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