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Needs Assessment
January 6th 2011
Dr Jane Buxton
Consider what do we mean by need
• What is need?
• How is it different from want?
• What is demand?
• How does supply fit in the picture?
What is need?
• A need is something that is necessary for organisms to live a healthy life
• Need = factors which must be addressed to improve the health of the population
Maslow’s hierarchy of needs (1954)
Why are the determinants of health important?
• Health care influences whether people get well when they are sick
• Determinants of health influence why some people are healthy and others not
• Consistent correlation between life expectancy & health status with measures of social status
(Evans et 1994)
The Determinants of Health• Social environment• Income and social status• Social support networks• Healthy child development• Education• Employment and working conditions• Physical environment• Biology and genetic endowment• Personal health practices and coping skills• Health and social services
Gender and culture have cross cutting, influential effects on all the other determinants
(Health Canada, 2001)
Wants - services the public request not knowing the costs
Demands – services requested when costs are known; What the patient asks for
Needs – expert opinion what ought to be provided
Use: health services actually used
Supply: What is provided
• A/B for URT viral infections• Health promotion, some screening• Waiting list e.g. TOP
Death rates UK
Q. Why the decline?
Thomas McKeown 1979
• Decrease mortality infectious disease E & W 1938-70 was not due to medical intervention alone– Nutrition– Living conditions– Birth spacing
Hans Rosling's 200 Countries, 200 Years, The Joy of Stats - BBC 4
http://www.youtube.com/watch?v=jbkSRLYSojo
How has life expectancy changed over time globally?
What is a needs assessment
• Is a process for determining and addressing needs, or "gaps" between current conditions and desired conditions
• Why do a needs assessment?
– Discuss
Why do health needs assessment?• Provides a rational basis for planning services
and allocating limited resources– Including med student time and efforts
• Identifies: – Service needs of community/population – Utilization patterns– Gaps in service provision
• Permits involvement of users of the health service in planning & avoids over-reliance on care providers’ perceptions
• Identifies alternatives for meeting these needs.
Consider this scenario:
• You are part of a team visiting a remote village in India. You are working with the local boarding school to improve the health of the children.
• What steps would you take to assess the needs of this group?
• How would you ensure that your actions are culturally sensitive?
• How would you ensure your actions are sustainable?
Spiti Valley, India
• Over 400 children (kindergarten – grade 10)
• Children stay in hostels, monitored by house mothers
• Closest hospital 8 km away
Enter GHI
• To improve health care in a culturally sensitive and sustainable way
• 2006: 3 UBC medical students and a family physician performed first needs assessment (and have continued doing so annually)
Spiti Project Needs AssessmentYear Action Key findings/concerns
2006 Conversation with locals
Lack of healthcare
Conversation with partner NGO’s
Transmission of illness in boarding schools
Health screens
Anemia, dental caries, intestinal disease, and skin disease.
2007 Health screens
88% of children were anemic
Spiti Project Needs AssessmentYear Action Key findings/concerns
2006 Conversation with locals
Lack of healthcare
Conversation with partner NGO’s
Transmission of illness in boarding schools
Health screens
Anemia, dental caries, intestinal disease, and skin disease.
2007 Health screens
88% of children were anemic
Spiti Project Needs AssessmentYear Action Key findings/concerns
2006 Conversation with locals
Lack of healthcare
Conversation with partner NGO’s
Transmission of illness in boarding schools
Health screens
Anemia, dental caries, intestinal disease, and skin disease.
2007 Health screens
88% of children were anemic
Spiti Project Needs AssessmentYear Action Key findings/concerns
2006 Conversation with locals
Lack of healthcare
Conversation with partner NGO’s
Transmission of illness in boarding schools
Health screens
Anemia, dental caries, intestinal disease, and skin disease.
2007 Health screens
88% of children were anemic
Spiti Project Needs AssessmentYear Action Key findings/concerns
2006 Conversation with locals
Lack of healthcare
Conversation with partner NGO’s
Transmission of illness in boarding schools
Health screens
Anemia, dental caries, intestinal disease, and skin disease.
