• Overview
• Guiding Principles
• Phases 1 & 2: Internal Capacity Assessment, Community Health Profile
• Phase 3: Community Health Assessment/Priority Themes
• Phase 4: Strategic Direction & Action Plans
• Completing the Community
• Health Improvement Process

What does it take to create a healthy community? Will decreasing the leading causes of  death and disability or increasing life expectancy through sophisticated technology lead to a substantial improvement in the quality of the life of a community? Or should the focus be on changing the determinants of ill health --unsafe and unhealthy environments or behaviors. Creating a healthy community requires a systems  approach that involves the whole community in problem solving.

In 1995, the Madison Department of Public Health launched the community health  improvement process, Health Quest: 

1. to meet the public health core function of health assessment; 
2. to implement the legal requirements of the State of Wisconsin public health statutes and Madison City Council resolution; and,
3. to fulfill the recommendations of the 1994 Community Assessment for Health  and Human Services Planning in Dane County. The Health Quest community health improvement process is a collaborative plan with broad based agreement on health priorities, clear measures for tracking improvement and a shared vision  of a healthy community.

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Guiding Principles

1. Data based: Health problems and priorities are based on health status, health behaviors data, and perceived health needs. Benchmarks such as Healthy  People 2000 and 2010 Healthier People in Wisconsin will be used to measure change.
2. Shared responsibility: Community health improvement is collaborative and the planning process involves all sectors of the community.
3. Dynamic: A community health assessment is not a one-time event, it is continuous over time.
4. Public health leadership is needed to develop partnerships for community health.

The Health Quest mission statement is: A collaborative community process to  identify local health status, determine priority health theme areas, establish  community health goals, and develop strategies to implement health improvement  plans. The goal of the community health improvement planning process is to build  a healthy community in which to live, work, learn and play.

The table below shows the six phases of the community health improvement process.

Phase 1 and 2: Internal Capacity Assessment and Community Health Profile

Phase 1 has been completed and two capacity assessments were prepared in 1995 and 1998.  Two publications of Picture of Health were published in 1995 and 2000 to complete Phase 2. (See Community Health Profile.)

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Phase 3: Community Health Assessment

The community health assessment phase has two major components: building partnerships and community involvement. Community involvement consisted of key informant discussion groups, a perceived health needs survey, and a community ballot. The outcome of this phase was determination of priority health themes for Madison.

KEY INFORMANT DISCUSSION GROUPS were held to gain input from community leaders knowledgeable about health issues in Madison: 

Six discussion groups involved 66 community leaders representing a wide variety of organizations and community stakeholders such as health care organizations, business, philanthropic organizations, faith community, environmental health, policy makers, civic groups, media, education and voluntary organizations, and advocates for the following age groups: infants, preschool, toddlers  (0 - 5 years); elementary aged children ( 6 - 11 years) ; middle school, teens and young adults (ages 12-24 years); adults (ages 25-44 years); middle adults (ages 45-64 years); older adults (ages 65+). 

The charge was to determine the most important health concerns facing Madison residents which require community attention. Participants purchased health priorities by spending a designated amount of money (each informant had a total of $16,000 to spend in 3 denominations --$10,000, $5,000 and $1,000.) The purchasing of health priorities allowed for weighting of health issues. Table 1 shows the ranking of health issues by the dollar or weighted ranking and by the total number of votes.

(1) Access and effectiveness of health education, education to new residents and consumer awareness.

(2) Alcohol, drugs, tobacco.

(3) Substance abuse related risk behaviors not included.

(4) Domestic violence, child abuse, firearms, and unintentional injuries.  

Top-ranked concerns:

Access to health care and health care for the underserved emerged as a priority health theme. Access issues are: access to dental health and affordable dental care; the uninsured; access and follow up care for Medical Assistance recipients; impacts of W-2 in decreasing health care access, support for community health center serving the uninsured, and access to primary care for the working poor.

Substance abuse, the third ranking concern, encompasses tobacco, alcohol and other drugs. Substance abuse related issues were: use of alcohol by young people, effects of parental alcohol abuse on children, misuse of drugs and alcohol, health effects of tobacco, and teenage tobacco use.

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THE PERCEIVED NEEDS SURVEY is the second component of community involvement:

A Madison market research firm was commissioned to survey the general public about what health issues City of Madison residents perceived to be the most important. A telephone survey of over 300+ households was conducted in October-November 1998. Issues and topics identified by key informant discussion groups were used to determine the selection of responses to each question. Residents were asked to use a numerical scale to rate a variety of responses as to importance.

