Assessment of Prior Assessments


The health needs of communities are connected across public health and public sector domains. Health needs are more urgent and chronic in groups and communities that experience poverty. These groups are also likely to experience discrimination, exploitation and trauma. Resilience and adaptability are present in these groups and communities. The following health needs were assessed in multiple reports, across health topics:

  • Linkage/navigation in and between services/agencies
  • Substance use prevention and treatment
  • Stable housing
  • Culturally appropriate services
  • Adequate and accurate information
  • Engagement of isolated groups and individuals
  • Resilience in the face of trauma, fear, stress, threats, discrimination and exploitation.

In these assessments, the most identified Health issues and health determinants were:

  • Alcohol and other drugs
  • Stress
  • Mental health
  • Health promotion and prevention.

A range of interventions are recommended across the strategic priority health needs, ranging from policy change to case management. Case management includes navigation/linkage within and between service areas. Access to Care should be defined broadly to include a range of services from prevention to specialized medical interventions. Multidisciplinary expertise and interagency approaches are required to address health needs, impact inequities and end disparities in health and health care.

Barriers to good health include barriers to social services and health care, including disjointed systems, legal problems, threat of deportation, and social isolation. Substance abuse in youth, which has long-term effects on all aspects of health, is identified as a health problem in all three SFHIP priority health need areas.

Systems that provide health care and health services require ongoing reform, training and coordination between agencies. These services require more strategic and coordinated use of data and technology and an equity framework for service provision.

A scan of the aims and findings of the assessments revealed these themes :

  • Inequities and disparities are well documented
  • Systemic barriers
  • Cost of health, systems problems
  • Health issues are interconnected, but services and data are not
  • Lack of coordination and alignment
  • Innovation and risk
  • Health is multigenerational and intergenerational
  • Capacity building and training for providers is needed in all health priority areas
  • Health is impacted by and relevant to practices in all social sectors
  • Equity frameworks are essential to gaining insight into population health needs and the many levels of intervention needed to address them

Assessments Summary

TABLE 1: Assessment Topics by Current SFHIP Strategic Priority Areas
A snapshot of health needs assessment topics categorized by SFHIP 2016 Strategic Priority Areas. Topics are listed in alphabetical order. Assessments may be categorized under more than one strategic priority area. The 2016 Strategic Priority Areas are explained here. Access to Care is defined broadly in this document, referring to health services ranging from (tertiary) prevention to specialized medical services. Two assessments addressed needs that did not fall under the three Strategic Priority Area categories.

TABLE 2: Current SFHIP Strategic Priority Areas, Assessment Topics, Number of Assessments and Populations Assessed
A snapshot of 2016 SFHIP Strategic Priority Areas with detailed assessment topics, number of assessments for each area and demographic/population variables whose needs were assessed. Many but not all of San Francisco’s communities/populations were included in these assessments. Some were the “target population” of the assessments; most were not. Geographic variables are the least often used in these assessments.

TABLE 3: Assessed Populations
Number of assessments by SF populations assessed. Categories can overlap and are counted each time they appear in an assessment. Populations are defined here as identity groups characterized by race/ethnicity, age, gender/sex, family status, language, sexuality, housing status, HIV status, substance use, incarceration status, disability, veteran status and income. As noted previously, assessed populations are populations/groups included in assessment analyses, not only assessment “target population/s.” This CHNA cycle there are groups/populations that are not analyzed in the assessments collected by the Working Group. These include refugees, newcomers, caregivers, and healthcare providers. With a few exceptions, assessments do not disaggregate “race/ethnic” categories such as African American, Chicano/Latino, Asian Pacific Islander and Native American, and therefore are missing significant and relevant population-specific information and insights. Assessments also do not routinely ask participants for geographic information or to identify the neighborhood where they reside. Groups assessed the most are African American, Chicano/Latino and Male. Because of xenophobic rhetoric and policies proposed and implemented at the federal level after 2016, it is important to note whether participation of Chicano/Latino and other immigrants and their families in services and assessments decreased (as we believe is the case) and how that skews our data and knowledge of community health needs.

TABLE 4: Categorization of Health Needs Assessments by Current SFHIP Strategic Priority Health Needs and Modified BARHII Continuum of Root Causes, Consequences and Interventions
Assessments use a range of approaches to identify, analyze and address health needs. To better understand these approaches, each health needs assessment was categorized by SFHIP 2016 Strategic Priority Area. Then elements of the Modified BARHII Framework (Root Causes, Consequences of Health Problems and Types of  Interventions) were identified in each assessment in the Strategic Priority Areas. These are inclusive – – assessments can be counted multiple times. Access to Care has the broadest range of Root Causes, Consequences and Interventions. See Charts 1-4 for distribution of Types of Consequences in the assessments.

TABLE 5: Distribution of Modified BARHII Intervention Recommendations by Current SFHIP Strategic Priority Health Needs
Recommended strategies to address health needs. Strategies characterized as health promotion and prevention are the most often recommended in all three areas of health need. Strategies characterized as case management are most often recommended to address Access to Care. All types of Modified BARHII Framework interventions have role to play in addressing health needs in the three SFHIP strategic health need priority areas.

