Health planning for and with the community is an essential component of community health nursing practice.

The term health planning seems

simple, but the underlying concept is quite complex. Like many of the other components of community health nursing, health planning tends to
vary at the different aggregate levels. Health planning with an individual or a family may focus on direct care needs or self-care responsibilities.
At the group level, the primary goal may be health education, and, at the community level, health planning may involve population disease
prevention or environmental hazard control.

II. Planning
A. Select one health problem or need, and identify the ultimate goal of intervention. Identify specific, measurable
objectives as mutually agreed upon by the student and aggregate.
B. Describe the alternative interventions that are necessary to accomplish the objectives. Consider interventions at each
system level where appropriate (e.g., aggregate system, suprasystem, and subsystems). Select and validate the
intervention(s) with the highest probability of success. Interventions may use existing resources, or they may require
the development of new resources.

7. Community Health Planning, Implementation, and Evaluation

CHAPTER 7

Community Health Planning,

Implementation, and Evaluation
Diane C. Martins and Patricia M. Burbank*

OUTLINE

Overview of Health Planning

Health Planning Model
Assessment
Planning
Intervention
Evaluation
Health Planning Projects
Successful Projects
Unsuccessful Projects
Discussion
Health Planning Federal Legislation
Hill-Burton Act
Regional Medical Programs
Comprehensive Health Planning
Certificate of Need
National Health Planning and Resources Development Act
Changing Focus of Health Planning
Nursing Implications

Objectives
Upon completion of this chapter, the reader will be able to do the following:
1. Describe the concept “community as client.”
2. Apply the nursing process to the larger aggregate within a system’s framework.
3. Describe the steps in the health planning model.
4. Identify the appropriate prevention level and system level for nursing interventions in families, groups, aggregates, and
communities.
5. Recognize major health planning legislation.
6. Analyze factors that have contributed to the failure of health planning legislation to control health care costs.
7. Describe the community health nurse’s role in health planning, implementation, and evaluation.

Key terms
certificate of need (CON)
community as client
health planning
Health Planning Model
Hill-Burton Act
key informant
National Health Planning and Resources Development Act
Partnership for Health Program (PHP)
Regional Medical Programs (RMPs)

Additional Material for Study, Review, and Further Exploration

evolve.elsevier.com/Nies
• Quiz
• Case Studies
• Glossary
• WebLinks

Health planning for and with the community is an essential component of community health nursing practice. The term health
planning seems simple, but the underlying concept is quite complex. Like many of the other components of community health
nursing, health planning tends to vary at the different aggregate levels. Health planning with an individual or a family may focus
on direct care needs or self-care responsibilities. At the group level, the primary goal may be health education, and, at the
community level, health planning may involve population disease prevention or environmental hazard control. The following
example illustrates the interaction of community health nursing roles with health planning at a variety of aggregate levels
Clinical Example
Bianca Tesch is an RN in a suburban high school. During the course of the school year, she noted an increasing incidence of
pregnancy-related dropouts. A nurse at the junior high school confirmed a corresponding increase in withdrawal among younger
pregnant teenagers. After reviewing information in nursing journals, other professional journals, and the general media, Bianca
discovered a national epidemic of unwed pregnant teenagers.
Bianca questioned the reason for the increased pregnancies. Her assessment of the problem included several findings. Sexually
active teenagers do not use contraception regularly because they want their actions to seem “spontaneous” and not “planned.”
Also, a variety of sexual misconceptions led teens to believe they were invulnerable to pregnancy. For example, a typical
misconception among female students was “I will not become pregnant if I do not have regular periods or if my boyfriend does not
ejaculate inside me.” Teenagers also find it difficult or embarrassing to obtain certain contraceptives. The suburb does not have a
local family planning clinic, and area physicians are reluctant to counsel teenagers or prescribe contraceptives without parental
permission. The nurse also discovered that, several years earlier, a group of parents stopped an attempt by the local school board to
establish sex education in the school system. The parents believed this responsibility belonged in the home.
Bianca considered all of these factors in developing her plan of action. She met with teachers, officials, and parents. Teachers and
school officials were willing to deal with this sensitive issue if parents could recognize its validity. In meetings, many parents
revealed they were uncomfortable discussing sexuality with their teenaged children and welcomed assistance. However, they were
concerned that teachers might introduce the mechanics of reproduction without giving proper attention to the moral decisions and
obligations involved in relationships. The parents expressed their desire to participate in curriculum planning and to meet with the
teachers instead of following a previous plan that required parents to sign a consent form for each teenager. In support of the
parents, Bianca asked a nearby metropolitan family planning agency to consider opening a part-time clinic in the suburb. The local
school board proposed instituting a home-tutoring program for pregnant teenagers, which would encourage their return to school.
 .
Implementing such a comprehensive plan is time consuming and requires community involvement and resources. The nurse
enlisted the aid of school officials and other community professionals. Time will reveal the plan’s long-term effectiveness in
reducing teen pregnancy.
This example shows how nurses can and should become involved in health planning. Teen pregnancy is a significant health
problem and often results in lower education and lower socioeconomic status, which can lead to further health problems. The
nurse’s assessment and planned interventions involved individual teenagers, parents and families, the school system, and
community resources.
This chapter provides an overview of health planning and evaluation from a nursing perspective. It also describes a model for
student involvement in health planning projects and a review of significant health planning legislation.

