Organization of Community Health Needs Assessment Report
Process and Methodology
Reflect on the Preceding CHNA
Key Steps in the CHNA Process
How the CHNA Differs
What Makes the CHNA Unique to the Service Area Population
Methodology
Community Demographic Profile
Population and Households
Race and Ethnicity
Economic Challenges
Educational Attainment Key Demographic Insights
Community Health Profile
Unmet Needs
Health Equity Concerns
Food Insecurity
Health Conditions
Women’s and Maternal Health
Oral Health
Senior Health
Contents cont.
Community Health Areas of Opportunity
Healthcare Access
Women’s and Maternal Health
Oral Health
Senior Health
Satisfaction with Healthcare Providers
Preventive Care
Awareness of Recommended Screenings
Healthy Lifestyle, Nutrition, and Food Security
Mental Wellness
Additional Community Needs
Community-Led Solutions
Residents’ Top Health Needs and Priorities
Other Concerns and Recommendations from Residents
Emphasizing Cultural Competency and Empathy
Raising Community Awareness Empowering Residents Enhancing RCHF’s Presence
RCHF’s Role in Mitigating Challenges
Appendix A. Secondary Data Indicators
Appendix B. RCHF Community Survey
Appendix C. Focus Group Consent Form
Appendix D. Focus Group Questions
Appendix E. Profile of Focus Group Participants
Appendix F. Interview Questions
Introduction and Background
Riverside Community Health Foundation (RCHF) has been a cornerstone of health advocacy in the Inland Empire. With a mission to enhance the health and well-being of Riverside County residents, RCHF operates community clinics, provides health education programs, and collaborates with local organizations to address pressing health challenges. This Community Health Needs Assessment (CHNA) serves as a critical tool for understanding the evolving health landscape and showing opportunities to effect meaningful change.
The 2024 CHNA focuses on RCHF’s expanded service area of 21 zip codes, which includes diverse cities such as Riverside, Jurupa Valley, Moreno Valley, Perris, and Corona-Norco. This region encompasses over 806,000 residents, being a tapestry of socioeconomic, cultural, and health disparities. By examining the complex interplay of social determinants of health, chronic disease prevalence, healthcare access, and community priorities, this assessment shows a data-driven foundation for RCHF’s strategic planning.
Acknowledgements
This report was prepared by RCHF with invaluable contributions from residents, our Steering Committee, and our Board of Directors. We are deeply grateful for the input and support from these participants, many of whom shared deeply personal challenges and experiences with us. Their openness has provided us with critical insights and a better understanding of the community’s needs.
We hope that the contents of this report will not only inform but also inspire action, fostering a more inclusive and healthy community. By acknowledging and addressing the challenges highlighted in this report, RCHF is committed to working collaboratively with community members and stakeholders to create lasting and impactful change.
Riverside Community Health Foundation Board Members
Cheylynda Barnard
LaRonda Fisher-Rogers
Rafael Elizalde Office of Congressman Mark Takano
Karl McCleary Loma Linda University Dr. Michelle Thomas Riverside Community Hospital – HCA Healthcare
Rich Erickson Lee & Associates Erin Phillips Gonser Gerber LLP Dr. Takashi Wada Inland Empire Health Plan
Rafaela King City of Monterey
Tom Podgorski CAtrs Teachers Retirement Services
Jamie Wrage Stream Kim Hicks Wrage & Alfaro, PC
Dr. Jason Lohr SAC Health System
Dr. Richard Rajaratnam Loma Linda University Health
Dr. Shené Bowie-Hussey Riverside Community Health Foundation
Michelle Burroughs, Chair UCR School of Medicine’s Center for Healthy Communities
Michelle Reyes, Secretary FUN by Michelle
Micah Tokuda, Treasurer Edward Jones
Steering
Committee Members
Jeffrey Glenn – Neighborhood Healthcare
Shor Denny – Community Now
Mimi Velazquez – Molina Healthcare
Alex Parada – Neighborhood Healthcare
Guramantra Khalsa – World Be Well
Stephanie Bryant – Riverside University Health
Louise Matus – REAL Member and Community Volunteer
Adrian Zavala – Neighborhood Healthcare
Dr. Ana Aguilera – Physician at Arlanza Family Health Center
Riverside Community Health Foundation’s Contributing Staff
Lisa Wright – President/CEO
Shené Bowie-Hussey, DrPH - President/CEO
Terri Akens - Sr. Director of Health Strategies
Michael Matthews, PhD – Director of Impact & Evaluation
Lauren Randall – Health Education and Evaluation Specialist
Bianca Reid – Sr. Health Educator
Carolina Bojorquez – Sr. Community Health Worker
Nakita Hooper – Community Health Worker
Miguel Lujano – Sr. Health Educator
Jay Cambare – Marketing Manager
Executive Summary
The Riverside Community Health Foundation (RCHF) conducted the 2024 Community Health Needs Assessment (CHNA) to find and address the health needs of the Greater Riverside area. This report integrates quantitative and qualitative data to provide a comprehensive understanding of community health trends, disparities, and challenges. The findings intend to guide strategic planning and targeted interventions aimed at improving the health and wellbeing of the diverse populations within RCHF’s service area.
Area Examined
RCHF’s service area encompasses 21 zip codes, including Riverside, Jurupa Valley, Moreno Valley, Perris, Corona, and Norco, collectively home to over 806,000 residents. These communities are a broad spectrum of socioeconomic, racial, and ethnic backgrounds, underscoring the need for tailored health initiatives.
Methodology
The CHNA employed a mixed-methods approach, including:
• Secondary Data Analysis: Insights from government and publicly available data sources.
• Community Surveys: Over 700 responses providing direct resident feedback.