CHART 1: Distribution of Living Conditions Addressed by Assessments
Social services is the most referenced element of living conditions, followed by safety and health care. Natural environment and occupational safety were not referenced.

CHART 2: Distribution of Health Behaviors Addressed by Assessments
Alcohol and other drugs is the most referenced health behavior, followed by nutrition and sexual health.

CHART 3: Distribution of Psychosocial Factors Addressed by Assessments
Stress is the most referenced psychosocial factor, followed by resilience and lack of control.

CHART 4: Distribution of Health and Well-being Issues Addressed by Assessments
Mental health is the most referenced element of health and well being, followed by chronic disease and communicable disease.

Methods and Limitations

San Francisco’s community-based organizations, healthcare service providers, public agencies and task forces conduct health needs assessments and publish reports of their activities for planning and evaluation purposes and to be accountable to those they serve. Our aim in conducting an assessment of these assessments and reports is to augment what we know for our citywide CHNA from routinely collected secondary health data and primary data collection through CHNA community engagement activities. We hope thereby to gain a better understanding of which communities/populations in San Francisco have been engaged in health needs assessment activities; what topics are of concern and interest to these communities/populations; and learn about promising and effective approaches to eliciting and addressing these concerns. We included both needs assessments and service reports in our definition of “assessments” for this assessment.

Beginning in January 2017, CHNA administrative leads from the SF Department of Public Health and UCSF and a small Assessment of Prior Assessments Working Group consisting of members of San Francisco’s three health equity/parity coalitions, UCSF health professions students, and UCSF clinical and translational research staff began conducting online searches for published assessment reports for the 2019 CHNA. The Working Group simultaneously reached out by email and phone to request health needs assessments reports that were not available online. By June 2018, the Working Group had collected 48 assessments, 33 of which met our inclusion criteria.

Working Group members were interested in finding assessments that pertain not only directly to health but also to the social determinants of health, especially those experienced by communities/populations bearing the burden of health inequities. As with the CHNA overall, this assessment used the San Francisco Framework For Assessing Population Health Equity to determine the breadth of circumstances affecting health. The Working Group added incarceration, experience with law enforcement, and community development/investment explicitly to the framework for the purposes of this assessment.

To be included, assessments were required to meet the following criteria:

  • Assessments involve primary data collection
  • Primary data are available for San Francisco alone
  • Primary data are collected in July 2013 or later
  • Data are published between July 1, 2015 – June 30, 2018
  • Data collection methods are identified
  • Assessed population(s) are clearly defined
  • The assessment topic explicitly includes the social determinants of health or relates to other health outcomes

During the collection of assessments, the assessment team encountered challenges obtaining several assessments. In some instances community health program leaders were not sure about sharing assessments they deemed too small, to “unscientific”, and/or not “analytic” enough. Others were wary of handing over their findings to a group of city leaders they had not previously had direct contact with. For these reasons, several community providers decided not to share their assessments with SFHIP or contribute them to the CHNA process. The Working Group has submitted recommendations to SFHIP leadership to address these challenges.

Some assessments of important health needs are not included in the information considered for this assessment because while they analyze data for San Francisco alone and they draw explicit analytic connections to social determinants of health and health outcomes, they do not collect primary data and instead exclusively produced analyses of existing datasets. The Working Group passed these on and where appropriate, data from these reports were incorporated into the CHNAs datasheets and infographics and are referenced throughout.

Among the reports included in this assessment, the primary data collection activities included focus groups, key informant interviews, online and in-person surveys (including a point-in-time count), community forum feedback, and thematic analysis of meeting notes. Several assessments used a racial/ethnic and/or income equity framework to analyze the data they collected.

The Working Group read the assessment reports and extracted information using an online survey that allowed reviewers to confirm each criterion was met and answer questions pertaining to the target populations, primary data collection methods, and social determinants of health or health outcomes addressed in the assessment. The survey asks readers to extract information on the upstream determinants of health (“Root Causes”), downstream outcomes (“Consequences”) and intervention strategies (“Interventions”) . The data extraction tool is available here.

There are significant limitations to using an assessment of prior assessments in the determination of community health needs. The Working Group was attentive to the need for a wide range of assessment topics and interested in assuring that topics relevant to the experiences of historically oppressed and marginalized communities were represented, some topics may be overrepresented and some missing. Lacking standardized definitions, parameters and methodologies regarding health, populations, and interventions or programs, these assessments cannot be used to generalize or draw definitive conclusions about health needs or the health status of communities. This assessment is meant to provide SFHIP leadership with information to augment other data sources in order to glean more in-depth and detailed insights into the urgency and distribution of San Francisco’s health needs, health disparities, and promising practices to address them. These analyses engage a broad spectrum of San Francisco’s population, but not evenly and not every community. Some groups are not assessed at all, some only as a small segment of the population engaged in one small assessment. But thanks to that one segment, we might know something new about the health needs of that group. When taken into account along with more rigorously and regularly analyzed data, these assessments present themes and patterns to guide the interpretation of all the data available as a whole in the determination and prioritization of health needs and ultimately, planning for implementation of interventions to address those priorities.