Overview of health planning

One of the major criticisms of community health nursing practice involves the shift in focus from the community and larger
aggregate to family caseload management or agency responsibilities. When focusing on the individual or family, nurses must
remember that these clients are members of a larger population group or community, and environmental factors influence them.
Nurses can identify these factors and plan health interventions by implementing an assessment of the entire aggregate or
community. Figure 7-1 illustrates this process.

FIGURE 7-1 The

community as client. Chapter 6, Table 6-1 (pp. 99-100), provides assessment parameters that help identify the
client’s assets and needs.
The concept of “community as client” is not new. Lillian Wald’s work at New York City’s Henry Street settlement in the late
1800s exemplifies this concept. At the Henry Street settlement, Miss Wald, Mary Brewster, and other public health nurses worked
with extremely poor immigrants.

The “case” element in Wald’s early reports received less and less emphasis; she instinctively went beyond the
symptoms to appraise the whole individual. She observed that one could not understand the individual without
 understanding the family and saw that the family was in the grip of larger social and economic forces, which it could
not control (Duffus, 1938).
The early beginnings of public health nursing incorporated visits to the homebound ill and applied the nursing process to larger
aggregates and communities to improve health for the greatest number of people. Wald’s goals, and those of other public health
nurses, were health promotion and disease prevention for the entire community (Silverstein, 1985). Health planning at the
aggregate or community level is necessary to accomplish these goals.
Through the 1950s, public health nursing adopted Wald’s nursing concepts, which focused on mobilizing communities to solve
local problems, treat the poor, and improve the environmental conditions that fostered disease. During the 1950s, social changes
such as suburbanization, increased family mobility, and enhanced government health expenditures updated nursing roles. Since the
mid-1960s, there has been a shift from public health nursing, which emphasizes community care, to community health nursing,
which includes all nonhospital nursing activities. New trends constantly emerge through health care reform debates. It has become
more important to use nurses as primary care providers in the health care system. A continued shift into the community requires
that community health nurses become increasingly visible and vocal leaders of health care reform.
The increased focus on community-based nursing practice yields a greater emphasis on the aggregate becoming the client or
care unit. However, the community health nurse should not neglect nursing care at the individual and family levels by focusing on
health care only at the aggregate level. Rather, the nurse can use this community information to help understand individual and
family health problems and improve their health status. Table 7-1 illustrates the differences in community health nursing practice at
the individual, family, and community levels.
TABLE 7-1
Levels of Community Health Nursing Practice

Client Example Characteristics Health Assessment Nursing Involvement

Individual Lisa McDonald An individual with various needs Individual strengths, problems, and needs Client-nurse interaction