• Focus Groups and Key Informant Interviews: Perspectives from 73 focus group participants and 20 stakeholders.
Key Findings
1. Access to Healthcare
• Barriers such as cost, transportation, and lack of awareness of low-cost services were significant challenges.
• Preventive care services were underutilized, with low awareness of routine screenings and health education programs.
2. Mental Health
• Residents expressed concerns about stress, trauma, and limited access to counseling and support services.
3. Health Equity and Food Security
• Disparities in healthcare access and outcomes were clear across zip codes.
• Food insecurity was prevalent, worsening chronic health conditions.
4. Chronic Diseases
• High rates of obesity, diabetes, and asthma highlighted the need for preventive health interventions
5. Maternal and Senior Health
• Gaps in maternal health services were linked to poor birth outcomes.
• Senior residents reported challenges accessing age-specific health services.
Driving Community Engagement
To build trust and strengthen relationships with the community, RCHF must actively engage residents in every stage of program development and implementation. This includes creating opportunities for residents to provide ongoing feedback and co-design solutions that address their needs. Community members expressed a desire for regular town halls, workshops, and forums where they can share their perspectives and stay informed about RCHF’s initiatives. Community members also called for stronger partnerships between RCHF and local organizations. Residents noted that these institutions often serve as trusted hubs for information and services, making them ideal partners for outreach and program delivery. By using these relationships, RCHF can deepen its connections with the community and ensure its efforts are both visible and impactful.
Community-Led Solutions
Residents provided thoughtful recommendations to address the health challenges in their neighborhoods. These solutions reflect a deep understanding of the barriers they face and a shared commitment to fostering healthier communities:
1. Healthcare Access
Residents proposed expanding mobile health clinics and telehealth services to reduce transportation barriers and increase accessibility for remote or underserved areas. They also emphasized the importance of extended clinic hours to accommodate working families.
2. Mental Health Services
Many advocated for trauma-informed counseling programs and peer support groups, particularly for youth and individuals facing substance use challenges. Community members also called for bilingual mental health professionals to ensure services are accessible to nonEnglish speakers.
3. Healthy Lifestyles and Nutrition
To combat food insecurity, residents suggested initiatives such as community gardens, partnerships with local farmers, and educational programs on healthy eating. They also recommended setting up more accessible spaces for physical activity, such as parks and recreation centers.
4. Senior and Maternal Health
Residents emphasized the need for senior wellness programs that include fitness activities, social engagement, and affordable healthcare services. For maternal health, they advocated for expanded prenatal care, parenting classes, and family planning resources.
5. Outreach and Education
Community members urged RCHF to invest in public awareness campaigns about available services and preventive health measures. This includes using social media, multilingual materials, and partnerships with schools and faith-based organizations to send information widely.
RCHF’s Role in Mitigating Challenges
The Riverside Community Health Foundation (RCHF) is uniquely positioned to tackle these challenges due to its long-standing presence, collaborative networks, and commitment to community health. Key strategies include:
1. Strengthening Community Engagement:
• Expand outreach efforts to raise awareness of available services.
• Build trust through culturally sensitive programs tailored to the region’s diverse populations.
2. Advancing Equity in Healthcare:
• Address systemic barriers by providing affordable, accessible care.
• Advocate for policy changes that support underserved populations.
3. Driving Collaborative Solutions:
• Leverage partnerships with local healthcare providers, schools, and nonprofits.
• Secure funding for targeted interventions addressing pressing health needs.
4. Promoting Preventive and Holistic Care:
• Integrate mental, physical, and social health services to create comprehensive care pathways.
• Emphasize education and prevention to reduce long-term healthcare costs.
The Riverside Community Health Foundation is uniquely positioned to address these pressing health needs. By using its strong community presence, collaborative partnerships, and commitment to health equity, RCHF can implement programs that:
1. Reduce barriers to care by expanding affordable and accessible services.
2. Promote health education to empower residents with knowledge and tools for healthy living.
3. Advocate for systemic changes that address the root causes of health disparities, such as housing, food insecurity, and education.
With this CHNA as a guiding framework, RCHF aims to drive lasting, fair improvements in health outcomes across its service area.
Introduction and Background
The Riverside Community Health Foundation (RCHF) has served the local community as a 501(c)(3) nonprofit public charity since 1997. With the mission of enhancing the health and well-being of Riverside residents, RCHF operates several community health clinics in the Eastside and Arlanza neighborhoods to support underserved populations. Additionally, RCHF offers a range of health education programs – from diabetes prevention and management classes to support services for cancer survivors. RCHF also funds and collaborates with other nonprofit organizations that align with its mission.
Community Definition
For most of its history, RCHF served 13 zip codes within the cities of Riverside and Jurupa Valley, as outlined in its articles of incorporation. In 2021, RCHF expanded its service area by adding 8 new zip codes in the adjacent cities of Perris, Moreno Valley, Corona, and Norco. This expansion was approved by the Office of the California Attorney General following a formal request. RCHF’s service area now includes 21 zip codes in Jurupa Valley, Riverside, Moreno Valley, Corona, Norco, and Perris: 92501; 92502; 92503; 92504; 92505; 92506; 92507; 92508; 92509, 92518; 92521; 92522; 92551; 92553; 92557; 92570; 92571; 91752; 92860; 92879; and 92881. With this expansion, RCHF added an estimated 170,000 new residents (a 35% increase) and over 200 square miles to its service area. The map below identifies the original (in light yellow) and expanded service area (in green).
Figure 1.
