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Community Needs Assessment: Heart Disease Initiative

Community Needs Assessment: Heart Disease Initiative

In the modern world, population health management has become essential, especially due to that many individuals facing sufficient health-related challenges. In order to realize reforms in the health system in accordance with the Affordable Care Act, it is important to implement population-based healthcare management. The U.S. healthcare system needs to include a broader arrangement that captures a community-based service provision, even though there have been scores of advancements in Medicare in this respect. Community involvement is an appropriate technique for providing excellent healthcare programs. The paper assesses heart disease as a community health issue and a proposed heart disease prevention initiative in Baltimore City.

The Heart Disease Initiative Proposal

Being a major cause of death in the United States and most nations around the world, heart disease, generally identified as cardiovascular disease, has become a global concern that put an increasing burden on all nations worldwide. Consistent with the 2014 data, 611,105 deaths occurred in the United States, and in Baltimore City, more than a quarter of all deaths were caused by heart illness (Homefacts.com., 2016). Every year, about 370,000 persons die from heart-related diseases (Centers for Disease Control and Prevention, 2015b). According to Wenger (2012), there are several risk factors that upsurge the threat of cardiovascular illness. They include tobacco smoking, high physical inactivity, blood pressure, being obese or overweight, and high cholesterol level, to list a few. In efforts to prevent and control the deadly heart illness, as a health administrator, I have developed a heart disease community-based initiative whose main objective is to improve the detection, prevention, and control of the heart ailment.

In terms of improvement of disease detection, the initiative focuses on raising the number of screening locations so as to distinguish the ill persons and those with a high risk of obtaining the disease in Baltimore City. To enhance the prevention of cardiovascular disease, the activity includes education of the community on the methods which an individual can use as a precaution to hinder the risk elements of cardiovascular disease. The initiative is based on the partnership with public organizations and nationally-funded healthcare amenities that will help in detecting patients with a high likelihood of the disease and sending them to publicly developed programs for an ailment for provision of self-managing aid, and offering more testing sites to upsurge discovery of undiagnosed hypertensive inhabitants. Additionally, the initiative entails enlightening program for the Baltimore population that will educate them on ways of identifying, tracking, and managing the risk factors that affect heart health.

Key Relevant Information from Data Analysis

In line with the United State Census data of the year 2014, Baltimore City is the biggest metropolitan in Maryland state as it has 622,793 people, while the United States had a population of 321,418,820 inhabitants (“Baltimore, Maryland,” 2016). The percentage of the population below 5 years and those aged 65 and above in Baltimore is 6.7% and 12.3% respectively (“Baltimore, Maryland,” 2016). In the U.S., the population under 5 years and those aged 65 and above represent 6.2% and 14.5% correspondingly (United States Census Bureau, 2015). The ratio of females to males in Baltimore City is 0.529 to 0.47, while that of the country, in general, is 0.508 to 0.492 (United States Census Bureau, 2015). Contrary to the U.S. population where white people make up the largest group representing 77.4% of the residents, Baltimore is an identified black municipality with the African-Americans group representing the largest portion of about 63.1% of the population (United States Census Bureau, 2015).

In terms of income and wealth, the city is considered a poor region, with a per capita income of $25,062 and average household earnings of $41,819 compared to the U.S. per capita income of $28,555 and average household earnings of $53,482 (Homefacts.com., 2016). In comparison with America as a whole, a greater proportion of the Baltimore population (23.3%) lives below the poverty line, in contrast to 14.8% of the U.S. population (Homefacts.com., 2016).

