Identify Needs and Resources in Your Community

Identify Needs and Resources in Your Community

Home visiting programs are diverse in both the inputs that they require to be successful and the outcomes that they aim to achieve. So how do you select the best home visiting program for your community? A good first step is to have a data-informed understanding of your community, including knowing families' needs as well as the resources available to them.

Why conduct needs and resources assessments?

A needs assessment is critical in identifying the most pressing needs of children and families in your community. A needs assessment will also help you to identify those populations that could most benefit from the home visiting program. Specifically, a needs assessment will help you answer questions such as:

  • How do kids and families in my community fare compared with kids and families in other states and nationwide?
  • What types of families in my community would most benefit from additional support from a home visiting program?

A resources assessment helps you understand what services are already available in your community. Resources can include organizations, the workforce focused on early childhood, and public safety-net programs (like the federal Women, Infants, and Children program [WIC]), to name a few. This will help you understand whether your community already has resources directed at meeting the needs you identified. It will also help you to identify agencies and groups that you might want to work with as you implement your home visiting program. Specifically, a resources assessment will help you answer questions such as:

  • What services are already being offered to families in my community?
  • What organizations in my community might be good partners for the delivery of a home visiting program?

Conducting the needs and resources assessments will help you decide what you want to accomplish and how you will accomplish it. This step will take you through the process of identifying and collecting the information necessary to ultimately select and implement the right home visiting program. Thus, this step is critical for success on the later GTO-HV steps, because you will know what it is that you want to improve, and what resources you have on-hand to help solve the problem. Also, this step can help gather support from constituencies by demonstrating the need for change and assess the readiness of constituencies and the community for proposed changes.

Assessing needs in your community

What are the needs of children and families in your area? This is an important question, and its answer will be critical to guiding how you proceed through the rest of this manual. When trying to identify the most important needs in the community, a good place to start is identifying how children and families in your communities fare on the eight domains emphasized in the U.S. Department of Health and Human Services' website "Home Visiting Evidence of Effectiveness" (HomVEE;

  • Child development and school readiness
  • Child health
  • Family economic self-sufficiency
  • Linkages and referrals
  • Maternal health
  • Positive parenting practices
  • Child maltreatment
  • Juvenile delinquency, family violence, and crime.

You should assess how your community fares according to each of these domains by examining how your community is doing on related indicators. An indicator "provides evidence that a certain condition exists" (Brizius & Campbell, 1991, pp. A-15). For example, child health is a broad domain that can be assessed using many different types of indicators. Rates of low birth weight and the number of children receiving timely well-child visits are both examples of specific indicators that can provide insight into whether child health is an issue in your community.

Tip 1-1 lists some example indicators for each of the U.S. Department of Health and Human Services' HomVEE website. These indicators have been shown in research to be associated with the eight domains listed above. We have organized the indicators into "positive" and "negative" indicators. That is, if your community performs well on a positive indicator, it indicates that the community is likely doing well in the domain associated with that indicator. Similarly, if your community has a higher rate of a negative indicator, it indicates that the community could use support in that particular domain.

You will notice that some indicators are in multiple categories. That is because they are associated with multiple domains. For example, the percentage of parents using harsh parenting strategies–for example, spanking or verbal abuse–is associated both with child maltreatment as well as negative parenting practices.

For a more comprehensive list of individual-level indicators and their associated measurement tools, see Design Options for Home Visiting Evaluation: DOHVE Compendium of Measurement Tools for MIECHV Grantees (MRDC, 2011). MIECHV is the U.S. Department of Health and Human Services Maternal, Infant, and Early Childhood Home Visiting program. This compendium includes a broad range of measurement tools related specifically to home visiting program outcome areas.