RCHF’s Service Area
Purpose of the Community Health Needs Assessment
As one of the largest nonprofit organizations in the Inland Empire, the Riverside Community Health Foundation (RCHF) is dedicated to developing a plan that not only ensures that we meet the needs of the Greater Riverside area but also effectively supports our expanding mission. We start this process with our Community Health Needs Assessment (CHNA), which we conduct every four years.
The CHNA has two main goals: first, to identify and measure the key health needs in the Greater Riverside area, and second, to find unmet needs that are not addressed by other organizations. By understanding these needs, we can ensure our programs and services align with what our community truly requires.
Insights from this Community Health Needs Assessment (CHNA) will inform our development of targeted initiatives to tackle current health challenges, promote long-term improvements, and create meaningful change in the Inland Empire.
This report does not specify which health issues RCHF will address. Rather, it shares key findings from our assessment and highlights potential areas of focus. After the completion of this CHNA, RCHF will collaborate with key stakeholders and community members to address gaps, enrich the findings, and guide the development of future programs and funding decisions.
Organization of Community Health Needs Assessment Report
RCHF’s Role in Mitigating Challenges
This Community Health Needs Assessment (CHNA) report is organized to provide a clear and actionable understanding of the health status, disparities, and needs within RCHF’s 21-zipcode service area.
First, we outline the process and methods used to conduct the Community Health Needs Assessment (CHNA) and explain our multi-method approach to data collection. presents the key findings from our assessment and identifies potential areas of focus.
Second, we provide a description of the community we serve, including its demographic and health profile, using data drawn from various government agencies and other organizations.
Third, we expand on the demographic and health data by presenting results from our own data collection efforts, which include surveys, interviews, and focus groups with residents and key stakeholders. Our findings are organized into four main areas identified early in the planning process: healthcare access, preventive care, healthy lifestyles and nutrition, and mental wellness. Additionally, we highlight the health needs and priorities identified by residents, along with their recommendations for improving the community’s health and well-being.
Finally, for those seeking more detailed information, the appendices provide additional context and information about how we conducted the needs assessment.
Process and Methodology
Preparation for this community health needs assessment began in November 2023 with the convening of our Steering Committee meeting, comprised of members from local healthcare providers (e.g., Neighborhood Healthcare), RCHF Board members, RCHF staff members, and other key stakeholders. During the preparation phase, we discussed the objectives of the needs assessment and reflected on past assessments.
Reflect on the Preceding CHNA
In September 2021, the California Attorney General’s Office conducted a brief needs assessment as part of its review of our request to extend our services beyond the original mandate. Although this assessment did not incorporate input from residents and stakeholders, it was the first to include our expanded service area. Consequently, it served as a reference point for the current assessment.
The 2021 needs assessment revealed several concerning health and social issues facing residents in our service area:
1. Poverty and Housing: The community faces high poverty rates and overcrowded households, which can negatively impact health and well-being.
2. Obesity: There are significant rates of obesity among both teens and adults, suggesting a need for improved nutrition and physical activity initiatives.
3. Substance Use: While binge drinking is prevalent, opioid drug use is lower than the average for the region, indicating differing patterns of substance use that require targeted attention.
4. Respiratory Health: The area has high rates of respiratory illnesses, such as asthma, especially among youth, highlighting a need for better air quality and health interventions.
5. Mental Health: Residents report poor mental health and high levels of stress, which are critical areas for intervention and support.
1. Infant Health Outcomes: The service area experiences poor infant mortality rates and low birth weights, both of which are worse than county averages, pointing to significant public health challenges.
2. Chronic Disease and Preventive Care: Although rates of chronic diseases like coronary heart disease (CHD) are lower in our service area, there are also low levels of screenings (e.g., for cancer and cholesterol) and preventive care among seniors. Additionally, routine checkups are less common compared to the county, suggesting gaps in healthcare access and utilization.
Key Steps in the CHNA Process
The Community Health Needs Assessment (CHNA) is an ongoing, cyclical process that evolves over time, with each phase building on insights from previous assessments.
1. Collect and Analyze Data: Gather relevant information on community health from various primary and secondary sources.
2. CHNA Report: Compile findings into a comprehensive report.
3. Prioritize Needs: Evaluate data to identify and prioritize health-related needs during the strategic planning process.
4. Implement: Take action on the identified priorities.
5. Evaluate Actions Taken: Assess the effectiveness of implemented actions.
Figure 2. RCHF’s Four-Year Needs Assessment Cycle
How the CHNA Differs
1. Localized Scope and Target Population:
• While local and statewide assessments often examine broad trends and aggregate data across larger populations, this CHNA focuses specifically on the 21 zip codes within RCHF’s service area.
• The CHNA targets unique demographic groups, such as the area’s younger-than-average population and its majority Hispanic/Latino community, ensuring the findings directly address local needs.
2. Depth of Community Engagement:
• Unlike statewide assessments, which rely heavily on secondary data, RCHF’s CHNA prioritizes direct community input through surveys, focus groups, and interviews.
• The inclusion of 721 survey responses, 73 focus group participants, and 20 key informant interviews ensures that the voices of residents, including those from underserved and hard-to-reach populations, are central to the analysis.
3. Tailored Methodology:
• This CHNA integrates both quantitative data (e.g., prevalence of chronic conditions, access to care metrics) and qualitative insights (e.g., cultural barriers, feelings of health priorities).
• The mixed-methods approach allows for a deeper understanding of the region’s unique health disparities and the systemic factors influencing them.
4. Alignment with RCHF’s Strategic Goals:
• Unlike broader assessments that aim to provide a generalized overview of health issues, this CHNA is specifically designed to inform RCHF’s strategic planning.
• The findings are actionable, showing focus areas such as women’s health, senior care, and food insecurity, which directly align with RCHF’s mission and ability to intervene.