2007 Health screens
88% of children were anemic
Spiti Project: AnemiaIntegrated approach looking at linked causes
Health screensHemoglobin
MeasurementBlood smears
Anemia
• Researched all linked causes of anemia (as per WHO guidelines and resources)
• Community surveys & focus groups:– Toileting behaviours– Vaccination practices– Hygiene practices– Water access– Greenhouse interest and knowledge– Women's health– Healthcare access in summer and winter – Nutrition analysis.
Spiti Project: AnemiaIntegrated approach looking at linked causes
• Explored cultural and religious issues– Consulted Tibetan experts in Vancouver (Ph.D
student at UBC), and local community members
• Explored gov't involvement in water and sanitation, food subsidy
• Took in suggestions from locals on how to address individual causes of anemia
Spiti Project: AnemiaIntegrated approach looking at linked causes
India project: anemiaIntegrated approach looking at linked causes
Greenhouses
WaterSanitation
InfrastructureHygiene
ToothbrushingHandwashing
Nutritionsurvey
Health Education
IronSupplementation
Deworming
Health screensHemoglobin
MeasurementBlood smears
Anemia
Types needs assessment
Subtypes/terminology– Rapid needs assessment– Health needs assessment– Community needs assessment
Health needs assessment systematic approach to ensuring the health services use its resources to improve the health of the population most efficiently
Community needs assessment evaluate possible solutions taking problems/deficits/ weaknesses and advantages/opportunities /strengths into consideration*
*Gupta, Kavita; Sleezer, Catherine M.; Russ-Eft, Darlene F. (2007-01-16). A Practical Guide to Needs Assessment (2 ed.).
If we don’t know where we are, we don’t know
where to go next
If we don’t know where we are going,
we’ll get lost
Framework for planning*• Working through Precede-Proceed model is like
solving a mystery• Start with vision desired end, work back to identify
forces influence attaining the vision• Phase 1: Social assess. & situational analysis;
hopes, concerns, engagement, cultural relevance
• Phase 2: Epidemiologic assessment; indicators, determinants of health, behaviour, life style. Environmental-economic, services
• Phase 3: Educational and ecologic; predisposing, reinforcing & enabling; KAB, values, rewards and feedback
*Health program planning; An educational and ecological approach. 4th ed. Green & Kreuter pub McGraw Hill
Population Health
• Community assessment/diagnosis– Identify determinants of health problem
↓
• Intervention/program options– Appraise, decide, implement
↓
• Evaluate
MEASURES OF HEALTH STATUS Mortality
Crude rates; Adjusted rates
Cause specific ratesInfant mortality Potential years of life lostLife expectancy
MorbidityMental illnessFunctional status; Disability adjusted life years (DALYS)
Quality adjusted life years (QALYS)Health Conditions
OverweightChronic conditions; Chronic painSelf-rated health;
Community assessment/diagnosis
INDIVIDUAL CAPACITIES reflect the stages of life Child development
Low birth weight; BreastfeedingAdolescent
High school graduation; Post secondary education Teen pregnancy rate
Adult: Healthy ChoicesSmoking; Heavy drinkingPhysical activity; Healthy eatingHigh-risk sexual practices
Elder
ENVIRONMENTAL HEALTH Air PM10 or PM2 air pollution
Exposure to second-hand smokeWater Water quality index including availability Watershed protectionFood Food sustainability Inspection of sources, distribution and retail Housing Availability and affordabilityExposure to hazards Blood lead levels in children Sun Protection ProgramsSustainability Greenhouse gas emissions Energy consumption
HEALTH SERVICESPublic Health Services
Childhood immunization; Influenza immunizationScreening mammography; Pap smearsSmoking cessation services
FacilitiesHospital bed availability from a facilityTypes of servicesDiagnostic ServicesCommunity Satisfaction Measures
ManpowerPhysician, nurses, lay practitioner etc.Dental Unmet health care needs
DISEASE AND INJURY OCCURRENCE AND PREVENTION Non-communicable diseases
Heart disease and stroke incidence and mortalityCancer incidence and mortalityRespiratory disease; Mental health
Communicable diseasesVaccine-preventable diseasesTuberculosis ; HIV infection; STIsFood and waterborne diseases
InjuriesUnintentional injuriesHip fracturesDomestic violence; Child abuse and neglectIllicit drug overdose; Suicide
Who is the data for?