With regard to health-related characteristics, statistics show that Baltimore has poor health compared to that of the United States. To demonstrate this, in the city, life expectancy is 73.33 years while in the U.S., it is 79.56 years (United States Census Bureau, 2016). Additionally, in 2014, the infant mortality rate in Baltimore was 9.7 deaths per 1,000 live births compared to that of the U.S. which was 6.17 per 1000 live births (United States Census Bureau, 2016). The main causes of death in the locality include: heart disease (25.8%), cancer, (23.1%), stroke (5.2%), HIV/AIDS (3.9%), chronic lower respiratory illness (3.9%), diabetes (2.9%), Influenza and Pneumonia (2.4%), Alzheimer’s disease (2.3%), accidents (2.0%), and Nephritis (1.9%) (“Baltimore, Maryland,” 2016). On the other hand, the major causes of death per year in the US are heart disease (611,105 deaths), cancer (584,881), chronic lower respiratory illnesses (149,205), accidents (130,557), stroke (128,978), Alzheimer’s (84,767), diabetes (75,578), influenza and pneumonia deaths (56,979), nephritis (47,112), and suicide (41,149) (United States Census Bureau, 2015).

Community Partnerships

It is vital to bond with the communities through the growth of effective partnerships and collaboration initiatives (Palmer-Wackerly, Krok, Dailey, Kight & Krieger, 2014). There is a great need to select the right partners when working together with the public. As a health administrator, I viewed the National Alliance for Nutrition and Activity (NANA) as a potential associate for a cardiovascular illness initiative as the organization has similar objectives as the initiative. The NANA advocates policies and programs that inspire healthy eating and regular physical exercise, with the aim of reducing the disease rates and symptoms, inabilities, premature deaths, and expenditures that are caused by cardiovascular risk factors (Center for Science in the Public Interest, 2014). In order to achieve an effective partnership, it is good to avoid cordial hypocrisy which can destroy the teamwork and makes reliable communication difficult. Apart from that, a set of mutual benefits is essential as all partners work toward achieving the same goal. A partnership can also be developed through joint planning to allow all participants to take part in planning activities from the beginning, and preserve room for all partners to have an equal voice throughout the partnership (Jefferson School of Population Health, 2014).

During the collaboration, conflict-of-interest disagreements may come up (Palmer-Wackerly et al., 2014). However, the initiative has come up with proper ways of handling such disputes. For instance, the problem can be controlled by involving numerous business associates such that there is no deal to any particular partaker. Similarly, a neutral space can be offered when all participants gather and concerns are discussed, and maintain open and vibrant governance strategies. Moreover, in the course of the partnership, intra-sectorial rivalry can be a barrier to the initiative’s success. To overcome this barrier, it is advisable to avoid collaborating with partners who are concerned about rivalry. A person can also opt to focus on the pre-competitive space to avoid intra-sectorial competition. Additionally, an associate may choose to leave the collaboration before time. To prevent this event from happening, a deep open discussion regarding governance, rules, and other matters is essential (Jefferson School of Population Health, 2014).

SWOT Analysis

A SWOT analysis of the initiative was carried out to determine the strengths, weaknesses, opportunities, and threats in the scope of the initiative. The SWOT analysis is important as it enables one to take advantage of the strengths and opportunities available to achieve the goals of the initiative. The tool also allows to work on the weaknesses and identify the best ways to manage the threats facing the initiative (Manktelow, & Carlson, 2010).


A number of strengths were observed after the conduction of the SWOT analysis. To begin with, the population of Baltimore City is relatively small (Baltimore, Maryland. (2016), thus making the assessment of heart illness manageable. The communication between stakeholders contributing to the detection, prevention, and control of cardiovascular illness was effective and reliable. Also, various social media platforms that facilitated education and augmented awareness of heart illness amongst the Baltimore inhabitants were accessible. Additionally, there was the availability of groups and collaborations skillfully handling the prevention and treatment of cardiovascular disease. Moreover, Federally Qualified Health Centers (FQHC) currently collect health data on cardiovascular risk factors (Baltimore City Health Department, 2016), making work easier. Finally, there was the involvement of several stakeholders who could positively impact on heart sickness issue.


There were various weaknesses of initiative observed. There was an unavailability of organized leadership for cardiovascular disease in Baltimore City. Also, in Baltimore City, it necessitated the representation of the Black American ethnic group for successful efforts to manage the heart ailment. Moreover, in Baltimore City, there is an absence of law guidelines linked to Patient-Centered Medical Homes (Baltimore City Health Department, 2016). Another weakness was that the initiative was not perceived as unified. Presently, Baltimore City lacks a perfect health policy to control cardiovascular ailments. Lastly, the validity of the initiative is weakened by the data indicating that Baltimore surpasses standard targets on signs associated with cardiovascular disease.