What Makes This CHNA Unique to the Service Area Population?
1. Focus on Health Equity and Disparities:
• The CHNA highlights localized inequities in access to healthcare, mental health services, and preventive care, particularly in low-income and Hispanic areas.
• For example, the service area’s higher rates of poverty, housing burden, and food insecurity are linked to worse health outcomes than county averages, underscoring the importance of equity-driven interventions.
2. Integration of Social Determinants of Health:
• This assessment goes beyond health indicators to explore the broader social and economic factors shaping community health, such as housing affordability, educational attainment, and transportation barriers.
3. Localized Data and Insights:
• Statewide assessments often dilute regional nuances. By contrast, this CHNA provides zip code-level data on chronic conditions, health behaviors, and unmet needs, offering a granular view of the service area.
• For example, the CHNA shows Perris and Moreno Valley as hotspots for chronic disease prevalence, food insecurity, and delayed preventive care, allowing RCHF to target these areas with tailored programs.
4. Community-Centric Solutions:
• The CHNA integrates resident recommendations for addressing health challenges, such as expanding mobile health units, promoting culturally competent care, and increasing awareness of local resources.
• This ensures that proposed solutions are community-driven and contextually relevant rather than top-down initiatives.
CHNA’s hyper-localized focus and integration of community perspectives set it apart from other assessments. By addressing the specific needs and disparities of the service area, the CHNA serves as a powerful tool for RCHF to design programs that drive fair and impactful health outcomes tailored to its population.
Methodology
The 2024 Community Health Needs Assessment (CHNA) followed a rigorous, mixed methods approach to uncover the health challenges and identify focus areas within RCHF’s service area. By synthesizing qualitative and quantitative data, the assessment offers a nuanced understanding of the community’s health landscape and shows a foundation for strategic interventions.
Approach
1. Secondary Data Analysis
o Data was sourced from local, state, and federal agencies, including SHAPE Riverside, California Healthy Places Index, and California Health Interview Survey.
o Key indicators examined included demographics, social determinants of health, access to care, preventive measures, and chronic disease prevalence.
2. Community Survey
o Designed with input from RCHF’s Steering Committee, the survey targeted residents across the service area and was offered in English and Spanish.
o Key topics included healthcare access, preventive care, mental wellness, and community health priorities
o A total of 721 responses were collected, being diverse perspectives, with 25% from residents in the expanded service area and 37% completed in Spanish.
3. Focus Groups
o Eleven focus groups were conducted across Riverside, Jurupa Valley, Moreno Valley, Perris, and Corona-Norco, with 73 participants providing in-depth feedback.
o Discussions centered on specific health issues such as teen health, maternal health, oral health, and senior care.
4. Key Informant Interviews
o Twenty interviews were conducted with RCHF Board members, healthcare professionals, and local officials.
o Topics included the effectiveness of current health services, gaps in care, and opportunities for enhanced collaboration.
voices of residents and key stakeholders
This robust method ensured that the voices of residents and key stakeholders were integrated into the assessment, offering actionable insights.
Community Demographic Profile
Data on population characteristics, economic challenges, and education in our service area offer insight into the community we serve. Analyzing these factors helps us understand the social determinants of health that significantly impact people’s lives and well-being.
Population and Households
Over 806,000 people live in our 21-zip code service area, with over 30% of residents living in just three zip codes – 92503 (Riverside), 92509 (Jurupa Valley), and 92553 (Moreno Valley). Nearly half (49%) of the 250,426 households in our service area have children, significantly higher than the County average.
Table 1. Population and Households in RCHF’s Service Area
Source: SHAPE Riverside (shaperivco.org)
Residents in our service area are typically younger than those in the county overall, with a higher percentage of individuals under 18 years of age and a slightly lower percentage of seniors aged 65 and older.
Source: SHAPE Riverside (shaperivco.org)
City Abbreviations
JV = Jurupa Valley
MARB = March Air Reserve Base
ML = Mira Loma
MV = Moreno Valley
RIV = Riverside
Table 2. Age Distribution in RCHF’s Service Area
Race and Ethnicity
Over sixty percent (62%) of residents in our service area identify as Hispanic/Latino, exceeding the percentage for Riverside County overall. Compared to the county average, our service area has a smaller percentage identifying as White, and a larger percentage identifying as “other”.
Source: SHAPE Riverside (shaperivco.org)
City Abbreviations
JV = Jurupa Valley
MARB = March Air Reserve Base
ML = Mira Loma
MV = Moreno Valley
RIV = Riverside
Table 3. Race and Ethnicity in RCHF’s Service Area
Economic Challenges
High poverty rates and other indicators of economic challenges highlight the need for community health initiatives and support programs aimed at improving health equity.
Source: SHAPE Riverside (shaperivco.org)
City Abbreviations
JV = Jurupa Valley
MARB = March Air Reserve Base
ML = Mira
MV = Moreno Valley
RIV = Riverside
Loma
Table 4. Poverty and Economic Disadvantage
The cost of housing in the region is also a significant burden for residents, particularly among lower-income households. In our service area, low-income residents in Perris, Jurupa Valley, and Corona are paying more than 80% of their income on housing.
Source: 2021 Census Tract Data; Income & tenure; low-income = 30% HUD Area Median Family Income.
Educational Attainment
While 83% of residents 25 and older in Riverside County have at least a high school diploma, several zip codes in our service area have high school diploma rates well below this. Only 5 zip codes in our region have rates of college degree attainment higher than the county. This low level of educational attainment correlates with limited job opportunities and higher rates of chronic illnesses.