Tip 1-1. The U.S. Department of Health and Human Services' Eight HomVEE Domains and Examples of Associated Indicators


Positive Indicators

(higher levels on these indicators
indicate that a community
is doing well in this domain)

Negative Indicators

(higher levels on these indicators
indicate that a community
could use support in this domain)

Child development and school readiness

  • Child scores on measures of cognitive development, such as the Peabody Picture Vocabulary Test or the Woodcock-Johnson assessments
  • Preschool participation rate
  • Measures of elementary school academic achievement; for example, test scores
  • Parent and child language skills
  • Percentage of parents that read to child daily
  • Scores on environmental ratings scales such as the Home Observation for Measurement of the Environment (HOME) scale
  • Percentage of children with early behavior problems
  • Percentage of children who are asked to leave child care because of behavioral problems

Child health

  • Child scores on mental health and physical health survey scales indicating good mental and/or physical health
  • Safe infant sleep environment
  • Percentage of families that use car seats
  • Percentage of children who have received all recommended vaccinations/well-child visits
  • Rate of low birth weight
  • Rate of preterm birth
  • Rate of infant mortality
  • Percentage of children who are overweight or obese
  • Percentage of parents/caretakers that use illegal substances
  • Percentage of babies born drug-addicted

Family economic self-sufficiency

  • Highest level of parent education
  • Family socioeconomic status
  • Percentage of parents with high school diploma/GED
  • Percentage of parents employed
  • Hours per week of parent employment
  • Percentage of parents with income above poverty line
  • Percentage of parents receiving food stamps
  • Percentage of parents receiving welfare
  • Percentage of teen parents
  • Percentage of single-parent households

Linkages and referrals

  • Percentage of families referred to services (housing assistance, Medicaid, job skills training)
  • Percentage of desired services that were received
  • Percentage of families that lack access to services and transportation

Maternal health

  • Maternal scores on mental health survey scales and physical health survey scales indicating good mental and/or physical health
  • Percentage of mothers with access to/use of prenatal health care
  • Percentage of mothers with access to/use of contraceptives
  • Percentage of mothers with adequate social support
  • Rate of low birth weight
  • Rate of preterm birth
  • Percentage of mothers who smoke
  • Percentage of mothers who use illegal substances
  • Percentage of mothers who are overweight or obese

Positive parenting practices

  • Percentage of parents that read to child daily
  • Reading frequency
  • Scores on environmental ratings scales, such as the Home Observation for Measurement of the Environment (HOME) scale
  • Percentage of parents using harsh parenting strategies

Child maltreatment

  • Percentage of parents with adequate social support
  • Parental scores on mental health survey scales and physical health survey scales indicating good mental and/or physical health
  • Number of families involved with Child Protective Services
  • Number confirmed cases of child maltreatment per 1,000 children
  • Percentage of children who have ever had injury needing medical care
  • Percentage of parents using harsh parenting strategies
  • Percentage of children hospitalized for trauma
  • Percentage of children hospitalized for ambulatory care
  • Percentage of mothers/parents that use illegal substances

Juvenile delinquency, family violence, and crime

  • Percentage of parents with adequate social support
  • Parental scores on mental health survey scales and physical health survey scales indicating good mental and/or physical health
  • Percentage of families with restraining orders
  • Percentage of families referred to family court
  • Number of arrests, convictions, and days in jail for family members
  • Rates of children or adolescents sent to youth corrections
  • Percentage of families with any domestic violence
  • Percentage of parents using harsh parenting strategies

So just how will you collect data on these indicators? Many data elements are publicly available on the Internet. In Tip 1-2, we have listed some resources that provide county- or city-level data on many of the indicators listed above. You might also consider some of these local sources of information:

  • Public health data–Various social and public health departments maintain information on various health conditions, including children hospitalized for trauma, new mothers with illegal substance dependence, families receiving welfare benefits, unemployment levels, and percentage of households below the poverty line.
  • Police arrest and court data–Police arrest figures provide information about crime in various areas of the community, and might be a good source of data on juvenile arrests and/or domestic violence.
  • Local hospital data–The hospitals in your community most likely keep records of things like infant mortality rates, hospital admissions of children under the age of 5, and low birth weight rates.

Tip 1-2. Links to Existing Data Sources to Help You Assess Needs in Your Community

PRAMS [as of 2/2017]

PRAMS, the Pregnancy Risk Assessment Monitoring System, is a surveillance project of the CDC and state health departments. PRAMS collects state-specific, population-based data on maternal attitudes and experiences before, during, and shortly after pregnancy. PRAMS may be a helfpul source of data on maternal and child health domains listed in Tip 1-1.