• Personal and Community Health Issues: Respondents were asked to evaluate various health issues for importance to them personally or for their families. Respondents were then asked to rate the importance of these issues for the entire community. The top three health issues -- cancer, heart disease and aging health problems -- are the same for both personal/family health and community health perspectives.

• Factors for a Healthy Madison: Fifty-five percent (55%) of all respondents rated safe food and drinking water as being very important. Affordable health care was rated as very important by 51%. As the following graph shows, Madison residents considered most factors listed as being important to ensuring a healthy Madison.

• Health Risk Behaviors: Unsafe sex and alcohol misuse were at the top of the list of risky behaviors.

Rating of Health Risk Behaviors

• One Thing Needed to Improve Health in Madison: The final survey question to determine the most significant or highest health priority was "What is the one thing needed to improve the health of Madison residents?" Approximately one-third of all respondents identified emphasizing health education and information, better awareness of health prevention and utilizing preventive services as the most important requirement for improving the health of Madison. Secondly, access to affordable health care was selected by almost one-fourth of all respondents. Access to health care also received a high importance rating as a key factor contributing to a healthy Madison. Women were much more likely than men to mention the need for access to care for everyone. Respondents were far  less concerned about drug and alcohol problems (9%) or personal fitness (6%).

THE COMMUNITY BALLOT was used to determine priority health theme areas requiring community attention and action. After a comparison of the key informant discussion group priority health issues, perceived needs survey rankings and other key data findings, the Madison Public Health Commission designated 10 preliminary health themes. To confirm priority theme areas and to narrow the priorities to the top five, a community ballot was distributed to over 450 community organizations. The results are presented in the following table.

Rank order was determined by using a weighted scoring system where first place votes received 5 points and the least important issues received 1 vote.

Access to health care received the highest weighted ranking, the highest number of total votes cast, and the highest number of first place votes. It is a broad priority theme which includes lack of access, barriers to receiving health care, health care for the uninsured and underinsured, and lack of access to dental care. Over 50 points separated access to health care from the other priority theme areas. The next four highest priorities--safe food and water, safety and injury prevention, infectious diseases, and prevention and health education--were grouped closely in terms of rank score

Other community ballot choices were: alcohol and drug abuse not including tobacco; teen health which included alcohol and tobacco use, teen pregnancy, and mental health; lifestyle choices such as lack of fitness, obesity, poor eating habits; minority health issues such as increased rates of certain diseases, cultural competence; and mental health which included diagnosis, needs and access and availability of services.

The Madison Public Health Commission endorsed the findings of the community ballot and recommended adoption of the priority themes to the Madison Common Council. On June 15, 1999 the Common Council designated access to health care, safe food and water, safety and injury prevention, infectious diseases, and prevention and health education, as priority health issues for the City of Madison.

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Phase 4: Strategic Directions & Action Plans

Strategic Directions:

The outcome of Phase Three was determination of priority health themes.  However, the designated priority health concerns are broad in scope.  To narrow the focus, strategic directions or topics that will be addressed first were selected to be the starting points for implementing health improvement plans.

• Access to Health Care/Dental Care: Considerable collaborative efforts are being focused on the problem of an access to health care for the uninsured, and these efforts will continue to be supported. There is an emerging and critical area not being addressed: access to dental care. Thus, the strategic focus for access to health care is to examine the scope of the problem related to access to dental care.  Issues raised during the community assessment phase related to dental access were:
  
  1.  Lack of access to dental services for those unable to pay for care
  2.  Lack of dental providers serving Medical Assistance patients
  3.  Barriers to receiving dental care, such as low Medical Assistance reimbursements, language barriers, and lack of transportation
  4.  Need for increased preventive services such as dental sealants
  5.  Insufficient capacity to serve the low income and underserved populations. 
  
  The strategic direction is to describe these issues in detail and 
  collect available supporting data.

• Safe Food and Water: While Madison's public water supply is of very high quality and poses a small risk for causing diseases, there are outbreaks every year of diseases associated with unsafe food. Health goals for the year 2000 for communicable diseases related to food borne illness are not being met.  For example, the Year 2000 goal for Campylobacter is 14/100,000 population. The 5-year mean incidence (94-97) in Madison is 26/100,000.  For salmonellosis, the year 2000 goal is 18/100,000 and the 5-year mean incidence is 29.5/100,000.  It is suspected that a lot of food borne illness is not being reported, making it difficult to know the full scope of the problems related to unsafe food. Determining public concerns about safe food and food borne illness is the strategic focus for this priority theme. One reason for choosing this is the need to increase public awareness about the importance of reporting suspected cases of food borne illnesses.
  
