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Benefits of Public Health Accreditation for Tribal Nations: Fact Sheet
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Tribal Public Health Accreditation Readiness Case Study: Chickasaw Nation
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Tribal Specific Companion Document to PHAB Standards and Measures
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NIHB Recognized by the Public Health Accreditation Board
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CHA/CHIP FAQ's for Indian Country

Community Health Assessments (CHAs) and Improvement Plans (CHIPs) are important tools for Tribes to use when evaluating and engaging in efforts to improve the health of their communities. This list of frequently asked questions (FAQs) is a compilation of questions NIHB has received from Tribes about conducting CHAs and CHIPs.

Table of Contents

  1. What is the difference between a community/Tribal health assessment (CHA) and a community/Tribal health improvement plan (CHIP)?
  2. Our Tribe is interested in conducting a CHA. Where do we start? 
  3. How long does it take to do a CHA/CHIP?
  4. An adjoining county does a CHA/CHIP and we participate. Why should we do our own CHA/CHIP? 
  5. Who should be on the CHA/CHIP team?
  6. How do partnerships play a role in conducting the CHA/CHIP?
  7. Do we have to develop our own survey for the CHA?
  8. How many questions should be in my survey tool?
  9. What kind of questions should be in my survey tool?
  10. How can I include indigenous indicators of health in my survey?
  11. Where can we get help with data analysis?
  12. How can we address social determinants with our CHA/CHIP? 
  13. How do we protect the information we collect? 
  14. How can I make sure that my CHA/CHIP is Tribally- driven?
  15. How can my CHA/CHIP be used to improve health outcomes in my community?
  16. How do we get buy-in from Tribal leaders for the CHA/CHIP?
  17. How often should we do a CHA and a CHIP?

What is the difference between a community health assessment (CHA) and a community health improvement plan (CHIP)?

A CHA is an assessment of the overall population health in a given community, and helps the community identify their key health needs. It is a comprehensive collection, analysis, and review of various data that either already exists or is collected. The data collected often goes beyond disease status and may identify social factors (such as the Social Determinants of Health), environmental, economic, and cultural factors that can lead to inequitable health outcomes in a community. A CHA can also highlight strengths and resiliency in a community. Some Tribes call their CHA a Tribal Health Assessment, or THA.

A Community Health Improvement Plan (CHIP) or Tribal Health Improvement Plan (THIP) is generally conducted following the CHA. The CHIP helps a community prioritize the key health needs identified in the CHA. The CHIP team will often seek feedback on the results of the CHA from stakeholders and the community at large. The CHIP process engages prioritization tools to develop along-term plan for addressing public health concerns identified in the CHA.

Both CHAs and CHIPs should be collaborative processes and engage Tribal community members and partners.

Additional Resources:

Our Tribe is interested in conducting a CHA. Where do we start?

NIHB has developed a sample workplan for those starting the CHA process. 

The first step to conducting a CHA is generally to develop a CHA/CHIP steering committee. In addition to the core CHA/CHIP team, this committee can include partners and stakeholders from a variety of sectors, including members of the Tribal community.

The next step is to decide how you are going to develop and conduct the CHA. Luckily, there are many great frameworks for conducting a CHA:

NIHB's website houses several examples of CHAs You can also contact the NIHB public health team to request examples of additional CHAs and CHA surveys.

Additional Resources:

How long does it take to do a CHA/CHIP?

The time a CHA and CHIP takes varies by Tribe, and depends on factors such as

  • The number of dedicated staff or availability of consultants, 
  • how much of a priority is conducting a CHA/CHIP
  • the organization's capacity to collect and analyze data, 
  • the existence of previous assessments,
  • the ability to engage with the community 

NIHB's sample CHA workplan takes 9 months, with an additional 9 months allocated for the sample CHIP workplan. Some Tribes may complete the full CHA/CHIP process within a year, while others may take 2 years or more to fully complete these plans. You should evaluate your department's capacity to conduct the CHA/CHIP and account for any unexpected delays that may occur.

Please note that the Public Health Accreditation Board (PHAB) framework requires CHAs to be completed every 5 years. If you plan to apply for public health accreditation, or to use PHAB's Standards and Measures (along with the Tribal supplement) to guide your CHA/CHIP process, you should plan ahead to ensure you have enough time to complete a new CHA every 5 years.

An adjoining county does a CHA/CHIP and we participate. Why should we do our own CHA/CHIP?

