A Mixed-Methods Approach to Understanding Community Participation in Community Health Needs Assessments

Perceived Health Needs of Church Leaders and Members: A Secondary Data Analysis of the Mid-South Congregational Health Survey

Needs assessments have been successful in helping communities and congregations focus their health ministry efforts; however, most have used leader perceptions of congregational health needs. The purpose of this study was to examine and compare the self-reported needs of both church leaders and members to be addressed by their congregation. Church leaders (n = 369) and members (n = 459) from 92 congregations completed the 2019 Mid-South Congregational Health Survey. Frequencies and generalized linear mixed models (GLMM) were performed to examine the top 10 self-reported needs and associations by church role, respectively. Of the top 10 congregational needs, anxiety or depression, high blood pressure, stress, and healthy foods were ranked identically regardless of church role. Church leaders perceived obesity and diabetes to be important congregational health needs, whereas members perceived affordable health care and heart disease to be important congregational health needs. GLMM, controlling for within-church clustering and covariates, revealed church leaders were more likely than members to report obesity (odds ratio [OR]: 1.93, 95% confidence interval [CI] = [1.39, 2.67], p < .0001) and diabetes (OR: 1.73, 95% CI = [1.24, 2.41], p = .001) as congregational needs. Findings display similarities and differences in needs reported by church role. Including many perspectives when conducting congregational health needs assessments will assist the development of effective faith-based health promotion programs.

Community Engagement in Nonprofit Hospital Community Health Needs Assessments and Implementation Plans

CONTEXT

Nonprofit hospitals are required to provide community benefits in exchange for their tax-exempt status. This includes a community health needs assessment (CHNA) to identify community needs and an implementation plan (IP) with strategies to address top needs every 3 years. In addition, hospitals are required to engage community members in these assessments.

OBJECTIVE

The objective of this study was to explore community engagement and representation in CHNAs and IPs.

DESIGN

The researchers conducted a content analysis of CHNAs and IPs from a nationally representative sample of 503 nonprofit hospitals between 2018 and 2021.

MAIN OUTCOME MEASURES

For CHNAs, a coding sheet was used to record the types of community members engaged by hospitals. For IPs, the team coded whether community engagement was reported at all and then performed an in-depth analysis to identify categories of community members, engagement methods used, and roles of community input. Finally, frequencies of categories across IPs were quantified.

RESULTS

Eighty-nine percent of hospitals (n = 449) engaged community members in their CHNA, but only 14% (n = 71) engaged community members in their IP. An in-depth look at these IPs found that hospitals engaged underserved/minority populations, low-income populations, high school students, public health experts, and stakeholder organizations. Community members were involved in multiple steps, including brainstorming ideas, narrowing down needs, developing strategies, and reacting to proposed strategies.

CONCLUSIONS

Although IPs are intended to benefit the community, there is a lack of community involvement reported in IPs. Hospitals may need incentives, resources, and personnel support to ensure representation of community members throughout the entire CHNA and IP process.

A scoping review of community health needs and assets assessment: concepts, rationale, tools and uses

BACKGROUND

Community health needs and assets assessment is a means of identifying and describing community health needs and resources, serving as a mechanism to gain the necessary information to make informed choices about community health. The current review of the literature was performed in order to shed more light on concepts, rationale, tools and uses of community health needs and assets assessment.

METHODS

We conducted a scoping review of the literature published in English using PubMed, Embase, Scopus, Web of Science, PDQ evidence, NIH database, Cochrane library, CDC library, Trip, and Global Health Library databases until March 2021.

RESULTS

A total of 169 articles including both empirical papers and theoretical and conceptual work were ultimately retained for analysis. Relevant concepts were examined guided by a conceptual framework. The empirical papers were dominantly conducted in the  United States. Qualitative, quantitative and mixed-method approaches were used to collect data on community health needs and assets, with an increasing trend of using mixed-method approaches. Almost half of the included empirical studies used participatory approaches to incorporate community inputs into the process.

CONCLUSION

Our findings highlight the need for having holistic approaches to assess community's health needs focusing on physical, mental and social wellbeing, along with considering the broader systems factors and structural challenges to individual and population health. Furthermore, the findings emphasize assessing community health assets as an integral component of the process, beginning foremost with community capabilities and knowledge. There has been a trend toward using mixed-methods approaches to conduct the assessment in recent years that led to the inclusion of the voices of all community members, particularly vulnerable and disadvantaged groups. A notable gap in the existing literature is the lack of long-term or longitudinal-assessment of the community health needs assessment impacts.

