, they are focused on maximizing the well-being of members, promoting survival, and meeting the needs of the community members. What are the goals of the community in which you live? Are they to provide safe housing for residents? One goal of the Morgan Senior Center is to provide socialization for its members. The community health nurse can assess the goals of the community by asking questions such as, “What is the purpose of the community?” A written statement of the community’s philosophy and goals, if available, is another source.


Characteristics are the physical, biological, and psychosocial factors of the community. These characteristics are often referred to as demographics. Characteristics are usually not easily changed, or they change slowly.

Physical Characteristics

Physical characteristics include (1) the length of time the community has been in existence, (2) pertinent demographic data about the community’s members (e.g., age, race, gender, ethnicity, education, income, housing, density of population), and (3) physical features of the community that influence behavior.

The length of time the community has been in existence (the age of the community) has implications regarding stability, health care services, and needs. On the one hand, a very new community may have few services simply because supply has not caught up with demand. On the other hand, communities that have been in existence for a long time may have many resources, or they may have resources that reflect past population needs but not the current needs (if population shifts have occurred).

Pertinent demographic data such as age, race, gender, ethnicity, and density of the population have significant meaning in the planning of health care services. By looking at the age, race, and gender of members of the community, the community/public health nurse can make some inferences about possible health care needs. A community with a large population of older individuals will have very different needs from persons of a community with a predominantly young population. Generally, older individuals need more services than do younger persons. Race is a factor in certain diseases (e.g., sickle cell anemia in the African American population; Tay-Sachs disease in Jewish populations). A population with an unusually high number of women will need more women’s health care services, and a community with a high number of adults may need blood pressure screening programs to detect early hypertension.

Ethnicity is reflected in customs, beliefs, and values and may affect how the community addresses certain health practices (refer to Chapter 10). The community/public health nurse must understand these customs and beliefs when assessing needs and planning interventions. In some areas, the cultural and ethnic backgrounds of the population have become the basis for the community. Some cities have sections that reflect the ethnic and cultural heritage of certain groups (e.g., Little Italy or Chinatown in San Francisco). Groups such as the Sons of Norway, the Sons of Italy, and the Polish Home Club have formed phenomenological communities on the basis of their ethnic and cultural heritages.

The type, condition, and amount of housing and density of the population are environmental factors that have implications for health. Crowded living conditions have long been associated with the increased transmission of some communicable diseases (e.g., tuberculosis, pediculosis). Also important to note is the condition of the housing and whether housing is available and financially accessible to people in the community. The type and condition of housing may say a lot about the resources and values of the people living in the community.

In a phenomenological community, the environment or the place in which the group meets might be examined. This review takes into consideration the environmental factors and the aesthetics that contribute to or interfere with members’ ability to feel comfortable in the physical environment.

Physical features of the community can influence the community’s behaviors. A community with fences around all houses demonstrates preference for privacy and may imply little social interaction or the presence of dogs or pools. A school with open classrooms influences the interaction among students. Other physical features such as living or working in a community with toxic substances may influence the level of health of the residents or workers.

Psychosocial Characteristics

Psychosocial characteristics that affect the emotional tones of the community include religion, socioeconomic class, education, occupation, and marital status. Some ways these characteristics may affect health behavior include the following:

Collecting demographic information can provide the nurse with some idea of the possible health needs of the community. Looking at a number of people with common characteristics and planning programs to meet their unique health care needs are the basis for aggregate/population health planning. Sources of demographic information are identified later in Tools for Data Collection.

External Influences

All communities have external influences that affect their functioning. External influences are matter, energy, and information that come from outside the community—that is, from the suprasystem. External influences may be either resources (assets or strengths) or demands (liabilities or weaknesses) on the community and may be mandated (required) or voluntary. Some of the most important external influences are money, facilities, human services, health information, legislation, and values of the suprasystem. Some of the areas to explore for each of these influences are summarized here:

• Money. Outside sources would include taxes, state or federal funds, contributions, grants, or endowments. Finding money that may be used to fund health services is important.

• Facilities. Look for the following potential outside facilities: health care facilities such as hospitals, health maintenance organizations (HMOs), nursing homes, home care agencies, and facilities and clinics that promote safety and transportation. Consider accessibility of facilities regarding location and cost, as well as transportation and attitude of staff. Ease of access and low cost are resources; excessive distance and poor staff attitudes are demands.