It is an individual decision if you should conduct your own CHA/CHIP or participate with the adjoining County or another jurisdiction. You may already participate in an adjoining county's CHA/CHIP, however, there are a number of reasons you may choose to conduct your own whole or partial CHA/CHIP process:

  • American Indians and Alaska Natives (AI/AN) are often under-represented in data. If AI/AN data only makes up a small percentage of the data in the adjoining County's CHA/CHIP or are not included due to data reporting challenges and mis-categorization, resources specific to your community may not be identified.
  • Your Tribe may have different health outcomes and goals than the adjoining County. 
  • Citizens of your Tribe may feel less comfortable providing data to the County compared to the Tribe.
  • With your own CHA/CHIP, you can set the priorities for your community and ensure the process is community-led.

While you may want to conduct your own CHA/CHIP, there is a benefit to aligning your documentation with the State/County health departments, and partnering with the County during the process. This alignment can lead to stronger partnerships as you pursue common health-related goals.

Additional Resources:

Who should be on the CHA/CHIP team?

A CHA/CHIP committee will likely be led by your core CHA/CHIP team, which may include Tribal staff members that work on performance, system, and/or quality improvement initiatives, and/or public health accreditation initiatives.

You may choose to include others on your CHA/CHIP committee, including public health professionals, healthcare professionals, Tribal and community leaders, traditional healers, and agencies providing service to the Tribe related to the social determinants of health, including education, environmental services, social services, behavioral health, and/or housing. You may also want to include outside partners, including academic partners and representatives from the surrounding state and county health departments, particularly if you plan to align your CHIPs. You can consider having formal or informal agreements with outside partners.

While this committee will work most closely with developing the CHA, you should also invite the broader Tribal community to participate in the planning process. You should consider including community members with diverse perspectives, including both elders and youth, community members of different genders, abilities, sexual orientations, incomes, employment status, and education levels, etc. Inviting community members to join early on in the process is key for developing a community-driven CHA, and will bolster community support and active partnerships.

Additional Resources: 

How do partnerships play a role in conducting the CHA/CHIP?

Public health programs do not operate in silos. Partners both within the Tribe and from external organizations often play a role in addressing public health challenges, including those related to the Social Determinants of Health.

For some Tribes, the agency conducting the CHA and responsible for the 10 Essential Public Health Services (below) may not directly provide all aspects of public health services. Partner organizations may have expertise in specific indicators of health, information regarding community assets, or the ability to access data.

When conducting the CHA/CHIP process, the core team may want to involve partners in planning meetings, may rely on partner for support in analyzing data, and may work with other organizations on implementing the CHIP. Involving partners every step of the process will ensure the alignment of CHIP interventions. 

The Public Health Accreditation Board requires the participation of partners outside of the health department, and shares recommendations of partners that could be considered, with additional considerations for Tribes.

Additional Resources:

Do we have to develop our own survey for the CHA?

No, that is up to the individual Tribe. A standard survey, such as the Behavior Risk Factor Surveillance System (BRFFS) questionnaire, may serve your needs. Other Tribes may share examples of surveys they have used. Some Tribal Epidemiology Centers (TECs) provide technical assistance in developing survey instruments.They may also help adapt existing tools. Additionally, some Tribes have participated in a neighboring county's survey rather than lead the process (see question 6). What is most important is that your survey tool will give you information that will be useful and meaningful to your Tribe. We recommend weighing the pros and cons of developing your own survey with your planning team. Also, see what other Tribes have used and lessons learned. Also inquire about what your TEC can offer. Whether you are developing your own instrument or shopping around, NIHB can assist you with examples and resources!

Additional Resources:

How many questions should be in my survey tool?

There is no set number of questions mandated. All questions included should provide actionable information, and a longer survey will generally have a lower response rate.

You can view Tribal examples of CHAs here.

NIHB has examples of Tribal surveys available upon request. Contact the NIHB public health department to request access.

Additional Resources:

What kind of questions should be in my survey tool?

Prior to developing a survey, you should determine what data you have access to, and what indicators of health are important to collect data on.

Surveys should include quantitative and qualitative data related to demographics, health outcomes, mortality rates, health risk factors, health behaviors, perceptions of health, community assets etc. You also should collect information about Social Determinants of Health, such as education level, income, housing security, and access to transportation, Adverse Childhood Experiences, or other key factors important to your community. You can combine your survey with focus groups, key informant interviews, town forums, listening sessions, and other methods of community feedback to gather this data.

You can view Tribal examples of CHAs here.

NIHB has examples of Tribal surveys available upon request. Contact the NIHB public health department to request access.

Additional Resources:

How can I include indigenous indicators of health in my survey?

Indigenous indicators of health are ways your community may measure the wellbeing of your people outside of the western model, which often focuses on health as strictly the absence of disease. Tribal communities may focus more on an overall sense of balance, and many Tribes choose to measure wellness using indicators that do not appear on state and local assessments.