Family Moniz family A family system with individual Individual and family strengths, problems, Interactions with individuals
and group needs and needs and the family group

Boy Scout troop Common interests, problems, Group dynamics

Alzheimer’s support and needs Fulfillment of goals
Group group Interdependency Group member and leader

Patients with AIDS in

a given state
Population Pregnant adolescents Large, unorganized group with Assessment of common problems, needs, Application of nursing process
group in a school district common interests, and vital statistics to identified needs
problems, and needs

A work place
A school
Organization Organized group in a common Relationship of goals, structure, Consultant and/or employee
location with shared communication, patterns of application of nursing
governance and goals organization to its strengths, process to identified
problems, and needs needs

Immigrant
neighborhood
Community Anytown, USA An aggregate of people in a Analysis of systems, strengths, Community leader, participant,
common location with characteristics, problems, and needs and health care provider
organized social systems
 However, before nurses can participate in health care planning, they must be knowledgeable about the process and comfortable
with the concept of community as client or care focus. It is essential that undergraduate and graduate nursing programs integrate
these concepts into the curricula. If basic and advanced nursing education includes health planning, the student becomes aware of
the process and the professional involvement opportunities.
Early efforts to provide students with learning experiences in community health investigation included Hegge’s (1973) use of
learning packets for independent study and Ruybal’s opportunities for students to apply epidemiological concepts in community
program planning and evaluation (Ruybal, Bauwens, and Fasla, 1975). However, neither of these approaches presented a complete
model that incorporated the nursing process into a health planning framework. Several other authors, including Budgen and
Cameron (2003) and Shuster and Goeppinger (2008), described the community health planning process. However, none of these
models uses practical examples for actual student implementation throughout the entire process.

Health planning model

A model based on Hogue’s (1985) group intervention model was developed in response to this need for population focus.
The Health Planning Model aims to improve aggregate health and applies the nursing process to the larger aggregate within a
systems framework. Figure 7-2 depicts this model. Incorporated into a health planning project, the model can help students view
larger client aggregates and gain knowledge and experience in the health planning process. Nurses must carefully consider each
step in the process, using this model. Box 7-1 outlines these steps. In addition, Box 7-2 provides the systems framework premises
that nurses should incorporate.

FIGURE 7-2 Health Planning Model.

BOX 7-1

Health Planning Project Objectives

I. Assessment
A. Specify the aggregate level for study (e.g., group, population group, or organization). Identify and provide a
general orientation to the aggregate (e.g., characteristics of the aggregate system, suprasystem, and subsystems).
Include the reasons for selecting this aggregate and the method for gaining entry.
B. Describe specific characteristics of the aggregate.
1. Sociodemographic characteristics: Including age, sex, race or ethnic group, religion, educational background
and level, occupation, income, and marital status.
2. Health status: Work or school attendance, disease categories, mortality, health care use, and population
growth and population pressure measurements (e.g., rates of birth and death, divorce, unemployment, and
drug and alcohol abuse). Select indicators appropriate for the chosen aggregate.
 3. Suprasystem influences: Existing health services to improve aggregate health and the existing or potential
positive and negative impact of other community-level social system variables on the aggregate. Identify
the data collection methods.
C. Provide relevant information from the literature review, especially in terms of the characteristics, problems, or
needs within this type of aggregate. Compare the health status of the aggregate with similar aggregates, the
community, the state, and the nation.
D. Identify the specific aggregate’s health problems and needs based on comparative data collection analysis and
interpretation and literature review. Include input from clients regarding their need perceptions. Give priorities
to health problems and needs, and indicate how to determine these priorities.
II. Planning
A. Select one health problem or need, and identify the ultimate goal of intervention. Identify specific, measurable
objectives as mutually agreed upon by the student and aggregate.
B. Describe the alternative interventions that are necessary to accomplish the objectives. Consider interventions at
each system level where appropriate (e.g., aggregate system, suprasystem, and subsystems). Select and validate
the intervention(s) with the highest probability of success. Interventions may use existing resources, or they may
require the development of new resources.
III. Intervention
A. Implement at least one level of planned intervention when possible.
B. If intervention was not implemented, provide reasons.
IV. Evaluation
A. Evaluate the plan, objectives, and outcomes of the intervention(s). Include the aggregate’s evaluation of the
project. Evaluation should consider the process, product, appropriateness, and effectiveness.
B. Make recommendations for further action based on the evaluation, and communicate these to the appropriate
individuals or system levels. Discuss implications for community health nursing.