• Safety and Injury Prevention: Health Quest  partnered with the Safe Community Coalition of Madison and Dane County to develop community injury prevention action plans. A series of neighborhood listening sessions were jointly sponsored to find out specific injury-related concerns and to develop solutions to prevent injuries. 
• Infectious Diseases:  Sexually transmitted diseases (STDs) are the focus for infectious disease. Some of the groundwork on problems related to these diseases was developed at the STD Summit. Strategies for continued work on this issue will be determined in 2003.
• Prevention and Health Education: Unlike the preceding issues, prevention and health education are not problems, but are actually a means for solving problems. Better use of preventive services or better health education methods will be part of the action improvement plans developed for the above four priority theme areas. Special attention will be paid to developing programs and educational materials for non-English speaking populations.

To begin developing action plans for specific issues, more data needs to be collected. This will provide a more accurate picture of the size of the problem. It is also important to obtain the community's views on concerns and ideas for addressing these concerns. This has taken place in two areas: access to oral health care and safety and injury prevention.

In the spring of 2000, data was collected to describe the unmet demand or need for dental care, the resources or capacity to meet this need, barriers to accessing dental care and why it is important to have available dental care in the Madison area. This information was published in the report Oral Health Access Concerns: A National Issue and a Madison Perspective.

An Executive Summary and Findings report was also prepared. There were two clear conclusions: 1) There is a major dental access problem in Madison; and 2) Dental access is a community wide problem which will require community wide solutions. The publication of the report was the springboard to begin working on solutions.

On November 28, 2000, Madison Mayor Susan J. M. Bauman convened the Dental Access Community Solutions Meeting. Over 90 participants attended, including dental providers, policy makers, health care professionals and patient and community advocates. At this meeting, they developed a framework for action for addressing dental access. Joining the City of Madison Public Health Department in sponsoring this meeting were Meriter Health Services including the Max W. Pohle Dental Clinic, Dean/St. Mary's, the Dane County Dental Society, Unity Health Plans, and the Madison Metropolitan School District.

Participants focused on three areas: 1) Increasing the capacity of public dental providers serving low income and vulnerable populations; 2) Recommendations for reducing barriers to dental access; and 3) Increasing public awareness about the importance of dental care -especially preventive dental services. A summary report of all solutions generated at the Community Solutions Meeting was prepared and distributed.  The participants developed an action plan, the framework for action, based on the community solutions meeting. 

I. Increase the number of dental providers serving low-income and uninsured populations.

1.  Expand the capacity of public dental providers: 
Develop collaborative partnerships to fund two full-time dentists and four dental chairs for the Harambee Dental Clinic.

2.  Increase the number of Medical Assistance patients receiving dental care:
Recommend legislative and policy changes to increase reimbursements and simplify paperwork and claims processing through legislative advocacy and linkages with other state professional associations and coalitions.

3.  Support expanded functions for dental auxiliaries:
Support legislative and administrative policy changes to expand scope of practice for dental hygienists and dental assistants, e.g., provide sealants without a dentist diagnosis.

II. Promote oral health education

1. Develop a media campaign about the importance of preventive dental care.
Convene a coalition to identify/create a dentally sound message about the importance of oral health care, and fund and implement a media campaign.

2.  Promote oral education in the schools.
Expand/provide dental health education to children and parents.

3.  Improve the integration of oral health and medical health care.
Increase education about the importance of oral health, especially at very early ages, and improve collaboration between health and dental providers.

Safety and Injury Prevention

Ten Safety and Injury Prevention Listening Sessions were conducted (over 80 Madison residents) between November 1999 and February 2000 by the Madison Department of Public Health and the Safe Community Coalition. Dane County Public Health and the Safe Community Coalition also conducted listening sessions in four Dane County communities in the spring of 2000. These listening sessions identified safety concerns in various settings, generated injury prevention solutions, and helped to mobilize the community to take action.

Details of the Madison listening sessions are found in the full report and executive summary of Mobilizing Madison Communities to take Action, Improve Safety and Reduce Injuries.

The results of the Safety and Injury Prevention Listening Sessions, along with local injury data, has helped direct the safety and injury prevention work of the Madison Department of Public Health and the project work of the Safe Community Coalition. The people who participated in these listening sessions have become active with many of these projects.

See Phase 5: Implementation for information on the safety and injury prevention work implemented.

See Safe Community Coalition of Madison and Dane County for further information about the coalition and their work.

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Completing action plans ends the community health improvement process for a specific issue (Phase 4). Phase 5 of the process is the actual implementation of the action plans followed by Phase 6, evaluation. The process is then repeated with different health issues selected as priority theme areas for improvement through action plan development, implementation and evaluation. The result is continuous health improvement and ultimately, a healthy  community.

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