Among the opportunities presented was that there was a possibility for Baltimore to link prevention to the medical policy. Also, through the promotion of a smoke-free atmosphere, the well-being of Baltimore residents could be enhanced. Additionally, the initiative could know the way an incorporated health system would look when highlighting the health policy. There was also a possibility of determining the health system diversity. Moreover, the mutual concern of numerous individuals and administrations to lower the frequencies of hospitalization could assist in connecting doctor performances to sanatoriums. Procuring licensed specialized status in pharmacies could grow the caregiver’s network. Lastly, the application of telemedicine could help support cardiovascular ailment control.


The scarcity of finance, resources, and politics was among the threats that faced the success of the initiative. Also, solving repayment and advocating issues related to testing and follow-up of the cardiovascular ailment was required. Additionally, there is a constant threat to the sustainability of the initiative and efforts. Another threat was that there was rivalry among stakeholders attempting to contribute to the concern. Moreover, public collaborations were not committed to making cardiovascular sickness issues apparent in a grassroots way. Finally, advocates with influence have banned healthy strategies (such as tobacco-free environments) from developing.

The Financial Consequences of the Initiative 

According to Mendis and Chestnov (2013), treatment cost the heart disease is very high creating a great liability on individuals’ finances. The expenses brought about by cardiovascular disease include diagnostic tests, hospitalization, immediate treatment, purchasing of medications, examinations to monitor the development of the ailment, and regular medical appointment costs (Lamas, Sermon & Lamas, 2013). The disease causes financial loss owing to deficiency in productivity and additional days off for ill workers. Also, the early deaths initiated by cardiovascular sickness negatively influence the productivity of the overall labor force. The cost of cardiovascular sickness accounts for nearly 30% of the Medicare budget (Epstein et al., 2014). The initiative helps in lowering the above costs. The strategy motivates people to adopt preventative adjustments, thus, lowering the possibility of acquiring heart sickness and consequently lowering the costs associated with the disease. The implementation of the heart disease initiative would result in people’s paying less for overall medical care since they would probably have improved overall health and well-being.

Program Evaluation

Pilot Study

A pilot study is a crucial phase of the investigation process (Nirmala, Edison & Suni, 2011). In order to avoid money and time wastage on an ineffective projected initiative, a pilot study was carried out before the final research. The individuals who took part in the pilot study were not to contribute to the final investigation so as to prevent the influence of the future performance of research subjects. The procedure was conducted to evaluate the strategy of the full-scale research and, therefore, in case of omission of some aspects in the pilot study, adjustments can be made to the final research in order to upsurge the likelihood of attaining strong results.

To evaluate the awareness, attitudes, and behavior of the public and medical experts in Baltimore concerning the significance of living a healthy life by eating healthy and exercising regularly to prevent cardiovascular disease, comprehensive interviews, and focus group methods were applied. For ensuring the reliability and accuracy of the findings, the questionnaire design used the same queries as in the interviews. The questionnaire included 20 multiple-selection queries linked to the risk elements for heart sickness, signs, and prevention techniques. On average, the queries had roughly 8 words in length. Additionally, there was a segment for comments and feedback from the respondents that would enhance the improvement of the questionnaire. The questionnaires were physically distributed to the individuals and others were sent to the subjects via e-mail. On average, it took 15 minutes of time to fill in the questionnaire.

Evaluation of the Pilot Study

Evaluation is a basic component of any research (Cossette, 2013). The purpose of the evaluation process is to find out if the projected findings were obtained and ascertain the strengths and weaknesses of the methodology applied for future policy-making, design, and improvement. Apart from that, an evaluation practice that involves the community will boost sustainability and extend the lifespan of intervention for the populace. The evaluation processes can be conducted on the process (which ensures that methodologies are used as stated in the initiative plan), or the outcome of the initiative (Cossette, 2013). The current study will use process evaluation, which will assure the plan is applied as planned and will also identify areas requiring improvements. The evaluation process applied a Six Sigma tool which assists to measure the quantity of ‘defects’ existing in the process, which will enable systematic identification of techniques for eliminating them and realizing as close to ‘zero defects’ as possible (Coskun, Unsal, Serteser & Inal, 2011).