The Pregnancy Nutrition Surveillance System (PNSS) is a program-based public health surveillance system that monitors risk factors associated with infant mortality and poor birth outcomes among low-income pregnant women who participate in federally funded public health programs. PNSS may be a helfpul source of data on maternal and child health domains listed in Tip 1-1.


Includes data on more than 100 indicators of child well-being, with community-level data in addition to city, state, and national data. Data can be used to create maps and charts on the site, and can also be embedded on users' websites or blogs. KIDS COUNT data may be a helfpul source of data on the child developmpent, child health, maternal health, family economic self-sufficiency, juvenile deliquency, family violence, and crime domains listed in Tip 1-1.

Census Bureau [as of 2/2017]

The Census Bureau website includes Census data for cities, counties, and states. The QuickFacts tool provides easily accessible reports on Census data at different levels. The Census Bureau may be a helfpul source of data on family economic self-sufficiencey and the maternal and child health domains listed in Tip 1-1.

County Health Rankings provides county-level health data as well as national and state benchmarks for a range of health behaviors and health outcomes. County Health Rankings may be a helfpul source of data on maternal and child health domains listed above.

Assessing indicators for different populations

If your community coalition has the resources and time to do so, you may want to look at how the measures you investigate differ among different populations. For example, is the rate of low birth weight births higher among teen moms? Is it different for certain racial/ethnic groups? This will help you identify a specific population that would benefit the most from home visiting.

If you are using existing data and want to assess indicators for certain distinct populations, find out whether the data sources can provide you with information for the population(s) of interest. For example, if you are interested in low birth weight among teen mothers, you might see if the local hospital can provide you with low birth weight information for mothers under 19 years old.

If you will be collecting your own data, then make sure that you also collect the demographic variables of interest. For example, if you are conducting a survey of parents and want to know if parenting practices are different for certain racial/ethnic groups, make sure that you ask parents about their racial/ethnic background in the survey.

Conducting a community needs assessment

In this section we present the Community Needs Assessment Tool, which will help you through the process of identifying the appropriate indicators and then finding data sources that you can use to see how your community is doing. In Townville example 1-1, you will find Townville's Community Needs Assessment Tool. This might help guide you in filling the tool out yourselves.

Tool 1-1. Community Needs Assessment

Instructions for completing the Community Needs Assessment Tool:

  1. Begin to identify the indicators that you would like to collect for your community under each of the eight outcomes listed above. You do not need to investigate all of the proposed indicators, and you may find some indicators that are not listed that you would like to investigate. Fill in your list of indicators on the first column of the table.
  2. It is ideal to examine your community's performance on selected indicators in two ways (Kilburn & Maloney, 2010):

a. compared with national, state, and/or county performance on the same indicators

b. over time, examining how your community has performed each year for several years.

Perhaps your state is unique, and comparing communities in your state to national numbers would be unfair given just how different your population is. In that case, you might decide to compare to other state's numbers. You might also decide on a certain level of comparison based on what level of data are available. If you will be comparing your community to national, state, and/or county performance on the same indicators, determine the appropriate level of comparison (the "comparison group") for your community and enter the name, e.g., "National comparison" into the top-right cell in the Community Needs Assessment Tool.

  1. If you will be comparing your community over several years, enter the years that you will be looking at the top of columns 4 through 6 in the Community Needs Assessment Tool.
  2. Begin to identify where you will find the data for each of the indicators that you have selected. Remember that you will have to find data for your community over several years, as well as your comparison group.

a. In general, you can collect many important indicators of child and family well-being in your community using existing data sources. See Tip 1-2 for some existing datasets that can assist you in this work. These datasets all offer national-level comparisons as well as local or county-specific information.

b. You might also want to look to see whether your state or county produces data with more detailed information on specific groups of children and families in your community (e.g., by certain racial/ethnic groups, certain school districts, etc.). Take a look at Step 1 for how you might use this information.

c. Note that some data elements might be straightforward to find if you get creative. For example, if there are only a few hospitals in your town, you might be able to approach these hospitals to get some data on indicators, such as the preterm birth, low birth weight, and infant mortality rates.