BOX 7-2

Systems Framework Premises

I. Each system is a goal-directed collection of interacting or interdependent parts, or subsystems.
II. The whole system is continually interacting with and adapting to the environment, or suprasystem.
III. There is a hierarchical structure (suprasystem → system → subsystems).
IV. Each system is characterized by the following:
A. Structure: Arrangement and organization of parts, or subsystems
1. Organization and configuration (e.g., traditional vs. nontraditional; greater variability [no right or wrong
and no proper vs. improper form])
2. Boundaries (open vs. closed; regulate input and output)
3. Territory (spatial and behavioral)
4. Role allocation
B. Functions: Goals and purpose of system and activities necessary to ensure survival, continuity, and growth of
system
1. General
a. Physical: Food, clothing, shelter, protection from danger, and provision for health and illness care
b. Affectional: Meeting the emotional needs of affection and security
c. Social: Identity, affiliation, socialization, and controls
2. Specific: Each family, group, or aggregate has its own individual agenda regarding values, aspirations, and
cultural obligations
C. Process and dynamics
1. Adaptation: Attempt to establish and maintain equilibrium; balance between stability, differentiation, and
growth; self-regulation and adaptation (equilibrium and homeostasis)
a. Internal: Families, groups, or aggregates
b. External: Interaction with suprasystem
2. Integration: Unity and ability to communicate
3. Decision making: Power distribution, consensus, accommodation, and authority

Several considerations affect how nurses choose a specific aggregate for study. The community may have extensive or limited
opportunities appropriate for nursing involvement. Additionally, each community offers different possibilities for health
intervention. For example, an urban area might have a variety of industrial and business settings that need assistance, whereas a
suburban community may offer a choice of family-oriented organizations such as boys and girls clubs and parent-teacher
associations that would benefit from intervention.
 A nurse should also consider personal interests and strengths in selecting an aggregate for intervention. For example, the nurse
should consider whether he or she has an interest in teaching health promotion and preventive health or in planning for
organizational change, whether his or her communication skills are better suited to large or small groups, and whether he or she has
a preference for working with the elderly or with children. Thoughtful consideration of these and other variables will facilitate
assessment and planning.