Measurement of Social Changes

Social changes will be evaluated by tracking the overall process. The staff, associates, and stakeholders related to the heart initiative strategies will collect information to make sure that the process and effective initiative results are achieved.

First, the data will be collected to determine the environments that back up the prevention of cardiovascular illness, regular physical exercise, healthy diet, and tobacco-free way of life for all inhabitants, highlighting the accessibility of resources, facilities, and priority residents. Examples of data collected under this goal include:

  1. Evidence of the developed strategies that are associated with the reduction of risk elements for cardiovascular sickness.
  2. Minutes of conferences linked to the strategy and ecological alterations to lessen risk factors for cardiovascular ailment in community, school, work sites, and health care backgrounds.
  3. Records of associates participating in the development of policies to prevent cardiovascular illness risk factors.
  4. Allocation and utilization of environmental resources to lessen cardiovascular risk factors.
  5. Execution of educational initiatives to upsurge awareness of cardiovascular disease risk factors.
  6. Records of associates operating collaboratively to execute strategies in order to mitigate and control heart disease risk factors.

Secondly, Baltimore residents will get evidence-based, socially suitable detection and treatment of risk elements for cardiovascular disease. Among the data that will be collected under this objective, there are:

  • Records of training offered to health care experts regarding social experience.
  • Implementation of the program into medical care amenities to advance cultural skills of health care givers and personnel.
  • Application of socially suitable education promotions that are intended to decrease disparities.
  • Screening procedures (including the number of participants and locations); records of socially appropriate resources used to educate patients.

Thirdly, to improve a harmonized system of care in Baltimore that offers appropriate care for individuals suffering from cardiovascular illness, the following data will be collected:

  1. A summary of novel strategies established that are concerned with the improvement of heart disease prevention;
  2. Proof of novel memorandums of partnership contracts developed;
  3. Records of associate commendations for forming an integrated system for heart disease occurrence in Baltimore.

Forth, to ensure the improvement of accessibility, integration, and quality of primary care treatment and long-term care in facilities for every cardiovascular disease survivor in Baltimore City, such data will be collected:

  • Records of novel collaboration agreements of understanding developed.
  • Application of educational promotions intended to educate Baltimore residents on primary care services.
  • Written reports of initiative strategies applied (methodology, respondents, impact, and undertakings).
  • Execution of training for healthcare givers regarding treatment and long-term care.

Lastly, to achieve the objective of collecting detailed cardiovascular disease data that are easily available to measure, observe and distribute, the following information will be collected:

  1. Records of statistics are distributed to associates, critical stakeholders, and the community.
  2. Detection of new cardiovascular illness indicators.
  3. Written reports emphasizing the liability of cardiovascular disease in Baltimore County.
  4. Records of media consideration received on the novel liability records and cardiovascular ailment reports.


Investments in appropriate prevention initiatives offer the greatest opportunity to advance the well-being of Baltimore residents and reduce healthcare costs. Various community-based programs have facilitated in identification and education of persons at risk. Health programs that are reproducible and fruitful should be implemented as models for current determinations at outreach and improved for more extensive usage. Community education on the risk factors of cardiovascular illness improves the prevention of heart disease. Future exploration and more effort is required, as well as sustained subsidy for existing evidence-grounded determinations, as a vital input to heart disease prevention.


Baltimore City Health Department. (2016). Heart disease and stroke. Retrieved from http://health.baltimorecity.gov/node/155

Center for Science in the Public Interest. (2014). National Alliance for Nutrition and Activity. Retrieved from http://www.cspinet.org/nutritionpolicy/nana.html

Homefacts.com. (2016). United States demographic data. Retrieved from http://www.homefacts.com/demographics.html

Jefferson School of Population Health. (2014, April 24). Connect ourselves and our communities: David Nash full presentation [Video file]. Retrieved from https://www.youtube.com/watch?v=LWL7UAidJXY