Figure 3. Percent of Low-Income Households Paying More than 30% of Monthly Household Income Towards Housing Costs
Table 5. Educational Attainment in RCHF’s Service Area
Source: SHAPE Riverside (shaperivco.org)
City Abbreviations
JV = Jurupa Valley
MARB = March Air Reserve Base
ML = Mira Loma
MV = Moreno Valley
RIV = Riverside
Key Demographic Insights
RCHF’s service area encompasses 21 zip codes, including Riverside, Jurupa Valley, Moreno Valley, Perris, and Corona-Norco, with a population of over 806,000 residents. The demographic diversity and socioeconomic variations across the region inform both the health disparities and the strategies needed to address them.
1. Age Distribution
o The service area has a younger population compared to Riverside County overall, with 27% of residents under 18, underscoring the need for pediatric and adolescent health services.
2. Race and Ethnicity
o Over 62% of residents identify as Hispanic/Latino, a significantly higher percentage than the county average.
o This diversity causes culturally tailored health interventions and enhanced language access in health services
3. Economic Challenges
o Poverty levels are markedly higher in key areas such as Moreno Valley and Perris, with some zip codes reporting over 20% of children living below the poverty line.
o Housing affordability is still a critical issue, with low-income households spending over 80% of their income on housing in some areas.
4. Educational Attainment
o Educational attainment in the service area lags county averages, with fewer residents holding a high school diploma or bachelor’s degree. This correlates with reduced health literacy and limited job opportunities.
Implications
These demographic factors highlight the intersection of social determinants of health, emphasizing the need for targeted initiatives that address both healthcare access and the underlying socioeconomic barriers.
Community Health Profile
Our analysis of key health indicators in our service area highlights the disparities and challenges faced by residents in our region. These indicators are useful because they combine several important drivers of health into one measure.
Unmet Needs
Many zip codes within our service area show significantly poorer health indicators compared to the county average. Two-thirds of the zip codes we serve have higher “Unmet Needs Scores” than the county overall, with some (e.g., 92570 in Perris and 92553 in Moreno Valley) being substantially higher.
Health Equity Concerns
The “Health Equity Index” suggests pronounced disparities in over two thirds of the zip codes we serve. These lower scores suggest that residents in these areas face considerable barriers in achieving optimal health.
Food Insecurity
The data also reveal striking levels of food insecurity across our service area, many with substantially higher index scores than the county average, emphasizing the need for enhanced food access initiatives to combat hunger in the community.
Data from California’s Office of Health Equity highlights the shortage of healthy food retailers in Riverside County. Out of 1,896 food retailers in the county, only 316 (or 16.7%) are designated as healthy food retailers. This percentage is significantly below the state average of 20.8%.
Table 6. Unmet Needs, Health Equity, and Food Insecurity
Source: SHAPE Riverside (shaperivco.org)
City Abbreviations
JV = Jurupa Valley
MARB = March Air Reserve Base
ML = Mira Loma
MV = Moreno Valley
RIV = Riverside
1 Health Equity Index is a measure of socioeconomic need that is correlated with poor health outcomes.
2 The Food Insecurity Index is a measure of economic and household hardship correlated with poor food access.
Health Conditions
An examination of the prevalence of various health behaviors and conditions in our service area reveals that the following are significant outliers, with rates higher than the county overall:
• Binge drinking
• Asthma³
• Diabetes
• Obesity (among all age groups)
• Consumption of sugary beverages
Source: SHAPE Riverside (shaperivco.org)
City Abbreviations
JV = Jurupa Valley
MARB = March Air Reserve Base
ML = Mira Loma
MV = Moreno Valley
RIV = Riverside
3 It is worth noting that high rates of binge drinking have been previously identified in needs assessments of the region. However, these issues did not emerge in other components of our assessment—for example, in the survey, interviews, or focus groups. This discrepancy suggests that while binge drinking is a known problem in the region, it may not be as visible or acknowledged as much as other health issues.
Table 7. Selected Health Conditions in RCHF’s Service Area
Rates of diabetes among adults, consumption of sugary drinks, and obesity are also significantly greater in our service area zip codes than rates for Riverside County.
Source: SHAPE Riverside (shaperivco.org)
City Abbreviations
JV = Jurupa Valley
MARB = March Air Reserve Base
ML = Mira Loma
MV = Moreno Valley
RIV = Riverside
Table 8. Diabetes and Obesity Rates in RCHF’s Service Area
Women’s and Maternal Health
Data on low birth weight in our service area suggests significant health needs among expectant mothers and infants. Nearly every zip code in our service area has rates of very low birth weight that are higher than Riverside County overall. Notably, these higher rates can indicate underlying issues such as limited access to prenatal care, socioeconomic challenges, and health disparities among the populations in these areas. The elevated prevalence of low birth weights signals a critical need for improved maternal health services and targeted interventions aimed at supporting pregnant women in these vulnerable communities.
Source: SHAPE Riverside (shaperivco.org)
City Abbreviations
JV = Jurupa Valley
MARB = March Air
ML = Mira
MV = Moreno Valley
RIV = Riverside
Reserve Base
Loma
Table 9. Low Birth Weight
Oral Health
Compared to the Riverside County average, which serves as a benchmark for assessing community needs, the oral health statistics in our service area suggest a need for community dental programs and outreach efforts to improve overall dental health and access to care.
Source: SHAPE Riverside (shaperivco.org)
City Abbreviations
JV = Jurupa Valley
MARB = March Air Reserve Base ML = Mira
MV = Moreno Valley
RIV = Riverside
Loma
Table 10. Oral Health Indicators
Senior Health
The health of seniors in the Riverside County service area presents another area of significant concern, particularly given the growing aging population. Many zip codes show a higher prevalence of disability and living difficulty among seniors compared to the county average.