Assessment
To establish a professional relationship with the chosen aggregate, a community health nurse must first gain entry into the group.
Good communication skills are essential to make a positive first impression. The nurse should make an appointment with the group
leaders to set up the first meeting.
The nurse must initially clarify his or her position, organizational affiliation, knowledge, and skills. The nurse should also clarify
mutual expectations and available times. Once entry is established, the nurse continues negotiation to maintain a mutually
beneficial relationship.
Meeting with the aggregate on a regular basis will allow the nurse to make an in-depth assessment. Determining
sociodemographic characteristics (e.g., distribution of age, sex, and race) may help the nurse ascertain health needs and develop
appropriate intervention methods. For example, adolescents need information regarding nutrition, abuse of drugs and alcohol, and
relationships with the opposite sex. They usually do not enjoy lectures in a classroom environment, but the nurse must possess
skills to initiate small-group involvement and participation. An adult group’s average educational level will affect the group’s
knowledge base and its comfort with formal versus informal learning settings. The nurse may find it more difficult to coordinate
time and energy commitments if an organization is the focus group, because the aggregate members may be more diverse.
The nurse may gather information about sociodemographic characteristics from a variety of sources. These sources include
observing the aggregate, consulting with other aggregate workers (e.g., the factory or school nurse, a Head Start teacher, or the
resident manager of a high-rise senior-citizen apartment building), reviewing available records or charts, interviewing members of
the aggregate (i.e., verbally or via a short questionnaire), and interviewing a key informant. A key informant is a formal or informal
leader in the community who provides data that is informed by his or her personal knowledge and experience with the community.
In assessing the aggregate’s health status, the nurse must consider both the positive and negative factors. Unemployment or the
presence of disease may suggest specific health problems, but low rates of absenteeism at work or school may suggest a need to
focus more on preventive interventions. The specific aggregate determines the appropriate health status measures. Immunization
levels are an important index for children, but nurses rarely collect this information for adults. However, the nurse should consider
the need for influenza and/or pneumonia vaccines with the elderly. Similarly, the nurse would expect a lower incidence of chronic
disease among children, whereas the elderly have higher rates of long-term morbidity and mortality.
The aggregate’s suprasystem may facilitate or impede health status. Different organizations and communities provide various
resources and services to their members. Some are obviously health related, such as the presence or absence of hospitals, clinics,
private practitioners, emergency facilities, health centers, home health agencies, and health departments. Support services and
facilities such as group meal sites or Meals on Wheels (MOW) for the elderly and recreational facilities and programs for children,
adolescents, and adults are also important. Transportation availability, reimbursement mechanisms or sliding-scale fees, and
community-based volunteer groups may determine the use of services. An assessment of these factors requires researching public
records (e.g., town halls, telephone directories, and community services directories) and interviewing health professionals,
volunteers, and key informants (i.e., someone who is familiar with the community) in the community. The nurse should augment
existing resources or create a new service rather than duplicating what is already available to the aggregate.
A literature review is an important means of comparing the aggregate with the norm. For example, children in a Head Start
setting, day care center, or elementary school may exhibit a high rate of upper respiratory tract infections during the winter. The
nurse should review the pediatric literature and determine the normal incidence for this age range in group environments. Further,
the nurse should research potential problems in an especially healthy aggregate (e.g., developmental stresses for adolescents or
work or family stresses for adults) or determine whether a factory’s experience with work-related injury is within an average range.
Comparing the foregoing assessment with research reports, statistics, and health information will help determine and prioritize the
aggregate’s health problems and needs.
The last phase of the initial assessment is identifying and prioritizing the specific aggregate’s health problems and needs. This
phase should relate directly to the assessment and the literature review and should include a comparative analysis of the two. Most
important, this step should reflect the aggregate’s perceptions of need. Depending on the aggregate, the nurse may consult the
aggregate members directly or interview others who work with the aggregate (e.g., a Head Start teacher). Interventions are seldom
successful if the nurse omits or ignores the clients’ input.
During the needs assessment, four types of needs should be assessed. The first is the expressed need or the need expressed by
the behavior. This is seen as the demand for services and the market behavior of the targeted population. The second need is
normative, which is the lack, deficit, or inadequacy as determined by expert health professionals. The third type of need is the
perceived need expressed by the audience. Perceived needs include the population’s wants and preferences. The final need is the
relative need, which is the gap showing health disparities between the advantaged and disadvantaged populations (Issel, 2009).
Finally, the nurse must prioritize the identified problems and needs to create an effective plan. The nurse should consider the
following factors when determining priorities:
 • Aggregate’s preferences
• Number of individuals in the aggregate affected by the health problem
• Severity of the health need or problem
• Availability of potential solutions to the problem
• Practical considerations such as individual skills, time limitations, and available resources
In addition, the nurse may further refine the priorities by applying a framework such as Maslow’s (1968) hierarchy of needs (i.e.,
lower-level needs have priority over higher-level needs) or Leavell and Clark’s (1965) levels of prevention (i.e., primary prevention
may take priority for children, whereas tertiary prevention may take higher priority for the elderly).
Assessment and data collection are ongoing throughout the nurse’s relationship with the aggregate. However, the nurse should
proceed to the planning stage once the initial assessment is complete. It is particularly important to link the assessment stage with
other stages at this step in the process. Planning should stem directly and logically from the assessment, and implementation should
be realistic.
An essential component of health planning is to have a strong level of community involvement. The nurse is responsible for
advocating for client empowerment throughout the assessment, planning, implementation, and evaluation phase of this process.
Community organization reinforces one of the field’s underlying premises as outlined by Nyswander (1956): “Start where the
people are.” Moreover, Labonte (1994) stated that the community is the engine of health promotion and a vehicle of empowerment.
He describes five spheres of an empowerment model, that focus on the following levels of social organization: interpersonal
(personal empowerment), intragroup (small-group development), intergroup (community collaboration), interorganizational
(coalition building), and political action. Attention to collective efforts and support of community involvement and empowerment,
rather than focusing on individual efforts, will help ensure that the outcomes reflect the needs of the community and truly make a
difference in people’s lives.
Labonte’s (1994) multilevel empowerment model allows us to consider both macro-level and micro-level forces that combine to
create both health and disease. Therefore, it seems that both micro and macro viewpoints on health education provide nurses with
multiple opportunities for intervention across a broad continuum. In summary, health education activities that have an “upstream”
focus examine the underlying causes of health inequalities through multilevel education and research. This allows nurses to be
informed by critical perspectives from education, anthropology, and public health (Israel et al., 2005).
Successful health programs rely on empowering citizens to make decisions about individual and community health.
Empowering citizens causes power to shift from health providers to community members in addressing health priorities.
Collaboration and cooperation among community members, academicians, clinicians, health agencies, and businesses help ensure
that scientific advances, community needs, sociopolitical needs, and environmental needs converge in a humanistic manner.