One Decade Later: The Generalizability, Diversity, and Inclusion of Community Health Needs Assessments

CONTEXT

The 2010 Patient Protection and Affordable Care Act aimed to reduce health disparities and change medicine to be more community-driven. To maintain tax-exempt status, hospitals must complete a Community Health Needs Assessment (CHNA) every 3 years. This assessment must ( a ) integrate input from individuals the community serves, ( b ) make the report publicly assessable, and ( c ) adopt an implementation strategy based on community health needs identified in the assessment. However, there is little information on how representative CHNAs are of the community.

DESIGN

A content analysis was performed on a random sample of CHNA reports.

SETTING

This investigation examined nonprofit hospitals across the United States.

OBJECTIVES

This investigation analyzed the quality of CHNAs and described existing CHNA practices through 4 means: (1) identified the type of data included; (2) examined the frequency in the methods of data collection; (3) understood how representative those data are of the hospital's service region; and (4) explored to what extent the hospital addressed diversity and inclusion such as through recruitment.

METHODS

A stratified random sample was drawn of CHNAs published in the past 3 years (n = 450 reports). The sample was stratified by the US Department of Agriculture's Rural-Urban Continuum codes to balance hospital representation from metro and nonmetro areas.

RESULTS

A series of dependent t tests revealed that these hospitals' reports represented a significantly more female, White, college-educated, and older population than the service area. In addition, only 3.12% of hospitals collected primary youth data. Finally, results also found that survey recruitment was not inclusive of individuals who did not have Internet access, could not read, or did not speak English fluently.

Undergraduate Medical School Health Fair Hepatitis Screenings: Utilizing Non-Profit Community Organizations

Background:

Undergraduate medical schools serve a critical role in providing screenings to medically underserved populations through the use of health fairs. Non-profit community organizations (NPCO) often participate by providing local credibility, administrative resources, and technical knowledge. Here we present a three-year narrative of hepatitis B and C screening efforts to highlight the challenges and benefits of undergraduate medical school and NPCO partnerships.

Methods:

Hepatitis screenings were conducted at biannual health fairs in Harlem, New York from 2017 to 2019. Meeting minutes from post-event debriefings were analyzed to identify any overarching themes with NPCOs.

Results:

NPCOs share a common goal in working with the community to advance their access to medical care and treatment. Communication and prompt follow-up are critical to maintaining expectations between NPCOs and health fair organizers.

Conclusions:

NPCOs can play an important role in encouraging, outreaching, and even managing hepatitis screening initiatives in conjunction with medical school health fairs.

Nonprofit Hospital Community Benefits: Collaboration With Local Health Departments to Address the Drug Epidemic

BACKGROUND

Nonprofit hospitals (NFPs) are required to provide community benefits, which have been historically focused on provision of medical care, to keep their tax exemption status. To increase hospital investment in community health, the Patient Protection and Affordable Care Act required NFPs to conduct community health needs assessments and address identified needs. Some states have leveraged this provision to encourage collaboration between NFPs and local health departments (LHDs) in local health planning.

OBJECTIVE

The objective of this study was to examine the association of NFP-LHD collaboration in local health planning targeting drug use, with drug-induced mortality.

RESEARCH DESIGN

We conducted difference-in-differences analyses using drug-induced mortality data from 2009 to 2016, encompassing the first 3 years after NFP-LHD collaboration in local health planning specific to drug use. We evaluated drug-induced mortality in 22 counties in which collaboration was required in comparison with that in 198 control counties. We used data collected from implementation strategy reports by NFPs and combined it with data on hospital characteristics, as well as state-level and county-level factors associated with drug-induced mortality.

MEASURES

The primary outcome was county-level drug-induced mortality per 100,000 population.

RESULTS

Counties, in which NFP-LHD collaboration in local health planning was required and in which NFPs and LHDs jointly prioritized drug use, experienced a deceleration in drug-induced mortality of ~8 deaths per 100,000 population compared with the mortality rate they would have experienced without collaboration.

CONCLUSIONS

Collaboration between NFPs and LHDs to address drug use was associated with a deceleration in drug-induced mortality. Policymakers can leverage community benefit regulation to encourage NFP-LHD collaboration in local health planning.