  1. If there are some data elements that you are certain you need and you cannot find using existing sources, you may need to collect your own data. If, by filling out this tool, you realized that the data that you need are not available, it might be necessary to collect your own data. See Tip 1-3 for more information on how you might go about this work.
  2. Once you have obtained all of the relevant data, sit down to discuss the findings: How did your community do relative to the comparison group? Document your analysis in the second-to-last column.
  3. The last column should remain blank until you have the data from the resource assessment to help guide you in setting priorities. Instructions for filling in the last column are given below in the section titled "Use the data to select priority needs."

Tool 1-1. Community Needs Assessment
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Tip 1-3. Collecting Your Own Needs and Resources Assessment Data

Most of the information you collect will likely come from existing data (e.g., hospital data and child welfare statistics). You may need to do some additional data collection on your own, however, to have a fuller picture of the needs in your community. This section provides a brief overview of the types of data that you might consider collecting. You might be able to implement certain data collection efforts on your own, but it is always best to hire or consult with an experienced research organization, university, or outside technical assistance provider who can ensure that these efforts are done well and get you the information that you need. Some different types of data that might be useful to collect are discussed below.

Qualitative data: interviews, meetings/forums, and focus groups

Qualitative data are typically collected by asking open-ended questions, which encourage respondents to answer using their own words. For example, you might ask, "What services are currently available in your community to assist parents with child rearing?" Qualitative data collection methods include:

  • Key informant interviews: Interviews are conducted with those individuals who are important leaders (e.g., mayor, police chief, local pastor) or representatives in their communities. They are knowledgeable about the community and are likely to be aware of many issues. Interviews can also be conducted with service recipients (e.g., teen moms receiving well-child visits at a local clinic) to learn more about the service itself and about what other services may be needed (e.g., prenatal care).
  • Community meetings/forums: Various community individuals are invited to a series of meetings and are asked about their opinions and perceptions of the needs in their community. Although key leaders are often present, the meetings are held to obtain information from the general public.
  • Focus groups: Focus groups may be particularly useful if you need to get information quickly or when you want an opinion from an established group. They are considered an ideal format for getting at underlying attitudes, feelings, beliefs, and behaviors of a group. Besides being more efficient than interviews, focus groups get discussions going that would not occur in one-on-one interactions and are effective in getting participants to identify false or extreme views. In a focus group format, 6–12 individuals convene and answer a predetermined set of open-ended questions posed by a facilitator. You can recruit a variety of people for each focus group. Or, it is sometimes preferable to convene participants for each group who have similar characteristics, such as parents, teachers, youth, or law enforcement officials.

These kinds of activities help to build public good will and community buy-in, which may prove valuable later when you seek financial, political, and collaborative support.

Quantitative data: surveys

Surveys are a common way to systematically collect information from a number of individuals. It is very important to remember that collecting your own survey data can be a demanding task, so you should check first to see if you can use existing data before you embark on designing and implementing a survey.

Surveys often ask a standardized set of questions or offer statements ("Families have a wide range of supports in this community to successfully take care of newborns") to which respondents typically choose a response from a number of choices (e.g., "strongly agree, agree, disagree, or strongly disagree"). Commonly, surveys for home visiting are addressed to:

  • Service providers: Service and treatment providers possess knowledge about the nature of problems in a community, what programs and resources are available, and who is and who is not being served.
  • Clients or participants: Clients and program participants are excellent sources of information on what needs are being met and what more should be done.
  • A targeted population: Self-report surveys completed by those targeted by the initiative (e.g., teen moms, fathers) provide useful information on their attitudes and beliefs. Because assessing problem behaviors in a survey can be a sensitive topic, it is best to use questions that have already been written and tested. If you plan to administer surveys among your target population, it would be best to consult with a person or organization experienced in administering surveys.

