How to Understand a Community and Its Needs


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A community assessment is a comprehensive profile that describes the area served by your organization and the people who live in a specific area. The community assessment is the first step in planning and provides information about particular ethnic or other special groups that may need your attention. It will also help you identify the needs of the target audience and determine if services and organizations currently exist that can provide necessary resources (community assets) such as volunteers, facilities and funding. The Community Assessment tool can be used to help you gather information about communities. See Other Sources of Data below for other sources of indirect data.



  • Census Bureau regional offices
  • State Department of Human Resources
  • Public library
  • Area Agencies on Aging
  • United Way
  • Information and Referral Services
  • Chamber of Commerce - Some communities have Hispanic Chambers of Commerce that would be helpful for collecting data about the Hispanic community.
  • Associations for minority businesses
  • Local newspapers
  • Minority community publications
  • Local chapters of national minority organizations
  • Health professionals or university students already working with the community



Before determining what programs and services to offer a community and how these should be delivered and promoted, it is helpful to get more detailed information about the needs and preferences of your target group. For example, what is the magnitude of problems associated with arthritis? How much is currently being done? Where and how should services be offered? What resources does the community have?  The community assessment process may have given you much of this information. Other ways to collect data include interviewing key informants, distributing surveys or conducting focus groups or convening town meetings. Use resources such as local universities to help you with these efforts. Your data gathering can be very informal and limited, depending upon the types of resources that you have available.


Key Informant Interviews

Interview key informants from the targeted groups, including bicultural health professionals, respected religious, community leaders, folk healers and representatives of agencies to validate and supplement the information you have already collected. See Possible Questions to Ask for examples of the types of information that would be useful in helping to plan your community outreach and program marketing activities.


Surveys and Focus Groups

Sometimes it is possible to distribute needs assessment questionnaires to key health professionals and health centers serving minority clients and/or to minority clients recruited through area community agencies. Consider using focus groups to gather more direct information from the members of a culturally diverse population about their needs and preferences. See Sample Needs Assessment/ Focus Group Questions for some sample questions to ask.


Town Meeting

To gather wider input into the planning process and to help cement community support for your outreach efforts, consider hosting a town meeting. Invite representatives of the targeted group who are already involved with your organization, and personally invite representatives from minority organizations, influential individuals such as bicultural health professionals, church leaders, school representatives and politicians to attend the town meeting. See Town Meeting Topics for an outline of possible topics to cover in a meeting.



  • What is the group’s ethnic and/or national origin? For example, with a Hispanic population, you need to determine what percent of the group is Mexican, Puerto Rican, Cuban, etc.
  • What is the average length of their residency in the United States and in your community? Are they temporary/seasonal immigrants, border commuters, recent immigrants, permanent immigrants, etc.?
  • What is the predominant age and sex of the population?
  • What is the preferred language used? (You can determine language spoken at home from Census data).
  • What is the literacy level in English and/or native language?
  • What is the average educational level?
  • What is the average income or extent of poverty?
  • How many are active members of the workforce? How many are unemployed?
  • What are the predominant family structures? Are they patriarchal, female head of household, extended, etc.?
  • What political, social, religious or business realities may influence their needs and the priority they place on health? What are some of the barriers to their involvement with programs? For example, are there many single parents, working mothers, latchkey children, documentation/ residency status issues, overcrowded housing concerns, need for food, clothing, transportation, financial limitations, etc.?




  • What are the needs of the targeted population?
  • Is the group at high risk for any particular type of arthritis? Is there a high prevalence of certain types of arthritis in the group?
  • Are there other health conditions such as obesity that are particularly prevalent in this population that could be addressed in tandem with arthritis?
  • What do group members currently know or believe about arthritis and its treatment? What do they perceive as problems related to arthritis? How worthwhile do they feel arthritis information and programs would be?         
  • What are the group’s current arthritis-related medical and self-care practices? For example, do they use clinics or private physicians, folk healers, non-traditional providers and therapies?
  • What health professionals, medical centers, hospitals, health departments, neighborhoodmedical clinics, visiting nurse agencies and other medical organizations are already servingthis population?