Compassionate Bodies, Compassionate Practice: Navigating Body Image Tensions among Gay Men

Our purpose in writing this Perspective in Practice is to create awareness about the role of compassion within dietetic practice, particularly the role of compassion for body image tensions. Nine self-identifying gay men were recruited to a photovoice research study that explored their beliefs, values, and practices relating to food and their bodies. Compassion was found as one way to navigate body images tensions. It is not the intent of this article to review all aspects of this research study but to use it as an example to illustrate compassion in dietetics. We suggest that our findings reveal the strength of using compassionate practice within the dietetic profession. In doing so, we call upon dietitians to incorporate compassion into their clinical and client care practices to foster health and healing for all communities, especially among those who struggle with body image tensions.

Non-profit Hospital Targeted Health Priorities and Collaboration With Local Health Departments in the First Round Post-ACA: A National Descriptive Study

We examined the community health needs assessments (CHNA) and implementation strategies of a national sample of 785 non-profit hospitals (NFPs) from the first round after the ACA. We found that the priorities targeted in the implementation strategies were well-aligned with the top community health priorities identified in CHNAs as reported in previous studies. The top five targeted priorities included obesity, access to care, diabetes, cancer, and mental health. We also found that 34% of sample NFPs collaborated with their local health department (LHD) to produce a single CHNA for their jurisdiction. Non-profit hospitals that collaborated with a LHD on the CHNA had higher odds of selecting behavioral health community issues (i.e., substance abuse, alcohol, and mental health), while hospitals located in counties with high uninsurance rates had lower odds of targeting these community issues. Our contribution was 3-fold; first, we examined a large sample of implementation strategies to extend on previous work that examined CHNAs only. This gives a more complete picture of which community issues identified in the CHNA are actually targeted for implementation. Second, this study was the first to present information on the status of NPF collaboration with LHDs to produce a single CHNA (from the NFP perspective). Third, we examined the association between targeted priorities with NFP and county-level characteristics. The community benefit requirement and Section 9007 of the ACA present an opportunity to nudge NFPs to improve the conditions for health in the communities they serve. The ACA has also challenged institutions in the health care sector to approach health through the social determinants of health framework. This framework moves beyond the provision of acute health services and emphasizes other inputs that improve population health. In this context, NFPs are particularly well-positioned to shift their contribution to improve population health beyond their four walls. Section 9007 is one mechanism to achieve such shift and has shown some promising changes among NFPs since its passage as reflected in the findings of this study. This study can inform future research related to NPF community benefit and local health planning.

Searching for new community engagement approaches in the Netherlands: a realist qualitative study

Background

Community engagement is increasingly seen as key to improving healthcare systems and to increasing communities’ involvement in the shaping of their own communities. This paper describes how ‘community engagement’ (CE) is understood and being operationalised in the Dutch healthcare system by investigating the CE approaches being implemented in six different regions and by examining engaged citizens’ and professionals’ experiences of those CE approaches.

Methods

For this realist study, interviews and focus groups were held with citizens (16) and professionals (42) involved in CE approaches in the six regions. Additionally, CE-related activities were observed to supplement interview data.

Results

This study shows that citizens and professionals defined and experienced CE differently and that they differed in who they felt had ownership of CE. The CE approaches implemented in community-led initiatives and organisationally-led initiatives varied accordingly. Furthermore, both citizens and professionals were searching for meaningful ways for citizens to have more control over healthcare in their own communities.

Conclusion

CE can be improved by, first of all, developing a shared and overarching vision of what CE should look like, establishing clear roles and remits for organisations and communities, and taking active measures to ensure CE is more inclusive and representative of harder-to-reach groups. At the same time, to help ensure such shared visions do not further entrench power imbalances between citizens and professionals, professionals require training in successful CE approaches.

Nonprofit Hospital Community Benefit in the U.S.: A Scoping Review From 2010 to 2019

Background: U.S. nonprofit hospital community benefit recently underwent significant regulatory revisions. Starting in 2009, the Internal Revenue Service (IRS) required hospitals to submit a new Schedule H that provided greater detail on community benefit activities. In addition, the Affordable Care Act (ACA), which became law in 2010, requires hospitals to conduct community health needs assessments (CHNA) and develop community health implementation plans (CHIP) as a response to priority needs every 3 years. These new requirements have led to greater transparency and accountability and this scoping review considers what has been learned about community benefit from 2010 to 2019.

Methods: This review identified peer-reviewed literature published from 2010 to 2019 using three methods. First, an OvidSP MEDLINE search using terms suggested previously by community benefit researchers. Second, a PubMed search using keywords frequently found in community benefit literature. Third, a SCOPUS search of the most frequently cited articles in this topic area. Articles were then selected based on their relevance to the research question. Articles were organized into topic areas using a qualitative strategy similar to axial coding.