Table 11. Health Indicators Relating to Seniors
Source: SHAPE Riverside (shaperivco.org)
City Abbreviations
JV = Jurupa Valley
MARB = March Air Reserve Base
ML = Mira Loma
MV = Moreno Valley
RIV = Riverside
Community Health Areas of Opportunity
The analysis of data from primary sources—such as community surveys, focus groups, and key informant interviews—combined with insights from secondary sources, reveals several key dimensions related to community health: (1) healthcare access, (2) preventive care, (3) healthy lifestyle practices and nutrition, and (4) mental wellness. Most of the specific issues identified in the assessment reflect one or more of these dimensions.
Healthcare Access
Access to healthcare was frequently mentioned by residents during our needs assessment. Secondary data indicates that approximately 1 in 4 adults in our service area have delayed or struggled to obtain care, with the percentage of uninsured adults being notably higher than the Riverside County average. Our survey reveals that nearly half (45%) of residents postponed medical or dental care in the past year, primarily due to work schedule conflict, transportation issues, and high costs.
Table 12. Key Findings: Health Care Access
Cost is a significant barrier to accessing medical and dental care, and awareness of local free or low-cost health clinics is low, with nearly half (49%) of surveyed residents unaware of these resources.
In addition to cost, an insufficient number of facilities and distance were mentioned as barriers to access, leaving many frustrated. For residents living in more remote areas of our service area, distance and a lack of transportation can be an obstacle to receiving care. When talking about prenatal care, one resident observed, “Sometimes people don’t have transportation and able to get to appointments, and pre prenatal health care is vital to the health and well-being of both mom and baby.”
Figure 4. Postponed Medical or Dental Care in the Last 12 Months
Figure 5. Awareness of Local Free or Low-Cost Health Clinics
Residents suggested that limited access to care significantly hinders the community’s ability to address important health issues, such as women’s and maternal health, oral health, and senior health.
Women’s and Maternal Health
The issues surrounding maternal health are often linked to inadequate access to prenatal care and socioeconomic challenges. Focus group discussions highlighted a pressing need for improved maternal health services. Residents expressed concerns about the lack of support for pregnant women and stressed the importance of involving them in their own care. A common theme was the necessity for more comprehensive prenatal support and education to ensure the health of both mothers and infants. “Healthy pregnant moms tend to make healthy babies, so keeping moms healthy and supported so important.”
Oral Health
According to residents, access to dental care in Riverside County is limited, with many areas reporting high rates of preventable dental diseases. Poor oral health disproportionately affects low-income families, leading to serious systemic health issues. One resident observed, “There is no program that I know of right now that helps with the dentist... it would be great to set up a program to help low-income people.” Residents see oral health care as vital but frequently feel that they cannot afford proper care, some mentioned that insurance does not cover enough: “I know, like, some basic things are included with Medi-Cal, but dental is very expensive. A lot of people can’t afford it. I think people need more help, financial help for those services.”
Senior Health
Seniors in our service area face significant health challenges, including higher rates of disability compared to the county average. As the elderly population continues to grow, there is an increasing demand for healthcare services tailored to their specific needs, such as preventive care and rehabilitation. Focus group discussions emphasized the importance of respectful and attentive care, with many participants noting that seniors often feel overlooked in healthcare conversations.
Residents made several suggestions to support seniors better, including adding fitness equipment to parks designed for their use, developing and promoting local senior centers, and raising awareness of low-cost resources available to them. These centers would help keep seniors connected to the community.
Many residents highlighted the importance of affordable solutions. One individual recalled an incident involving a senior family member in need of dental care, saying, “I think we need more resources, like clinics that don’t charge for elders, because it gets pretty expensive... He’s not able to go to a doctor because they’re gonna charge him a lot, and he doesn’t want us to spend.”
Satisfaction with Healthcare Providers
Overall satisfaction with healthcare providers is lukewarm, suggesting that patients do not feel their needs are being met. Vision care providers received the most positive feedback, while addiction services were viewed the least favorably. Average ratings for all types of providers are in the neutral range, with none achieving an average rating in “satisfied” or “very satisfied” range.
Figure 6. Satisfaction with Healthcare Providers (Average Rating)
Preventive Care
Preventive healthcare encompasses measures taken to avoid diseases or injuries before they occur, including vaccinations, regular screenings, and lifestyle counseling. It is an important indicator of community health as it reflects the effectiveness of healthcare systems in promoting wellness and reducing chronic disease incidence. High rates of preventive care utilization not only lower healthcare costs and improve quality of life but also signify health equity by ensuring community members have access to essential resources and education for maintaining their well-being.
Data from our community needs assessment suggest that significant gaps in preventive care exist in the Greater Riverside area.
The percentage of residents who have had a routine checkup, as well as the percentage of seniors who have received their recommended preventive services, is significantly lower in our service area compared to Riverside County overall.
Table 13. Key Findings: Preventive Care
Table 14. Rates of Routine and Preventive Care
Source: SHAPE Riverside (shaperivco.org)
City Abbreviations
JV = Jurupa Valley
MARB = March Air Reserve Base
ML = Mira Loma
MV = Moreno Valley
RIV = Riverside
Our secondary data analysis revealed that a smaller percentage of adults in our service area zip codes have had their cholesterol checked in the last five years compared to the county average. Additionally, the rates of medication compliance, particularly for taking prescribed blood pressure medication, are lower than the county overall.
Table 15. Screening and Medication Compliance
Source: SHAPE Riverside (shaperivco.org)
City Abbreviations
JV = Jurupa Valley
MARB = March Air Reserve Base
ML = Mira Loma
MV = Moreno Valley
RIV = Riverside
4This indicator shows the percentage of adults who have had their blood cholesterol checked in the past five years.