When interpreting this assessment of prior assessments, care was taken to keep in mind that “target populations” are not the same as “assessed populations.” Assessment readers may have interpreted SFHIP Strategic Priority Areas and Modified BARHII Root Causes, Consequences and Interventions differently. Assessment topics as they are identified and listed in this report may be incomplete or may obfuscate sub-topics. We do the best we can to represent the topics, health needs assessed, interventions interrogated and their places in a framework that expands the meaning of health and how disparities and inequities happen and can be undone.

Readers interested in assessment topics are encouraged to access the assessments and read about the issue more deeply. All publicly available assessments are referenced in this summary [see Appendix Four – List of Assessments]. Requests for an assessment that is not publicly available should be directed to the program that conducted it.

The implementation of xenophobic policies at the federal level from 2016-present (2019) have caused local immigrant populations to avoid participating in programs, services and assessments. They are likely to be under-counted and their health needs unassessed.

List of Assessments

Andersen, R. (2016). Chief of Police Recruitment Public Process Report. City and County of San Francisco. Link here.

Applied Survey Research. (2017). San Francisco County Homeless Point-In-Time Count & Survey. Link here.

Applied Survey Research. (2017). San Francisco Homeless Unique Youth Count and Survey: Comprehensive Report. Link here.

Cohn, K., Ahmad, H., Brown, L., Herrera, M., Lo, D., Melgoza, C., Saavedra, S., Smith, A., and Yu, K. (2017). Promoting Housing Security and Healthy Homes for Families Served by Maternal, Child, and Adolescent Health Programs. Link here.

Healthy Southeast Coalition. Bayview HEAL. (2016). Food Access Survey Results. Link here.

Hennessy, V., Garcia, B., and Guy, R. (2016). Work Group to Re-Envision the Jail Replacement Program. Link here.

Hjord, H. (2016). An Assessment of San Francisco Department of Public Health’s Alcohol Prevention Efforts: Final Report and Recommendations. Link here.

Joint Perinatal Health Equity Project. (2018). Preterm Birth Initiative. Link here.

Nance, A. (2017). San Francisco Juvenile Probation Department 2017 Statistical Report. Link here.

Office of Early Care and Education. (2017). Summary of Stakeholder Input for Phase One Implementation of Citywide Plan for ECE. Link here.

San Francisco Budget and Legislative Analyst. (2017). Economic and Administrative Costs Related to Alcohol Abuse in the City and County of San Francisco. Link here.

San Francisco Human Services Agency Planning Unit. (2016). Assessment of the Needs of San Francisco Seniors and Adults with Disabilities; Part I: Demographic Profile. San Francisco Department of Aging and Adult Services. Link here.

San Francisco Human Services Agency Planning Unit. (2016). Assessment of the Needs of San Francisco Seniors and Adults with Disabilities; Part II: Analysis of Needs and Services. San Francisco Department of Aging and Adult Services. Link here.

San Francisco Department of Aging and Adult Services. (2018). Dignity Fund Community Needs Assessment. Link here.

San Francisco Department of Public Health, Environmental Health. (2014). Improving Health in SROs Health Impact Assessment. Key Informant Interview Summary here. Final report here.

San Francisco Department of Public Health. (2017). Cannabis Legalization in San Francisco: A Health Impact Assessment. Executive summary here. Final report here. Appendices here.

San Francisco Department of Public Health. (2016). Healthy Stores for a Healthy Community. Infographic here. Intercept survey findings here. Policy report here.

San Francisco Department of Public Health. (2017). San Francisco 2018 – 2023 Substance Use Disorder Prevention Strategic Plan. Link here.

San Francisco Office of Early Care and Education. (2017). Understanding and Improving the Child Care Experience for Families. Link here.

San Francisco Post-Acute Care Project Team. (2016). Framing San Francisco’s Post-Acute Care Challenge. Link here.

San Francisco Safe Injection Services Task Force. (2017). 2017 Final Report. San Francisco Department of Public Health. Link here.

San Francisco State University Health Equity Institute. (2016). Housing, Pregnancy and Preterm Birth in San Francisco: A Community-Academic Partnership for Research, Policy & Practice. Link here.

Su, M. (2016). A Snapshot of San Francisco’s Children and Families. San Francisco Department of Children, Youth and Their Families. Link here.

Tenderloin Health Corner Store Coalition. (2017). 2017 Tenderloin Healthy Shopping Guide. Link here.

Vietnamese Youth Development Center. (2018). Youth Attitudes on Menthol & Flavored Tobacco Survey Findings. VYDC findings here. Ten CAM findings here.

Youth Movement of Justice and Organizing. (2017). Our Healing in Our Hands: Findings from a Mental Health Survey with San Francisco Unified School District High School Youth. Link here.