Planning
Again, the nurse should determine which problems or needs require intervention in conjunction with the aggregate’s perception of
its health problems and needs, and based on the outcomes of prioritization. Then the nurse must identify the desired outcome or
ultimate goal of the intervention. For example, the nurse should determine whether to increase the aggregate’s knowledge level and
whether an intervention will cause a change in health behavior. It is important to have specific and measurable goals and desired
outcomes. This will facilitate planning the nursing interventions and determining the evaluation process.
Planning interventions is a multistep process. First, the nurse must determine the intervention levels (e.g., subsystem, aggregate
system, and/or suprasystem). A system is a set of interacting and interdependent parts (subsystems), organized as a whole with a
specific purpose. Just as the human body can be viewed as a set of interacting subsystems (e.g., circulatory, neurological,
integumentary), a family, a worksite, or a senior high-rise can also be viewed as a system. Each system then interacts with, and is
further influenced by, its physical and social environment, or suprasystem (for example, the larger community).
Second, the nurse should plan interventions for each system level, which may center on the primary, secondary, or tertiary levels
of prevention. These levels apply to aggregates, communities, and individuals. Primary prevention consists of health promotion
and activities that protect the client from illness or dysfunction. Secondary prevention includes early diagnosis and treatment to
reduce the duration and severity of disease or dysfunction. Tertiary prevention applies to irreversible disability or damage and aims
to rehabilitate and restore an optimal level of functioning. Plans should include goals and activities that reflect the identified
problem’s prevention level.
Third, the nurse should validate the practicality of the planned interventions according to available personal as well as aggregate
and suprasystem resources. Although teaching is often a major component of community health nursing, the nurse should consider
other potential forms of intervention (e.g., personal counseling, policy change, or community service development). Input from
other disciplines or community agencies may also be helpful. Finally, the nurse should coordinate the planned interventions with
the aggregate’s input to maximize participation.

Goals and Objectives

Development of goals and objectives is essential. The goal is generally where the nurse wants to be, and the objectives are the steps needed to get
there. Measurable objectives are the specific measures used to determine whether or not the nurse is successful in achieving the goal. The
objectives are instructions about what the nurse wants the population to be able to do. In writing the objectives, the nurse should use verbs and
include specific conditions (how well or how many) that describe to what degree the population will be able to demonstrate mastery of the task.
 The objectives may be used to later measure learning outcomes, but the objectives need to be measurable. Objectives may also be
referred to as behavioral objectives or outcomes because they describe observable behavior rather than knowledge. An example of
the goals and measurable objectives for a city with a high rate of childhood obesity is shown in Box 7-3.