There is growing interest at the local, state, and national levels in developing and disseminating profiles of community health. Public health agencies and their community partners use community health profiles to monitor and track health conditions; define community health problems; set priorities; educate professionals, planners, and the public about the health status of the community; initiate policy and delivery system change; facilitate advocacy by local groups; and as a mechanism for social marketing. The production of periodic "community health report cards" is one method used to profile multiple health issues, and their broader determinants, in geographically defined populations. The term "community health report card" refers to a variety of reports, variously termed community health profiles, needs assessments, scorecards, quality of life indices, health status reports, and progress reports. In their various forms, these reports are increasingly cited as critical components of community-based approaches to improving the health and quality of life of communities.

Initiatives to generate report cards proliferated at the national, state, county, and community levels during the 1990s. A noteworthy example at the national level is the Community Health Status Indicator (CHSI) Project, which is a collaborative effort between the Health Resources and Services Administration (HRSA), the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials (NACCHO) and the Public Health Foundation. In 2000, the project published and disseminated community health status reports for all 3,082U.S. counties. These reports provide county-level data, including peer county and national comparisons, for every county in the country. They are designed to support health planning by local health departments, local health planners, community residents, and others interested in community health improvement.

Another example of a national report card is the Annie E. Casey Foundation's KIDS COUNT Data Book. The Casey Foundation has produced the national KIDS COUNT Data Book annually since 1990, using the best available data to measure the educational, social, economic, and physical well being of children and families. In 1991, the Casey Foundation began supporting state-level KIDS COUNT projects, and by 1996 there were KIDS COUNT projects in all fifty states and in the District of Columbia. The vision of KIDS COUNT is to raise the nation's awareness and accountability about the condition of children and families in two ways: first, by measuring and reporting on the status of children at the state and local levels; and second, by using the data creatively to inform the public debate and to strengthen public action on behalf of children and families.

In addition, the 1990s saw an explosion of local community health report card projects around the country, both in large cities and small towns, and often as an integral part of local community health improvement initiatives. These community health improvement initiatives have grown out of three major trends: (1) an increasing recognition of the importance of local community action to solve local problems, (2) an increasing emphasis on outcomes and accountability, and (3) the Healthy Cities/Healthy Communities movement. Community health report cards can be a useful tool in efforts to help identify areas where change is needed, to set priorities for action, and to track changes in population health over time.

One of the earliest, best known, and continuous community health report card projects is in Jacksonville, Florida: Quality of Life in Jacksonville: Indicators for Progress is coordinated by the Jacksonville Community Council, Inc (JCCI). Jacksonville has published a report on seventy-one indicators every year since 1985, and those reports have served as a model for subsequent report cards produced in other cities. Moreover, the JCCI team has extended its work to link the indicators with performance-based budgeting for the city. Several other well-known and exemplary community health report cards that are linked to local community health improvement initiatives include: The Quality of Life in Pasadena, 1998: An Index for the 90s and Beyond (Pasadena, CA), the Santa Cruz County Community Assessment Project (Santa Cruz, CA), the Spokane Community Report Card (Spokane, WA), and Pathways to a Coordinated System of Health Care and Human Services for Children and Families (Rochester, NY). A directory of sixty-five community health report card projects from around the country can be found in The National Directory of Community Health Report Cards, produced by the UCLA Center for Healthier Children, Families, and Communities.

A community health report card is a profile of a community's "health" in the broadest sense of the term. More comprehensive report cards include a set of indicators that describe not only the health status and health-risk factors of the total population, but also address quality-of-life issues, the broader determinants of health, and community assets and resources. Many community health improvement efforts, particularly those in the Healthy Cities/Healthy Communities movement, view community health and its determinants broadly, and they use a set of indicators (to track their progress) that reflects this broad definition. These indicators might include:

• Physical and mental health status;
• Educational achievement;
• Economic prosperity;
• Public safety;
• Adequate housing and transportation;
• A clean and safe physical environment;
• Recreational and cultural opportunities.