Results: Literature appeared around several topic areas: governance; CHNA and CHIP process, content, and impact; community programs and their evaluation; spending patterns and spending influences; population health; and policy recommendations. The plurality of literature centered on spending and needs assessments, likely because they can draw upon publicly available data. The vast majority of articles in these areas use spending data from 2009 to 2012 and the first cycle of CHNAs in 2013. Policy recommendations focus on accountability for impact, enhancing collaboration, and incentivizing action in areas other than clinical care.

Discussion: There are several areas of community benefit in need of further study. Longitudinal studies on needs assessments and spending patterns would help inform whether organizations have changed and improved operations over time. Governance, program evaluation, and collaboration are some of the consequential areas about which relatively little is known. Gaps in knowledge also exist related to the operational realities that drive community benefit activities. Shaping organizational action and public policy would benefit from additional research in these and other areas.

The Importance of Individual-Site and System-Wide Community Health Needs Assessments

In order to fulfill the Patient Protection and Affordable Care Act's Community Health Needs Assessment requirements, hospital systems sometimes vary in detail between individual hospital sites or locations and performing an assessment for the entire system. This article examines needs assessments and their accompanying implementation plans across a large university hospital system and finds support for conducting assessments at the local site-level but evidence that system-wide approaches may also have significant benefits, especially at the implementation phase. It suggests a hybrid approach to the needs assessment process where systems and their individual hospitals work together to maximize health benefits to the communities served.

A Measure of the Potential Impact of Hospital Community Health Activities on Population Health and Equity

CONTEXT

Many hospitals in the United States are exploring greater investment in community health activities that address upstream causes of poor health.

OBJECTIVE

Develop and apply a measure to categorize and estimate the potential impact of hospitals' community health activities on population health and equity.

DESIGN, SETTING, AND PARTICIPANTS

We propose a scale of potential impact on population health and equity, based on the cliff analogy developed by Jones and colleagues. The scale is applied to the 317 activities reported in the community health needs assessment implementation plan reports of 23 health care organizations in the Minneapolis-St Paul, Minnesota, metropolitan area in 2015.

MAIN OUTCOME MEASURE

Using a 5-point ordinal scale, we assigned a score of potential impact on population health and equity to each community health activity.

RESULTS

A majority (50.2%) of health care organizations' community health activities are classified as addressing social determinants of health (level 4 on the 5-point scale), though very few (5.4%) address structural causes of health equity (level 5 on the 5-point scale). Activities that score highest on potential impact fall into the topic categories of "community health and connectedness" and "healthy lifestyles and wellness." Lower-scoring activities focus on sick or at-risk individuals, such as the topic category of "chronic disease prevention, management, and screening." Health care organizations in the Minneapolis-St Paul metropolitan area vary substantially in the potential impact of their aggregated community health activities.

CONCLUSIONS

Hospitals can be significant contributors to investment in upstream community health programs. This article provides a scale that can be used not only by hospitals but by other health care and public health organizations to better align their community health strategies, investments, and partnerships with programming and policies that address the foundational causes of population health and equity within the communities they serve.

Community Priorities for Hospital-Based Prevention Initiatives: Results From a Deliberating Public

CONTEXT

Internal revenue service provisions require not-for-profit hospitals to provide "community benefit." In addition, the Affordable Care Act requires these hospitals to conduct community health needs assessments that involve appropriate stakeholders. These requirements signal government interest in creating opportunities for developing programs that are well tailored and responsive to the needs of the communities served. Gaining meaningful input from residents is a critical aspect of these processes.

OBJECTIVE

To implement public deliberations that explore local resident priorities for use of a hospital's community benefit resources to prevent chronic disease.

METHODS

Public deliberation is a method of community engagement that can provide guidance to decision makers on value-laden issues when technical solutions alone are inadequate to provide direction or set priorities. Three deliberations featuring presentations by experts and discussions among participants were convened with a cross section of residents in Brooklyn, New York. Participants were asked whether new hospital initiatives should prioritize: clinical prevention, community-based interventions, or action on broader policies affecting population health. Pre- and postsurveys, as well as qualitative methods, were used to assess knowledge and attitudes.

RESULTS

Postdeliberation, participants had significant changes in knowledge, particularly on the impact of education on health. Participants prioritized community-based and policy interventions over expanding clinical prevention capacity.