• Human services. These resources may be formal or informal. Examples of formal human services include professional resources, nurses, physicians, the local health department, and health insurance companies. Examples of informal services are often voluntary services, individuals, and organizations such as religious groups and other volunteer support groups for a variety of health conditions (e.g., Alcoholics Anonymous). Physicians and nurses outside the community who will see community members are a resource; physicians or clients who will not accept community members are a demand.

• Health information. Health information is communicated through printed matter, radio, television, the Internet, or person-to-person. If the suprasystem has helpful information but does not have an effective way to communicate this information, this represents a demand.

• Legislation. This type of influence takes the form of laws, policies, and procedures that may affect a community in either a positive (resource) or a negative (demand) manner. The geopolitical community has laws that affect the community’s health, including environmental pollution and zoning laws; the phenomenological community can be affected by external legislation, policies, and procedures. For example, legislation affects the health and health care of older adults (the Older Americans Act and Medicare legislation).

• Values of the suprasystem. Consider if the suprasystem’s values are consistent or inconsistent with the values of the community. When the two sets of values are consistent, little conflict takes place, and there is increased likelihood that the suprasystem will be supportive of community requests. When the two sets of values differ, conflict is more likely, and the suprasystem will be less supportive of community needs and requests.

Data Sources for Suprasystem Information

Because the external influences come from the suprasystem, obtaining data about the suprasystem is important. Where can these data be found? A wealth of information is provided by review of the suprasystem budget, local telephone book and newspapers, health or human service directories, and information and referral services; systematic tours of services and agencies; interviews with members of the community; and review of legal and policy and procedure books.

Internal Functions of the Community

Internal functioning of the community occurs through its internal structures and processes. For the purpose of data collection and analysis, the tool examines four functional areas: economy, polity, communication, and values (University of Maryland School of Nursing, 1975). Resources and demands may be found within each of these subsystems.

When assessing individual human functioning, it is essential to determine areas of strength as well as areas of need. Nurses work with individuals to build on their strengths to overcome and adapt to health deficits. The same is true when assessing a community. Asset models of community assessment stress the positive abilities and capacities of communities to identify their own health problems and plan solutions. Such a model encourages community participation and has the potential to empower communities. Community resiliency is the ability of a community to use its assets and resources to adapt to adversity and improve its capacity (Kulig, 2000; Moorhead et al., 2008; Racher & Annis, 2008). Community capacity may include social participation, sense of community, networks among organizations, skills, knowledge, and leadership necessary “to promote future community health and welfare” (Trickett et al., 2011, p. 1411).


The goal of the economy subsystem is production and distribution of goods and services. Economy includes categories such as human services; money; facilities, equipment, and goods; and education. These factors are the same as those discussed in the assessment of external influences. However, the factors to examine here are those within the community itself.

1. Human services. Services available within the community may be either formal (e.g., nurses and physicians) or informal (e.g., volunteers). Questions to ask include the following:

• What human services are available within the community to meet the community’s health needs?

• Are services adequate and sufficiently accessible to meet the community’s needs, or are services available only to a certain segment of the population, for example, persons who can afford to pay for or have transportation?

• Are the human services responsive to the needs of the community?

2. Money. What is the budget? How does the community get its money? How is revenue generated from within the community? What are the fund-raising activities? For what is the money spent?

3. Facilities, equipment, and goods. What health care facilities (e.g., hospitals, clinics, home health agencies, nursing homes, daycare centers) are available within the community? How are they used? Are they accessible, appropriate, and adequate for the population in the community? Does the facility have the equipment and supplies it needs to produce its goods? What does it produce? What is its contribution to the larger society? For example, is this a high-technology geopolitical community that supplies research and development, or is it a phenomenological community (e.g., Mothers Against Drunk Driving [MADD]) that provides support to its members and information to the larger suprasystem? These are examples of positive production (resources). Producing a negative effect on the larger society is possible for a community. For example, a community with many drug abusers may produce a negative effect (demand) on the system and the suprasystem. A community with many illegal drug users will require more health care services and put greater demand on health care facilities than would a community with fewer drug users.

4. Education. Education assists people in learning how to function productively in society so it is included in this subsystem. How are the members educated? In a geopolitical community, we can examine the numbers and types of schools, as well as the level of education. In a phenomenological community, we examine the needs for education of the group and what types of education are taking place. For example, what education about pregnancy is being provided to pregnant adolescents?

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Jul 24, 2016 | Posted by in NURSING | Comments Off on Community Assessment
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