5This indicator shows the percentage of adults aged 18 or over with high blood pressure who report taking medications for high blood pressure.
Except for mammograms, screening rates for a variety of health conditions – for example, cervical cancer, colon cancer, etc. – moreover are strikingly low, as are rates for routine checkups and vaccinations. Recommended preventative services are also very low among seniors (65 and older) in our service area compared to county rates.
Source: SHAPE Riverside (shaperivco.org)
City Abbreviations
JV = Jurupa Valley
MARB = March Air Reserve Base
ML = Mira Loma
MV = Moreno Valley
RIV = Riverside
6Sigmodoscopy past 5 years and FOBT past 3 years, colonoscopy past 10 years, or FOBT past year
Table 16. Cancer Screening Rates
Awareness of Recommended Screenings
In general, residents lack awareness about preventive screenings, including the timing and frequency of such screenings. Less than half of the respondents know how often they should check their blood pressure or cholesterol, or be screened for diabetes, colorectal cancer, prostate cancer, or osteoporosis.
Figure 7. Percent of Residents Aware of How Often Preventive Screenings Are Needed
Healthy Lifestyle, Nutrition, and Food Security
Healthy lifestyle practices, such as maintaining good nutrition and engaging in regular exercise, are essential components of preventive care. They help reduce the risk of chronic diseases and enhance overall well-being. By adopting these habits, individuals can take proactive steps to prevent health issues before they arise.
Food security is a crucial aspect of maintaining a healthy lifestyle and good nutrition. Our needs assessment highlights residents’ concerns about food accessibility, nutrition, and healthy lifestyle practices within the communities we serve.
• Children and teens in our service area zip codes are less likely to rate their health as good, very good, or excellent than the county average.
• In eight of our service zip codes, roughly 1 in 5 adults describe their health as just “fair” or “poor”, higher than the county average. In 92509 (Jurupa Valley), nearly 1 in 3 adults describe their health this way.
• Promoting healthy behaviors is ranked as one of the most important health priorities by residents we asked, with 28% of residents surveyed believing it is the top priority in their community (see Figure 9).
• Healthy eating ranks third behind only mental health and access to affordable care in terms of perceived importance (see Figure 10).
• Residents want to see programs focused on physical activity and exercise and nutrition and healthy eating, which rank as the top and third most desired type of program by residents (see Figure 6).
Table 17. Key Findings: Healthy Lifestyle and Nutrition
• While recognizing the importance of nutrition, many residents from Riverside, Jurupa Valley, and Corona-Norco are concerned about the lack of access to healthy foods. One resident asked, “How can we help have more fresh food accessibility in our community, like farmers markets and things like that…?” This sentiment also appeared in our interviews, with one stakeholder expressing a desire to establish a sustainable food network to support lowincome neighborhoods and seniors. Residents felt that ensuring food accessibility is a crucial first step in improving overall community health. As one resident noted, “Once people’s basic needs are met, they can thrive. But so many people are just lacking having their basic needs met.”
• Residents emphasize the importance of promoting healthy habits, especially among teens, through educational initiatives that raise awareness of healthy lifestyle choices. For example, one resident mentioned the need for “ways to help people be proactive in their lives so that they can have good health.”
Figure 8. Top Program Topics Favored by Residents
Mental Wellness
Mental wellness refers to a state of emotional and psychological well-being that allows individuals to manage stress, maintain healthy relationships, and engage productively in their daily lives. Higher levels of mental wellness reduce the likelihood of mental health issues, increase social cohesion, and enhance overall quality of life. Prioritizing mental wellness addresses individual health needs and fosters a supportive environment that benefits the entire community.
Mental wellness is a major concern in the Greater Riverside area, as indicated by both our primary and secondary data collection efforts.
Residents report rates of depression that exceed the county average in nearly every zip code in our service area, with only one exception (i.e., 92518).
Additionally, the percentage of residents experiencing poor mental health for 14 or more days in the past month is also higher than the county rate.
Table 18. Key Findings: Mental Wellness
Source: SHAPE Riverside (shaperivco.org)
City Abbreviations
JV = Jurupa Valley
MARB = March Air Reserve Base
ML = Mira Loma
MV = Moreno Valley
RIV = Riverside
A large percentage of residents in our service area feel that they lack effective coping strategies for stress and trauma, with 21% indicating they do not know how to manage stress at all.
Total: 566
Residents are deeply concerned about gaps in mental health services and the lack of resources, viewing mental health issues as a major obstacle to a healthy community. One resident commented, “There’s so much mental illness on our streets... and issues with mental health that our community isn’t as healthy and thriving as it could be”’
The lack of mental health resources is a significant concern. One resident noted the lack of therapists in the community, and that to see a therapist (as opposed to a psychiatrist) required a long trip: “And to go to an actual therapist, we have to go all the way to Riverside or Temecula and stuff like that. You know, it’s 30 to almost an hour away depending on traffic.”
Another resident highlighted the mental health needs of youth, pointing out the gaps in services for younger individuals, noting that counselors are available for older students: “But it’s [having counselors] also needed, a psychologist or a social worker in middle school and elementary because they’re that’s where they’re also seeing a trend of younger kids committing suicide just because there’s lack of resources or anyone to talk to.”
Overall, 36% of residents want more counseling services in their community, making it the most frequently identified need. This is followed by support groups at 15% and educational resources at 14%.
Figure 9. Residents’ Familiarity with Techniques to Manage Stress or Trauma
Yes, (n=276), 49%
Some (n=169), 30%
(n=121), 21%
Total: 721
Additional Community Needs
Residents, particularly during the focus groups and interviews, identified additional needs and themes that were as common as the ones identified above.