  • Where does the population live? Are there any housing projects, senior citizen apartment complexes or other residential areas that have a concentration of the cultural group?
  • What services does the population need?
  • What types of self-help and exercise programs are currently being offered to this community by your organization or others?
  • Where are these services currently being offered? For example, are they offered at hospitals, public health clinics, wellness centers, community centers, and private offices, nutrition/ Women, Infant and Children (WIC) program sites, schools, etc.? 
  • Are they accessible to the target groups?
  • What forms of transportation does the target group use to access services?
  • To what extent is the group aware of these existing programs? To what extent are the needs of the target group being met by these existing services?
  • What services/ programs were offered in the past? What did they accomplish? What lessons were learned from these projects?
  • Where should services be offered? Where do groups typically congregate? What are their community activities? What area businesses do they use and what community organizations are currently serving the group? For example:

    • Churches, synagogues, religious and faith-based organizations
    • Civic, community and business organizations such as Junior League, League of Women Voters, Area Agencies on Aging, Lions Clubs, Rotary Clubs, etc.
    • Unions, union halls and lodges
    • Fraternal, cultural groups and local chapters of minority organizations
    • Block associations, tenant councils and rural cooperatives
    • Senior centers, community centers, nutrition centers, dance halls, schools, libraries and other recreational or meeting centers
    • Businesses within the community such as laundromats, beauty salons, markets/ stores, pharmacies, child-care centers, etc.
  • Which agencies does the group hold in highest regard? And what is their attitude towards your organization? For example, are they unaware, do they distrust or respect the organization?
  • Who has credibility in the community? Who are the politicians, businessmen, media personalities, health workers, religious leaders, educators and community leaders who are respected locally?
  • Who are the informal indigenous leaders who can become spokespeople and program volunteers? These might include:
    • Midwives
    • Barbers
    • Beauticians
    • Respected elderly men or women
    • Neighborhood grocery store owners
    • Service station proprietors
    • Mail carriers, etc.
  • What are the formal and informal channels of communication within the group?
  • How should services be promoted/how can the group be reached?
  • Where do they currently get health information? 
  • What media do they use? For example, do they pay attention to influential family members, lay and professional leaders, Spanish television and radio, African American radio, local newspapers, bus/subway signs, billboards, etc.?



  • Do you have arthritis? If so, what kind did your doctor say you have?
  • How would you rate your own health? Excellent, good, fair, poor?
  • What comes to mind when you think of arthritis?
  • What five to 10 things can you do to help your arthritis?
  • What makes your arthritis worse?
  • If you are sick, where would you go for medical treatment?
  • What sources do you use for medical information?
  • What kinds of people do you turn to when you feel bad or sick? (If looking for specific names of informal leaders, ask for the names of these individuals.)
  • Has the group or members of the group utilized AF services? If yes, what was their impression?
  • How should we get the word out to your community about arthritis? For example, are you most effective by communicating person to person or by newspaper, TV, radio, bus placards, community center flyers, church newsletters, etc.?
  • What agencies/organizations in your community are most important to work with in establishing an effective arthritis outreach network?
  • Where would be the best place to host an arthritis education program?
  • If there were a program that did this (for example, describe the AF Self-Help, AF Exercise or AF Aquatic Program—that could help relieve pain and stiffness/ provide other benefits), would you come? If not, what are the reasons?
  • If we were able to solve that problem, would you come then?



  • Share backgrounds and interests in arthritis and the minority population.
  • Summarize the data already collected about the problems faced by minorities with arthritis and discuss the magnitude of the needs.  Also summarize the data already collected about the community’s assets and how these resources may be used to overcome barriers.
  • Describe the AF Life Improvement Series Programs and other services.
  • Explain the value of a community network in order to assure better use of existing resources through coordination and integration of services.
  • Invite the other agencies to describe what they currently provide or would be willing to provide.
  • Discuss what the group would like to see happen next.




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