Needs Assessment
January 6th 2011
Dr Jane Buxton
Consider what do we mean by need
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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
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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
How has life expectancy changed
over time globally?
Hans Rosling's 200 Countries, 200
Years, The Joy of Stats - BBC 4
http://www.youtube.com/watch?v=jbkSRLYSojo
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 Assessment
Year
Action
2006
Conversation Lack of healthcare
with locals
2007
Key findings/concerns
Conversation
with partner
NGO’s
Health
screens
Transmission of illness in
boarding schools
Health
screens
88% of children were anemic
§ Anemia, dental caries,
intestinal disease, and skin
disease.
Spiti Project Needs Assessment
Year
Action
2006
Conversation Lack of healthcare
with locals
2007
Key findings/concerns
Conversation
with partner
NGO’s
Health
screens
Transmission of illness in
boarding schools
Health
screens
88% of children were anemic
§ Anemia, dental caries,
intestinal disease, and skin
disease.
Spiti Project Needs Assessment
Year
Action
2006
Conversation Lack of healthcare
with locals
2007
Key findings/concerns
Conversation
with partner
NGO’s
Health
screens
Transmission of illness in
boarding schools
Health
screens
88% of children were anemic
§ Anemia, dental caries,
intestinal disease, and skin
disease.
Spiti Project Needs Assessment
Year
Action
2006
Conversation Lack of healthcare
with locals
2007
Key findings/concerns
Conversation
with partner
NGO’s
Health
screens
Transmission of illness in
boarding schools
Health
screens
88% of children were anemic
Anemia, dental caries,
intestinal disease, and skin
disease.
Spiti Project Needs Assessment
Year
Action
2006
Conversation Lack of healthcare
with locals
2007
Key findings/concerns
Conversation
with partner
NGO’s
Health
screens
Transmission of illness in
boarding schools
Health
screens
88% of children were anemic
Anemia, dental caries,
intestinal disease, and skin
disease.
Spiti Project: Anemia
Integrated approach looking at linked causes
Health screens
Hemoglobin
Measurement
Blood smears
Anemia
Spiti Project: Anemia
Integrated approach looking at linked causes
• Researched all linked causes of anemia (as per
WHO guidelines and resources)
• Community surveys & focus groups:
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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: Anemia
Integrated 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
India project: anemia
Integrated approach looking at linked causes
Health screens
Hemoglobin
Measurement
Blood smears
Greenhouses
Iron
Supplementation
Deworming
Anemia
Health
Education
Water
Sanitation
Infrastructure
Hygiene
Toothbrushing
Handwashing
Nutrition
survey
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
Community assessment/diagnosis
MEASURES OF HEALTH STATUS
Mortality
Crude rates;
Adjusted rates
Cause specific rates
Infant mortality
Potential years of life lost
Life expectancy
Morbidity
Mental illness
Functional status;
Disability adjusted life years (DALYS)
Quality adjusted life years (QALYS)
Health Conditions
Overweight
Chronic conditions;
Chronic pain
Self-rated health;
INDIVIDUAL CAPACITIES reflect the stages of life
Child development
Low birth weight; Breastfeeding
Adolescent
High school graduation; Post secondary education
Teen pregnancy rate
Adult: Healthy Choices
Smoking;
Heavy drinking
Physical activity;
Healthy eating
High-risk sexual practices
Elder
ENVIRONMENTAL HEALTH
Air
PM10 or PM2 air pollution
Exposure to second-hand smoke
Water
Water quality index including availability
Watershed protection
Food
Food sustainability
Inspection of sources, distribution and retail
Housing
Availability and affordability
Exposure to hazards
Blood lead levels in children
Sun Protection Programs
Sustainability
Greenhouse gas emissions
Energy consumption
HEALTH SERVICES
Public Health Services
Childhood immunization;
Influenza immunization
Screening mammography;
Pap smears
Smoking cessation services
Facilities
Hospital bed availability from a facility
Types of services
Diagnostic Services
Community Satisfaction Measures
Manpower
Physician, nurses, lay practitioner etc.
Dental
Unmet health care needs
DISEASE AND INJURY OCCURRENCE AND PREVENTION
Non-communicable diseases
Heart disease and stroke incidence and mortality
Cancer incidence and mortality
Respiratory disease;
Mental health
Communicable diseases
Vaccine-preventable diseases
Tuberculosis ;
HIV infection;
STIs
Food and waterborne diseases
Injuries
Unintentional injuries
Hip fractures
Domestic violence; Child abuse and neglect
Illicit 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
Global
Region
Literature
search
Community
Clinic/school/church Pop.
Family
Individual
client
Community intervention:
Medical
students
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 -survey
Numeric; 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 8th
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