Community Safety
Residents are concerned about crime, violence, and a lack of respect within the community. There is a strong desire for safer neighborhoods with increased community policing, neighborhood watch programs, and active community involvement.
Community Cleanliness and Organization
Residents we spoke to also expressed their desire for cleaner and better-organized public spaces (e.g., parks or community centers).
Employment Opportunities
Residents were concerned about the availability of employment Concerns were raised about the types of jobs available and their impact on residents’ wellbeing. There is a call for improved employment opportunities that positively contribute to the community’s economic and social health.
Youth Activities and Mentorship
The need for more youth engagement activities and mentorship programs was emphasized. Providing young people with constructive activities and positive role models was seen as crucial for fostering a healthy and vibrant community. One resident commented, “If there were more things for kids to actually do, safe places for them to go... that might really help with depression, anxiety, mental health issues.”
Figure
Community-Led Solutions
Residents provided their views on the health needs that should be addressed in their community and shared insights on how RCHF can collaborate with other organizations and health partners to enhance its impact. Their suggestions outline potential pathways for RCHF to consider as it develops future health priorities.
Residents’ Top Health Needs and Priorities
When asked to identify the most important areas for improving community health, residents showed a nearly even preference between expanding mental health services—such as counseling and support groups—and encouraging healthy behaviors through education. Together, these two focus areas accounted for over half (57%) of all survey responses. The third most selected area was enhancing healthcare infrastructure, including improvements to physical facilities, technology, and staffing.
Total: 721
Residents conveyed that all health needs and issues, including chronic diseases, substance abuse, and maternal and child health, were important to some degree, reflecting a general concern for community health. However, when asked to rank these issues, the three most pressing concerns identified were: (1) access to affordable care, (2) mental health and wellbeing, and (3) nutrition and healthy eating.
Figure 11. Residents’ Top Priority for Enhancing Community Health
Other Concerns and Recommendations from Residents
Residents offered several recommendations related to collaboration and improving communication and community engagement.
Emphasizing Cultural Competency and Empathy
One of the primary concerns raised by residents is the need for healthcare providers to demonstrate cultural competency and empathy. Participants emphasize that understanding the diverse backgrounds of patients is essential, particularly for marginalized communities. One resident recounted a bad experience with a healthcare provider the resident felt was racially motivated, “They think that we don’t know our rights. So, I saw and I felt that racism.”
Others identify culture and language as significant barriers to accessing healthcare. One resident observed, “Another thing that affects us a lot in the Hispanic community is social taboos... people sometimes do not seek resources because they fear being judged for having a certain illness.” Additionally, language differences are cited as obstacles; some residents mention that they often do not seek care “precisely because of the barriers, because of the language.”
Figure 12. Average Rating of Health Needs Importance by Residents (Out of 10)
Raising Community Awareness
Effective communication and community engagement were highlighted as critical themes. Participants stressed that increasing community awareness is essential to improving access to care. One recommendation was to establish dedicated spaces, whether physical or online, where community members can easily access vital health information. As one participant suggested, “If we have a special location where everyone can just reach in and see bulletins, flyers, or anything... that type of communication will definitely help this community.”
Residents pointed out that a major obstacle to getting care is a lack of information. For example, one resident noted, “A lot of people don’t know where to call, and they’re left with, ‘Oh, well, there’s nothing I can do.’” Another resident added, “There are resources and services, but many people are not informed and do not know about the programs that exist.”
Empowering Residents
Raising awareness alone may not improve access to care if residents are uncomfortable navigating the healthcare system or lack the confidence to advocate for their own health or that of their family members. One solution that residents proposed is to equip residents with the knowledge and skills they need to advocate for themselves within the healthcare system. As one participant urged, “...we also need to be educated on how to talk to doctors and how to connect with them.”
Residents provided valuable feedback on various strategies for collaboration and community engagement. Key recommendations included:
• Emphasizing cultural competency among healthcare providers,
• Enhancing communication channels to ensure residents are informed about available resources,
• Implementing proactive outreach through informational sessions,
• Establishing feedback mechanisms for service improvement, and
• Empowering community members with advocacy education.
By exploring these suggestions and identified health needs, RCHF can develop a comprehensive approach to enhance overall community health, ensuring that the diverse needs of residents are effectively addressed.
Enhancing RCHF’s Presence
Stakeholders have suggested that the Riverside Community Health Foundation (RCHF) consider adding satellite offices in other cities within its service area, such as Perris, Moreno Valley, and Corona-Norco, rather than only maintaining its current office in Riverside. With the expansion of its service area, RCHF and its staff now cover a wider geographic region. Establishing satellite offices would help address this challenge, ensuring more efficient and accessible service delivery. Additionally, having a presence in these other regions would raise RCHF’s visibility within the community, helping to better serve residents and strengthen community engagement.
From this assessment, we have identified several focus areas (health needs) for the Riverside Community Health Foundation (RCHF) in the Greater Riverside area.
Appendix A. Secondary Data Indicators
The following is a list of indicators used from other sources we consulted. Most of the data were collected from the online tool SHAPE Riverside (www.shaperivco.org).
Appendix B. RCHF Community Survey
Appendix C. Focus Group Consent Form
Appendix D. Focus Group Questions
Appendix E. Profile of Focus Group Participants
This section includes a brief description of the focus group participants. In all, we had 73 participants across 11 focus groups. We conducted 2 focus groups in the areas of Jurupa Valley, Riverside, Corona-Norco, and Perris; and 3 in Moreno Valley. Except for Jurupa Valley, where both focus groups were conducted in Spanish, we conducted at least one focus group in English and one in Spanish. Below is a profile of participants based on the information we collected when they volunteered.
