In 2019, the Fresno County Department of Public Health aimed to understand the needs of vulnerable populations that affect their health outcomes. Evidence shows that Fresno County’s pollution disproportionately affect low-income communities of color, this was the foundation and theoretical framework guiding the development of methodology, outreach, and implementation strategies throughout the community health needs assessment process.

Secondary data from the CalEnviroScreen version 3.0, Regional Opportunity Index (ROI), Community Interview Survey, and the Office of Statewide Health Planning and Development was used to identify placed-based and population-based (e.g., older adults and young adults) focus groups. CalEnviro Screen version 3.0 was utilized to identify census tracks with the highest pollution burden. Previous health assessment helped us identify the vulnerable groups to reach out in this community health needs assessment, some of these were racial/ethnic communities (Punjabi, Southeast Asians, Native Americans) and others were identified because of their socioeconomic status (e.g., immigrants, ex-offenders, low-income housing) and other excluded/marginalized groups (eg., LGBTQ and individuals with disabilities). The analysis of secondary data was helpful to include different ways residents define community.

Social Determinants of Health framework was utilized to develop the focus group guide to understand how social factors affect residents’ health outcomes. Using Grounded Theory, themes were identified by assessing the frequency and magnitude (agreement among the focus group discussion) of the code to identify primarily Priority areas for 1) Place-based populations, 2) Vulnerable Populations. The finalized coding rubric was utilized to analyze 3) Key Informants, and 4) Stakeholders independently. We created Priority Areas of Agreement across the different data sources by identifying areas of consensus. These represent upstream areas of need beyond the healthcare system to improve community health outcomes identified primarily by community and supported by local stakeholders.

The inclusiveness within the methodology that included placed-based, vulnerable communities and diversity of stakeholders was challenging. The primary data collected demonstrated the variety of needs each population had. Utilizing the SDOH framework was integral in analyzing the areas of agreement need where upstream stewardship should be happening to improve the health outcomes of many vulnerable populations.