CONCLUSIONS

Public deliberation offers a method to probe informed constituent views of how a hospital can best promote its community's health. Informed local residents felt that hospitals should frame health-promoting activities more broadly than is current practice. Not-for-profit hospitals gain significant tax advantages. Increased insurance rates suggest that some hospitals will experience savings in uncompensated care that can be used to promote health more broadly. Vetting priorities for the use of new resources with informed community members can be accomplished through public deliberation. These results suggest community support for nonclinical approaches to disease prevention.

Identifying community priorities for neighborhood livability: Engaging neighborhood residents to facilitate community assessment

Identifying community-driven priorities to improve health outcomes is crucial toward achieving health equity. Seldom are communities experiencing health disparities included in community health assessment (CHA) and health improvement planning efforts (Pennel, McLeroy, Burdine, Matarrita-Cascante, & Wang, 2017). The purpose of this project was to conduct a CHA using a socio-ecological framework and community engagement (CE) process. In this paper we describe an exemplar engaging local residents as community facilitators to assess indicators of neighborhood livability, challenges and lessons learned, and implications for public health and community/public health nursing. Community residents were trained to facilitate focus groups and participated in analyzing these data. Data analysis yielded five neighborhood livability indicators and priorities reflecting the social determinants of health. Engaging community residents as stakeholders in CHA and health improvement planning is critical for identifying structural factors affecting neighborhood livability and priorities to improve health and well-being. Public health and health care system partnerships employing inclusive CE practices are necessary to improve overall population health outcomes. Public health nursing's role as strategy and system leaders can contribute toward the success of these cross-sector partnerships with diverse communities and populations.

Changes in Teaching Hospitals' Community Benefit Spending After Implementation of the Affordable Care Act

PURPOSE

U.S. teaching hospitals that qualify as 501(c)(3) organizations (a not-for-profit designation) are required to demonstrate community benefit annually. Increases in health insurance access driven by Affordable Care Act (ACA) implementation, along with new regulations, research opportunities, and educational expectations, may be changing hospitals' allocations of community benefit dollars. This study aimed to describe changes in teaching hospitals' community benefit spending between 2012 (pre-ACA implementation) and 2015 (post-ACA implementation), and to explore differences in spending changes between hospitals in Medicaid expansion and nonexpansion states.

METHOD

In 2017, for each teaching hospital member of the Association of American Medical Colleges' (AAMC's) Council of Teaching Hospitals and Health Systems required to submit Form 990s to the Internal Revenue Service, the authors sought community benefit spending data for 2012 and 2015 as reported on Schedule H.

RESULTS

The analysis included 169 pairs of Form 990s representing 184 AAMC member teaching hospitals (93% of 198 eligible hospitals). Compared with 2012, hospitals in 2015 spent $3.1 billion (20.14%) more on community benefit despite spending $804 million (16.17%) less on charity care. Hospitals in Medicaid expansion states increased spending on subsidized health services and Medicaid shortfalls at rates higher than hospitals in nonexpansion states. The latter increased spending at higher rates on community health improvement and cash/in-kind contributions.

CONCLUSIONS

After ACA implementation, teaching hospitals increased their overall community benefit spending while their charity care spending declined. Changes in community benefit spending differed according to states' Medicaid expansion status, demonstrating hospitals' responsiveness to state and local realities.

The Role Of Nonprofit Hospitals In Identifying And Addressing Health Inequities In Cities

For nonprofit hospitals to maintain their tax-exempt status, the Affordable Care Act requires them to conduct a community health needs assessment, in which they evaluate the health needs of the community they serve, and to create an implementation strategy, in which they propose ways to address these needs. We explored the extent to which nonprofit urban hospitals identified equity among the health needs of their communities and proposed health equity strategies to address this need. We conducted a content analysis of publicly available community health needs assessments and implementation strategies from 179 hospitals in twenty-eight US cities in the period August-December 2016. All of the needs assessments included at least one implicit health equity term (such as disparities, disadvantage, poor, or minorities), while 65 percent included at least one explicit health equity term (equity, health equity, inequity, or health inequity). Thirty-five percent of implementation strategies included one or more explicit health equity terms, but only 9 percent included an explicit activity to promote health equity. While needs assessment reporting requirements have the potential to encourage urban nonprofit hospitals to address health inequities in their communities, hospitals need incentives and additional capacity to invest in strategies that address the underlying structural social and economic conditions that cause health inequities.