Online resources can help you identify high-quality survey questions that have already been tested:

Townville Example 1-1. Townville's Needs Assessment

What did Townville's needs assessment reveal? In conducting their needs assessment, the Townville community coalition assessed a range of indicators in their community. Most startling was Child Protective Services data that revealed high rates of child maltreatment that have been increasing over the past few years. Townville also looked at the number of children being hospitalized for unintentional injury and discovered that the rates in Townville were higher than rates in other communities in the state. (The example here shows child maltreatment only.)

The Townville coalition also organized a series of focus groups with mothers of young children. In these groups, mothers reported that they had a strong support network, namely that they relied on the mothers in their network for a variety of childrearing needs and learning about available community resources.


Measures chosen
(pick several from list
in each category)


Rate of selected measures in my community
(note years)

Rate of selected measures in my comparison:

How did the community do relative to the comparison?

Is this a priority area?

Year 1:

Year 2:

Year 3:

Child maltreatment

Number of substantiated child abuse and neglect allegations per 1,000

State Child Welfare data system

30 cases per 1,000 in the county

38 cases per 1,000 in the county

42 cases per 1,000 in the county

18.5 cases per 1,000 children in the state in 2010

Townville has more than double the state's rate of substantiated child maltreatment cases


Hospitalization for unintentional injury among children age 0-4

Hospital Inpatient Discharge Data, Department of Health

17.2 per 10,000 in the county

18.5 per 10,000 in the county

19.8 per 10,000 in the county

14.2 per 10,000 in the state

Townville has slightly higher rates than the state rates


Mothers with adequate social support

Focus groups held with mothers

Most mothers felt that they had strong support from other mothers in the community (2010)


Townville did not assess a comparison, but parents view their levels of social support as adequate


Assessing community resources

The next step in your community assessment is determining what resources already exist in your community that can help support implementation of your program. Resources (sometimes called community assets) include agencies, companies, facilities, and services in the community that provide assistance to children and families, and could be anything from a public transportation service to an intervention for families referred to Child Protective Services (CPS) (Kilburn & Maloney, 2010).

Understanding the resources available in your community will help you see what gaps may exist in the system of care and what's already working, and taking stock of existing resources may spark some ideas about who you might partner with to solve problems, save time and money, and avoid duplicating services.

You will want to know who's already working on the problems you want to solve so you can avoid duplication of effort and not waste resources. Also, home visiting programs work best when implemented within a system of care, which includes at least the following:

  • Services providing basic needs (e.g., WIC)
  • Medical/health care
  • Early care and education providers
  • Parent supports and services
  • Domestic violence services
  • Mental health services
  • Substance abuse services
  • Job counseling and placement
  • Housing services
  • Family safety
  • Justice organizations.

Your community might have a very different list. Think of a wide range of existing programs and institutions in your community, including community colleges, faith-based groups, service groups, and cultural organizations, that might help to support this work. They could even include libraries or the local YMCA. Do not forget about government-funded programs, such as child welfare services or health care clinics offering prenatal care screenings. Be sure to restrict your resource list to those agencies that serve young children and their families in some capacity.

To conduct a resource assessment, get in touch with the agencies that you have identified and have a conversation about what they are currently doing to support children and families in your area. This can be an informal data collection process, but be sure that you document your findings. You can do this in a written document in narrative form or in a spreadsheet or other document. We have provided a Resources Assessment Tool that can help guide this process. After the tool, you will find the Townville example that you can use to help guide you in filling the tool out yourselves.

Tool 1-2. Community Resources Assessment

Instructions for using the Community Resources Assessment Tool:

