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December 2002 |
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A QUESTION OF NEED |  Back to contents | |
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A health needs assessment (HNA) researches the current status of health and need within a community - ie a geographical area or social group of people - as a basis for decision-making. Fundamentally, HNA is about profiling a community to determine which health issues should be tackled and how.1 Both existing and new organisations charged with delivering public health through partnership arrangements - notably to inform health improvement plans (HIMPs), community strategies and local strategic partnerships - have to take a needs-assessed approach, with an emphasis on ensuring that identified, evidence-based health inequalities are addressed. Further, in an increasingly competitive funding environment, that requires almost constant justification as to value for money, HNA is becoming increasingly important in attracting resources to an area or community. HNA, which involves looking at the health problems that have a major impact on the population and the recurring factors so that better services can be provided locally1, helps to provide accurate information on:
Unravelling the definitions Before getting started on a HNA, it is important to achieve consensus from partnership organisations (statutory, voluntary, community etc) as to what is understood by the concepts of "health" and "need", as these terms can mean different things to different people. It is also necessary to determine the "community" that is subject to assessment, which could be either geographically based or a dispersed social group. Methods of research and analysis selected need to be valid, reliable, objective and rigorous enough to withstand scrutiny.2 At the earliest stage, the organisations commissioning the HNA research must decide its purpose so that it can be appropriately directed and managed. Health, need and community A HNA seeks to identify, measure and source health information in its widest sense, unravel the causes, and find out what action to take to best address the issues. Although much of the literature on HNA is placed firmly in the remit of the NHS, it is clear that improvements need to reach far beyond the NHS to those charged with delivering positive change to address the underlying causes of ill-health - notably environmental and public health specialists. But this must be centred around communities that need support - many of whom have already filled the gaps in state provision and begun to find their own health solutions. HNA and resulting policy is not about public sector organisations domineering grass roots organisations, but looking at why and how they work, and providing appropriate support. A health need can be seen as a subjective, relative concept, identified by a professional or community. However, needs defined by the former reflect a professional judgement and may be very different to those identified by the community. Thus, it is essential that those most in need of information, support or services are able to express their needs and have them taken into account. While community profiling can result in a wish list, limited resources means that not all needs can be met. Whether subjective or objective, the purpose of identifying health needs is to assist in prioritising action to secure health improvements and to reduce inequalities. Action must be based on qualitative and quantitative data and medical, environmental and social data should be layered on top. Information on health status, the community itself and on the determinants of health, ie lifestyles, quality of housing, levels of employment and access to health services, is needed. Invariably, much HNA is related to the population or "community" in a geographical area - such as a local authority, a neighbourhood, or ward - as this normally relates to funding regimes and initiatives. HNA on a geographical basis is relatively straightforward - the boundary is clearly defined, easy to understand and a community is either included in the assessment or it is not. Most population information is specific to geography, and it is relatively easy to compile socio-economic, environmental and health information about an area. However, there are some difficulties in a geographically specific approach. Not all vulnerable people live in deprived areas, and not everyone living in a deprived area is vulnerable. The impact of globalisation, personal mobility, cultural evolution and evolving class differentials means that lifestyle has become increasingly important in health determination. The fact that health status in an area has changed may be more to do with gentrification than actual improvements in the health of existing residents. Recorded trends in health - as well as individual perceptions about health - may not provide an accurate picture of what is really occurring as data may be skewed or distorted.
Compiling the data HNA is essentially a research project, carried out on multiple
levels, for the assessment and planning of how to improve the health
of a community (figure 2). Besides regionally and nationally collated
data sources, organisations like local authorities and primary care
trusts (PCTs) already collate and map many sources of data that
can provide the information needed in the initial stages of a HNA.
Since health and social care delivery organisations
The HNA focus on both quantitative and qualitative data reflects the wider shift in thinking in public health away from the traditional medical model and toward a socio-economic model that recognises the underlying causes of ill-health that environmental and associated health specialists deliver on a daily basis. Qualitative data is the "why" in social research and provides valuable understanding and insight into why a situation is as it is and enables patterns of interrelated issues to be made clearer. It can be complied by questionnaires, focus groups, and community networks. It provides personal and community perceptions which give valuable insight into the impact of a policy that may not be fully revealed by statistical data alone, rather than just concentrating on what that overall statistics are (apparently) saying about an area. This is becoming increasingly important to the social agenda as communities are engaging with policy makers in local decision making - a fundamental part of developing inclusive and bottom up partnerships so that communities themselves can self-identify need and how it can be met. It provides decision-makers with the data to support or refute policy and implementation processes. Social capital HNA is not just about finding out what is not adequate, or suitably sufficient in a community, it is also about recognising the potential of what is already there in the form of social capital - relationships and networks in civil society that help formulate collective community action3,4 - and its importance to the community resolving its own issues. A HNA needs to be local and contribute toward this as part of problem solving and democratic participation.3 However, communities may be experiencing "survey fatigue" or have had bad experiences of governmental organisations in the past, leading to some disinterest in current health research activity. Thus, HNA needs to be approached with sensitivity and tact, valuing the contribution than many communities already provide themselves. Uses and presentation HNA needs to be presented - orally or in written form - in such a way that something positive will actually come from it. It is important to consider the key message of the research and to communicate this in the right way to the right audience. What was the research for? Is it accurate and contemporary? Has it been successful and useful? Has it confirmed or refuted earlier perceptions? Who is going to read it and in what format? Why? What is its current and future use in policy change or advocacy? Do we recognise the issues and move forward? The final document may take several drafts before it is acceptable for public scrutiny and it may be appropriate to publish interim findings to help maintain momentum and interest, particularly if a very long time delay is anticipated between collating and analysing the data. The expected audience needs to be able to understand what is being said and to be sure that what is being said is factual and accurate. There is no point in pouring resources into a HNA that goes nowhere or that is so complex or secretive that no one can make sense of it. It may be that the results need to be reported in a variety of formats suited to recipient and a summary report is extremely useful. Sufficient resources should be set aside so that that the final document can be professionally prepared. It should be a document that provides evidence-based data that is comparable over time. Contact Jill Stewart at: J.L.Stewart@greenwich.ac.uk or Dr Fiona Bushell at: J.L.Stewart@greenwich.ac.uk References
This is an edited version of a chapter of the book Environmental health as public health, by Jill Stewart and Fiona Bushell, to be published by Chadwick House Publishing next year. For further details e-mail: s.mcguire@chgl.com
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A
more accurate and thorough understanding of a community's health
also needs to consider individual groups of people, such as ethnic
minorities, female-headed households in bed and breakfast accommodation,
gypsies, or those sharing some similarities in health status and
experience, such as those with a particular disability, AIDS, or
older people leaving hospital and returning to their homes alone.
However, although professionals may group those with similar perceived
"needs" for their own purposes, it does not follow that
the same group will recognises itself as a community with common
interests or features (figure 1)
Initial
profiling involves asking a broad range of people and professionals
what they consider to be the key health problems, as well as collecting
data on an area. The information obtained will contain interrelated
issues to show how medical, environmental, social and economic factors
influencing health are linked and how an integrated approach is
needed to tackle them.1 This can
help map medical, environmental and socio-economic data across boundaries
to identify common patterns and to obtain an integrated, partnership-based
approach to identifying the gaps and links, and solving problems.