MPH 505 Module 1 Community Needs Assessment Example

Finding the Need: A Community Health Needs Assessment for Prediabetes in a Border County

Student Name

Master of Public Health Program, Aspen University

MPH 505: Public Health Education and Program Oversight

Instructor Name

Month Day, Year

Finding the Need: A Community Health Needs Assessment for Prediabetes in a Border County

Every sound public health education program begins with a clear picture of the people it will serve. A needs assessment gathers data on health problems, their causes and the resources a community already has, then uses that evidence to choose a focus. This paper reports a needs assessment for a composite Southwestern county of 240,000 residents, conducted to select the population and problem for a new health education program run by the county health department.

Purpose and Scope

The health department had funding for one new program over three years and wanted to direct it where need was greatest and where education could make a measurable difference. The assessment team, two epidemiologists, a health educator and three community health workers, set out to answer three questions: which chronic conditions carry the heaviest local burden, which groups carry more than their share, and what assets could support a program.

Assessment Methods

The team combined secondary data with new primary data. Secondary sources included census and American Community Survey estimates, the state's behavioral risk survey, hospital discharge data and records from the county's two federally qualified health centers. Primary data came from a household survey of 612 adults, four focus groups and interviews with twelve leaders from churches, schools, clinics and employers. A study of exemplary community health improvement processes found that small-area census data and clear, measurable objectives are hallmarks of strong assessments, advice the team followed (Stoto et al., 2019).

Population Profile

The county is 58% Hispanic, and 31% of adults speak Spanish at home. Median household income is about 20% below the state figure, 17% of adults lack health insurance and the largest employers are agriculture, food processing and retail. Two neighborhoods on the county's south side have the highest poverty rates and the fewest primary care clinics.

What the Data Showed

The table summarizes the main indicators the team compared.

Survey Findings

In the household survey, 41% of Spanish-speaking respondents said they had never had a blood sugar test, compared with 22% of English-speaking respondents. Only 9% of respondents had heard the word prediabetes. More than half named cost of healthy food and lack of time as barriers to eating well, and many women said they did not feel safe walking in their neighborhoods after dark.

Focus Group Themes

Four themes emerged. Participants saw diabetes as almost inevitable in their families. Many feared insulin and amputation but did not know that the disease could be delayed. Family meals were central to daily life, so change had to involve the household. And participants trusted promotoras and church leaders more than clinic staff for health advice.

Community Assets

The assets inventory counted 14 churches with meeting halls, a network of 22 trained community health workers, two health centers offering sliding-scale fees, a school district with walking tracks open to the public and a Spanish-language radio station with a popular morning health segment. These assets suggested that a program could be delivered in trusted places without building new infrastructure.

Setting Priorities

The team scored five candidate problems, diabetes, childhood asthma, unintentional injury, depression and teen pregnancy, on burden, disparity, preventability, community concern and fit with available resources. Diabetes prevention among Spanish-speaking adults scored highest on every criterion except community concern, where it tied with depression.

Why Prediabetes

Focusing on prediabetes rather than diagnosed diabetes offered the greatest chance of prevention. A landmark trial showed that an intensive lifestyle program cut the development of type 2 diabetes by 58% over about three years in adults at high risk, a larger reduction than metformin achieved (Diabetes Prevention Program Research Group, 2002). The same approach now runs at thousands of community sites nationwide, where participants who attend more sessions lose more weight (Ely et al., 2017). An education program could therefore change the course of disease for many residents before complications began.

Selected Population

The program will serve Spanish-speaking adults aged 30 to 70 in the county's south side who have prediabetes or risk factors such as overweight, a family history of diabetes or a history of gestational diabetes. The team estimated that roughly 9,000 adults in the target area meet these criteria, most of them unaware of their risk.

Limitations

The household survey used a convenience sample drawn partly through churches and may overrepresent people connected to faith communities. Behavioral risk survey estimates for a single county carry wide confidence intervals. Health center records cover only patients who come to the clinics. The team treated each source as partial and looked for agreement across them.

Link to the Core Functions

In practice, a needs assessment carries out public health's assessment function and the essential service of monitoring the population's health. The findings will now guide policy development, in the form of a program plan, and assurance, through delivery and evaluation. Sharing the results with residents also fulfills the essential service of informing and educating the public.

Sharing the Findings

Before choosing a focus, the team presented its draft findings at three community meetings held in Spanish, one in a church hall, one at a health center and one at a school. About 140 residents attended. Their comments confirmed the diabetes finding and added a point the data had missed: many adults worked two jobs and could attend only in the evening or on weekends. That detail later shaped when classes were scheduled.

Ethics of Assessment

Survey participants gave verbal consent, no names were recorded and focus group notes were stored without identifiers. Community health workers conducted interviews in Spanish so that residents with limited English could take part. The team also committed to returning results to the community, since assessments that take information without giving anything back erode trust in future work.

Conclusion

The assessment pointed clearly toward prediabetes among Spanish-speaking adults on the county's south side: the burden is high, the gap with the state is wide, awareness is low and trusted community assets exist to reach people. The next step is to choose a planning model and build a program around what residents said about family, trust and barriers.

References

Diabetes Prevention Program Research Group. (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine, 346(6), 393-403. https://doi.org/10.1056/NEJMoa012512

Ely, E. K., Gruss, S. M., Luman, E. T., Gregg, E. W., Ali, M. K., Nhim, K., Rolka, D. B., & Albright, A. L. (2017). A national effort to prevent type 2 diabetes: Participant-level evaluation of CDC's National Diabetes Prevention Program. Diabetes Care, 40(10), 1331-1341. https://doi.org/10.2337/dc16-2099

Stoto, M. A., Davis, M. V., & Atkins, A. (2019). Making better use of population health data for community health needs assessments. eGEMs, 7(1), Article 44. https://doi.org/10.5334/egems.305