To determine which indigenous indicators to include in your survey, you should engage with your community to determine how they measure their own health. Examples of indigenous indicators may include engagement in cultural practices, connection with the community, the physical ability to participate in certain traditions, access to indigenous knowledge, understanding of indigenous languages, the health of the environment, etc. The indigenous indicators of health in your community may be unique to your population.

You may also choose to collect data using alternative methods for conducting a CHA, as these may add an additional layer of culturally relevant data.

Additional Resources:

Where can we get help with data analysis?

Data analysis assistance can come from various places. While some Tribes engage their own staff in data analysis, other Tribes tap into resources such as Tribal Epidemiology Centers (TECs), consulting companies, and universities.

NIHB has several resources for understanding, interpreting, and presenting data.

Additional Resources:

How can we address social determinants with our CHA/CHIP?

Looking at the social determinants of health is a key component of the CHA/CHIP process. Certain members of your population may be at higher risk of health disparities, and solutions need to involve collaboration across agencies that can alleviate barriers to health access.

For the CHA, identifying both health disparities and their causes is a requirement for PHAB accreditation. You can incorporate questions in your survey about risk factors such as housing, education, transportation, connection to culture, etc., or use pre-existing data. CDC has a list of resources where data on the social determinants of health may be available.

Often, a root cause analysis can be helpful in identifying the social determinants of health during the CHIP process. When selecting a CHIP priority, you can use various tools to identify the root cause.

Additional Resources:

How do we protect the information we collect?

Each Tribe should make their own decision on sharing the information collected. You should balance the benefits of having the data be public with the concerns over data privacy. In smaller communities, consider how likely it will be for participants to be identified.

Sharing aggregate (combined) data is generally lower risk.

If data will be shared with an outside partner (contractor or university), consider a formal agreement to ensure the Tribe maintains ownership of the data. You may also need to go through an IRB process prior to collecting this data.

If data will be made public, participants should be informed of this before providing information. You should always follow HIPPA guidelines, and never share identifying information about a community member.

Whether the data is shared publicly or not, there is a responsibility for public health officials to share data they collect with the population they serve. Consider how you will present this data ahead of time.

Additional Resources:

How can I make sure that my CHA/CHIP is Tribally- driven?

CHA/CHIPs are not one-size fits all. When developing your survey tool, think about how your Tribe measures health. You can include Tribal specific indicators based on what your community values, such as the ability to participate in certain traditions or events, ability to spend time with family members, connection with the community, etc. You should also think about what determinants of health are specific concerns in your Tribe, and engage community members and Tribal leaders throughout the CHA/CHIP process. 

Examples of community and leadership engagement may include testing your CHA survey with community members prior to releasing it, reviewing results with community members in meetings or focus groups /key informant interviews, and including your community in the prioritization process. This engagement can promote community ownership of the overall CHA/CHIP process and gathered data, and ensure you are measuring health in a way that is meaningful to Tribal citizens.

Additional Resources:

How can my CHA/CHIP be used to improve health outcomes in my community?

The CHA/CHIP process is the first step to identifying health needs in a community and prioritizing the most pressing health issues. CHA/CHIPs also look at root causes of health issues, including the social determinants of health. The data from the CHA, and the resulting plan outlined in your CHIP can guide your health department towards stronger services and lasting change. To ensure this, you will want to monitor your progress towards your CHIP's goals.

Additionally, the next step many health departments take is a strategic plan- a long term plan for what your organization will do next and how success will be measured. Using data from your CHA, and building off the goals set in your CHIP, your organization can plan to reduce health disparities, increase equity, and elevate the health of your Tribe.

Additional Resources:

How do we get buy-in from Tribal leaders for the CHA/CHIP?

Tribal leaders are often busy, and need to balance many competing priorities. However, buy in from Tribal leaders is a key component to gaining community and financial support for your CHA/CHIP process and other performance improvement measures.

Tribal leaders often want to hear about the benefits of performance improvement activities such as CHAs and CHIPS. NIHB has also developed a video in which Tribal leaders from across the United States share their perspective of the public health accreditation process (of which the CHA/CHIP is a key component).

Tribal leaders may also have limited time to consider a proposal such as a CHA/CHIP process. NIHB has prepared a creating an elevator speech guide and worksheet specific to Tribal public health accreditation. An elevator speech allows you to communicate an important need in under 90 seconds. This guide can be adapted to develop an elevator speech that is more specific to the CHA/CHIP process.

How often should we do a CHA and a CHIP?

A CHA/CHIP is typically updated every 3-5 years. To meet PHAB requirements, the CHA should be conducted at least every 5 years. 



 

Public Health Inquiries:

Tyler Dougherty, MPH
Director of Public Health Policy and Programs

National Indian Health Board
910 Pennsylvania Ave, SE
Phone: 202-922-0100
Washington, DC 20003
[email protected]

 

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