  1. Starting at the top of the tool, in row 1 (Name of Resource), write the name of the resource, program, or organization you are interested in.
  2. In row 2 (Location), if relevant, note the location of the resource or where it is delivered.
  3. In row 3 (Contact Information), provide contact information, such as phone, email, fax, and contact person's name and position, if available.
  4. In row 4 (Hours of Operation), describe how often the resource is available, including hours of operation or how often it operates. It is important to be specific here. The frequency and intensity of the resource dictates the appropriate dosage of the services, just as the amount of medicine a person takes and how often dictates the dosage of medicine.
  5. In row 5 (Who Served?), describe what you know about who uses the program or resource. This goes beyond eligibility requirements and gets more at demographic information about who is served.
  6. In row 6 (Services Provided), describe the specific programs or services offered by this resource.
  7. In row 7 (What's Working), collect any information you can find on what the successes are associated with this resource or program. You might want to limit your investigation on this topic to those services related to young children and their families.
  8. In row 8 (Is any action needed to expand this resource?), identify any actions that might be necessary for more families in the community to be able to access the resource. This might include things like expanded capacity or broader dissemination of recruitment materials.
  9. Add as many additional columns to the Tool as needed to complete this task. You may want to print out additional copies of the document, or keep track of this information in a different format if you have many resources to record.

Tool 1-2. Community Resources Assessment
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Townville Example 1-2. Townville's Resources Assessment

What did Townville's resources assessment reveal? The Townville team first talked to child-and-family-serving agencies in their community. They found a range of great resources for parents that they would be able to draw upon throughout the implementation process. They also identified easy ways to link parents to more services using the resources' distribution networks.



Contact info

Hours of operation

Who is served?

Services provided

What's working?

Is any action needed to expand this resource?

Local hospital

123 Main Street

Dr. Alex Chapman

24 hours


Intensive and emergency care, some prenatal care, birthing services

Distribute parenting information kits to new mothers and provide immediate nurse contact after birth to support safe sleep and breastfeeding

No, this resource has full coverage in our community


456 Townville Road

Nina Smith


All ages

Summer camp, wellness classes for toddler through adult, child care

Parenting classes and women's support
groups for
new parents

Attendance at parenting classes is low, might consider promoting the classes through some new channels.

Women, Infants and Children (WIC) Food and Nutrition Program

789 Center Drive

Rocio Torres


Mothers of infants and children ages 1-5

Food vouchers, parenting classes, nutrition education

Breastfeeding classes are highly attended

No, this resource is very highly utilized. Might consider WIC distributing materials related to YMCA parenting classes.

Use the information you have collected to select priority needs

If you have not already done so, now use the results of your assessments to select and prioritize those needs that you want to address in your community. You will do this in the final column of the Community Needs Assessment Tool (see how Townville did this in Townville Example 1-1).

Think about these questions as you work on developing your priorities:

  • What are the most pressing issues for young children and families in your community?
  • Which of these needs is it most important to address to make the greatest improvements in the lives of children and families?
  • Which resources will the community have or need to mobilize in order to make an impact on these needs?
  • Are there sufficient resources in your community to make an impact, or do you need to spend time building the system of care?

As you generate the list of priority needs, revisit the Community Needs Assessment Tool. Now you have the information to fill out the remaining column on the Tool, where you identify priority needs.

If you have not yet reached a point where you are confident about the priorities you want to establish, then you can use the tools we've given you in this chapter to think more about them. Convene members of your community coalition to go over the results of your assessments and decide which priorities are the most important to address among families in your community.

At this stage, you might also want to share the results of the assessments with a wider group beyond the coalition in order to be transparent and build community buy-in.

Checklist 1-1. Completion of Step 1

When you finish working on this step, you should have done the following:

  • Reviewed available data sources on the well-being of children and families in your community.
  • Conducted a needs assessment to identify the needs of children and families in your community.
  • Conducted a resource assessment to identify resources that may be already available to help you improve the well-being of children and families.
  • Reviewed the findings of the needs and resources assessments.
  • Selected priority needs which emerged from your assessments.

Before moving on to Step 2

Now you'll move on to using the information you've gathered and the priorities you've identified to develop specific goals and desired outcomes. The priorities from Step 1 and the goals and desired outcomes you develop in Step 2 will form the basis for selecting the programs and strategies you plan to implement as well as the outcomes you eventually plan to measure.

As a note–It is okay if at this step you have realized that implementing a home visiting program is not your community's first priority. Perhaps aligning the system of care is more important, and you will wish to revisit home visiting once there is a stronger system in place. You can continue to use this manual and the GTO-HV 10-step approach to address any alternative efforts, but keep in mind that the examples and supporting materials specifically refer to a home visiting program.