Funding Priorities: Data-Driven Approach for Prioritizing Community Health Needs in Vulnerable Communities

The Patient Protection and Affordable Care Act of 2010 mandated nonprofit hospitals to complete community health needs assessments (CHNAs) every 3 years to identify priority health needs for the community they serve. The CHNA must include input from the community in the determination of health needs. Large variation exists across CHNAs on methods used in the integration of quantitative and qualitative data both in the determination and prioritization of health needs and those needs chosen by the hospital for community benefit funding. An important part of the CHNA is the prioritization of the needs identified, as it can influence hospital community benefit funding decisions. This article describes a method for clearly integrating qualitative and quantitative data in the CHNA process offering a best practice strategy for conducting CHNAs. The method uses an approach based on flexible, objective decision points that can be used to both generate a list of significant health needs and a prioritization of those needs based on community input, influencing funding priorities of the hospital. The method provides a standard approach useful across multiple hospital CHNAs in both rural and urban settings, and in collaborative-based CHNAs (local public health departments and hospitals) as well.

Achieving successful community engagement: a rapid realist review

Background

Community engagement is increasingly seen as crucial to achieving high quality, efficient and collaborative care. However, organisations are still searching for the best and most effective ways to engage citizens in the shaping of health and care services. This review highlights the barriers and enablers for engaging communities in the planning, designing, governing, and/or delivering of health and care services on the macro or meso level. It provides policymakers and professionals with evidence-based guiding principles to implement their own effective community engagement (CE) strategies.

Methods

A Rapid Realist Review was conducted to investigate how interventions interact with contexts and mechanisms to influence the effectiveness of CE. A local reference panel, consisting of health and care professionals and experts, assisted in the development of the research questions and search strategy. The panel’s input helped to refine the review’s findings. A systematic search of the peer-reviewed literature was conducted.

Results

Eight action-oriented guiding principles were identified:

Ensure staff provide supportive and facilitative leadership to citizens based on transparency;

foster a safe and trusting environment enabling citizens to provide input;

ensure citizens’ early involvement;

share decision-making and governance control with citizens;

acknowledge and address citizens’ experiences of power imbalances between citizens and professionals;

invest in citizens who feel they lack the skills and confidence to engage;

create quick and tangible wins;

take into account both citizens’ and organisations’ motivations.

Conclusions

An especially important thread throughout the CE literature is the influence of power imbalances and organisations’ willingness, or not, to address such imbalances. The literature suggests that ‘meaningful participation’ of citizens can only be achieved if organisational processes are adapted to ensure that they are inclusive, accessible and supportive of citizens.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3090-1) contains supplementary material, which is available to authorized users.

"One program that could improve health in this neighbourhood is ____?" using concept mapping to engage communities as part of a health and human services needs assessment

BACKGROUND

This paper presents the findings of a rapid needs assessment conducted at the request of the local health authority responsible for health care services, the Toronto Central Local Health Integration Network (Ontario, Canada), to inform health and social service planning.

METHODS

We utilized concept mapping methodology to facilitate engagement with diverse stakeholders-more than 300 community members and service providers-with a focus on hard to reach populations. Key informant interviews with service providers were used to augment findings.

RESULTS

Participants identified 48 unique services or service approaches they believed would improve the health of residents in the area, including those addressing health care, mental health and addictions, youth, families, people experiencing homelessness, seniors, general social services, and services targeting specific populations. While service providers consistently identified a critical need for mental health and addiction services, community members placed greater importance on the social determinants of health including access to housing, job placement supports and training and service accessibility. Both groups agreed that services and programs for seniors and people experiencing homelessness would be highly important.

CONCLUSION

Our study provides a unique example of using concept mapping as a tool to aid a rapid service gap analysis and community engagement in a metropolitan area. The findings also reinforce the importance of working cross-sectorally, using a Health in All Policies approach when planning services for underserved populations.

Macro Trends and the Future of Public Health Practice

Public health practice in the twenty-first century is in a state of significant flux. Several macro trends are impacting the current practice of governmental public health and will likely have effects for many years to come. These macro trends are described as forces of change, which are changes that affect the context in which the community and its public health system operate. This article focuses on seven such forces of change: the Patient Protection and Affordable Care Act, public health agency accreditation, climate change, health in all policies, social media and informatics, demographic transitions, and globalized travel. Following the description of each of these, this article then turns to possible approaches to measuring, tracking, and understanding the impact of these forces of change on public health practice, including the use of evidence-based public health, practice-based research, and policy surveillance.