NATIONAL STUDY OF COMMUNITY HEALTH REPORT CARDS

A 1996–1997 study by the UCLA Center for Healthier Children, Families, and Communities surveyed sixty-five community health-report card projects from across the country. The study sought to better understand: (1) the report card development process, including community participation;(2) report card design and content; and (3) the links between report cards and community health improvement activities. The study found that three quarters of the report card projects were initiated in 1992 or later. Most of the projects planned to produce report cards on an ongoing basis, many at least every one to two years. The purpose of the report cards ranged from increasing public awareness to improving the community health planning and evaluation process and facilitating policy formulation. In three-fifths of the communities, the report cards were part of a larger community health improvement process.

In the study sample, the largest number of report cards (43%) were produced at the county level; others consisted of data from state (22%), regional, or multi-county areas (12%), city, (22%), or, occasionally, a more local neighborhood level. A little over half (54%) included only health indicators, while about one quarter (23%) included a broader set of indicators reflecting multiple aspects of quality of life, including crime, transportation, education, and the environment. Another 25 percent focused on a particular subpopulation such as children, adolescents, Latinos, or elders.

The content and quality of the community health report cards surveyed varied tremendously. Increasingly, communities are using more creative approaches to translate raw data into meaningful and attention-getting information formats designed to appeal to a broader audience and to serve as a catalyst for action. More and more, report-card development draws on the skills of graphic designers and social marketing specialists to communicate messages more effectively.

In the study, problems with data collection and the lack of existing data were the most frequently identified barriers in report-card production. Nearly two-thirds of the projects collected both primary and secondary data to include in their report. Primary data focused mainly on perceived needs, behaviors, and health status, and it was most often collected by survey research firms or the local health department. The most frequent sources of secondary data were the state (62%) and local (31%) health departments and local social service agencies (23%). In fact, local health departments were most likely to initiate and be involved in every stage of the report-card development process. Other partners in the process included hospitals, local governments, state health departments (especially for data collection), local colleges and universities, community residents, nonprofit civic organizations, and social service agencies. The factors most frequently cited as contributing to successful report-card production included: collaboration among different community groups and organizations, community participation, strong leadership, adequate funding, and local/state government support. However, while collaboration and community participation are important in creating an effective report card, about one-fifth of the communities reported that the time and effort required to get all the stakeholders together was their greatest challenge.

The UCLA study also found that community health report card production is a relatively long and resource-intensive process, usually requiring between six and eighteen months from the first organizational meeting to production of the report card. The average cost of report-card production in the UCLA sample was $60,000, with costs ranging from $0 to $1 million.

The following are characteristics of effective community report cards:

• The format is clear, well-organized, and "user-friendly."
• Multiple forms of data presentation are used, including text, graphs, charts, maps, and quotations.
• A geographic/demographic profile of the population is included.
• Both primary and secondary data are presented.
• There is a clear, balanced interpretation of the data.
• There is a clear presentation of community assets as well as needs.
• The link between the data and opportunities for action is articulated.
• Comparisons to peer communities (counties, states, etc.) are made.
• Comparisons to other benchmarks (e.g., state/national data, Healthy People objectives) are made.
• Trend data is presented.
• Data sources are identified.
• Graphic design features are used, including photographs.
• Multiple products are developed for different audiences.
• Broad and participatory community effort is involved.

THE FUTURE OF COMMUNITY HEALTH REPORT CARDS

The development of community health report cards, for the most part, has been highly local in nature and dependent on local sociopolitical conditions and data constraints. To enhance the effectiveness of community health report cards, there is a clear need for a more supportive infrastructure, including innovative data systems that can provide more data at the local level, more information on disparities in health among different subpopulations, as well as data on community assets and resources. There is also a need for more primarydata collection. Communities also need support with indicator selection. The wide variation in indicators used argues for the development of a conceptual framework to facilitate the selection of indicators that, as a set, present a contextual view of community health and its determinants. Both the Institute of Medicine report, Improving Health in the Community, and the RAND/UCLA report, California Health Report, provide examples of frameworks that use a broad definition of health and account for the role of multiple determinants in health outcomes.

Community health report cards will also benefit from efforts to enhance their presentation and accessibility, including the use of social marketing expertise to create effective messages. Report cards can also make use of technology to communicate to a broader audience. Mapping techniques such as geographic information systems (GIS) and Internet access are two such methods.

CAROL SUTHERLAND

NEAL HALFON

JONATHAN E. FIELDING

(SEE ALSO: Community Health; Community Organization; Health Goals; Healthy People 2010; Healthy Communities)