• Whose perspective / who funds?– Government, regional or local public health
and healthcare organizations– Disaster relief organizations (Red Cross)– Law enforcement– Utilities (e.g. electricity, water)– Media, etc.– Medical students to develop program
Process – Questions to be addressed
• Why? What is the purpose of the needs assessment?
• Who are the stakeholders?
• What types of data are required?
• How will the data be collected?
• How will the data be analysed?
Community engagement
• Who are the experts?– Nothing about us without us
• Not just service provision– Accessibility; acceptability, culturally appropriate
• E.g. well
• Community engagement in Spiti Valley
Context: micro/meso/macro
Individual client
Family
Clinic/school/church Pop.
Community
Region
Global
Medical students
Community intervention:
Literature search
Who are the stakeholders?
• Current or potential consumers of service
• Service providers– Health care providers
• Professional organizations & decision makers– School principal, community elders, pastors
• Government organizations
• Medical students
Types of data; how collected
PRE-VISIT• Literature searches
– Medline, targeted sources WHO, UN Country Teams, OECD, Google, feedback from medical students
DURING: • Qualitative
– Observation, Key informant interviews, Focus groups
• Quantitative– Local details, service utilization etc– Survey
POST VISIT
Qualitative vs. Quantitative
Qualitative• Why? Identify issues • How
– Observation, field work – Key informant interviews– Focus groups
Methods/principles/theory– Grounded theory, narrative inquiry
• Semi-structured interviews– open ended Q, Interview guide, probes– Less is more
• Descriptive, not generalizeable
Quantitative -surveyNumeric; How?
• In person– Interviewer administered (literacy levels)– Pen and paper (assisted)
• By phone– RDD– Computer assisted
• On computer– E-mail etc
What type of questions? Y/N, Likert scale, open ended. Reflect purpose, what to do with answers. Pilot, valid. Theoretically based. HBM, Prochaska
Who? Sampling frame
Sampling Rapid Needs Assessment
• Based on WHO Expanded programme on immunization (EPI)
• Used to estimate community impact of Hurricane Andrew in South Florida in 1992
• Also used after the Sept 11, 2001 attacks in NYC to assess needs in residents of Lower Manhattan
Cluster Sampling Methods• Systematic sampling of 30
‘clusters’• Create a grid over the area
to be sampled– ¼ mile squares on street
map
• Assign each square or ‘cluster’ a number
• Determine interval e.g. 120 squares interval 4 (120/30)
• Random start (btw 1 & 4)• Select 30 clusters
Cluster Sampling Methods
• Go to the centre of the first cluster (i.e. square) • Determine sampling unit (Us. people/ households)
• Determine # of units to be sampled in each cluster (e.g. 10 households)
• Proceed in a randomly picked direction to the first occupied household
• Interview the first adult at the occupied residence• Go consecutively to the next occupied household until
you have reached 10 in that cluster• If a multi-unit dwelling or apartment building pick first
occupied unit for interview• Move to next selected cluster
Systematic sampling; e.g. every 8thExample: systematic sampling
Source: D. Coulombier, Epicentre
Source: MSF
Benefits
• Practical and standardized methods allow for rational assessment (not based on rumours)
• Gives a picture of what needs are and helps direct relief operations– E.g. switch from mass casualty trauma services to
primary care and preventive services
• Can monitor over time
“Being roughly right is generally more useful than being precisely
wrong”
Guha-Sapir, D. Rapid assessment of health needs in mass emergencies: Review of current concepts and methods. World Health Stat Q.
1991;44:171-181.
How will the data be analysed?• Qualitative
– Identify themes; recorded & transcribed, notes, highlighter; print and cut; qual program eg NVivo to organize,
– Take back to participants (member checking)– Language challenges
• Quantitative– Analyse survey statistical, based on theory
• Write it up– Present it to community, get buy in,
Ethics, Collecting data for action