Preface
Chapter 5 Health Needs Assessment and the Community Nurse
Susie Sykes
61
(Quigleyet al. 2005). Health Needs Assessments are now regarded to be a core public health function and with the public health role of com- munity nurses developing, their involvement in population-based HNA, as well as assessment of individual patient need, is likely to increase further in the future. In addition to an increased spectrum of professional involvement, the gov- ernment’s patient and public involvement agenda (DH 2000, 2006) has led local communities groups to become more actively engaged both as providers of data to inform the compilation of HNAs and as partners in the facilitation of the needs assessment process.
Defi ning health needs assessment An HNA is frequently described as: ‘a system- atic review of the health issues facing a popu- lation leading to agreed priorities and resource allocation that will improve health and reduce inequalities’ (Hooper & Longworth 2002). It seeks not only to describe the extent of disease and disability of local people, but to under- stand the patterns and inequalities that exist, the impact that these have on individuals and the community as a whole, and the percep- tions and values that are placed on such issues by local people and the professionals who work with them (Rawaf & Marshall 1999). As such, it is not a one-off exercise but is a ‘dynamic ongoing process’ (Manitoba Health, p. 4) that involves a complex and pluralistic assessment of data on a continuous basis. It is a project that does not end on the completion of a report but which triggers planning and policy-making and which is refl ected on continuously and amended over time (World Health Organization [WHO]
2001).
While the assessment of health care needs of individuals or families remains an important role for community nurses, the term HNA has become synonymous with assessments that look at whole populations. This might mean a geo- graphical community but, equally, may mean assessing the needs of a community defi ned by social experience, setting, interest, characteris- tics or experience of a health condition (HDA
2005). The assessment of individual need may in turn contribute to the picture being built up of the whole community.
Despite attempts to provide consistent frame- works and guidelines for carrying out HNAs (Cavanagh & Chadwick 2005; Hooper &
Longworth 2002) there exist a number of dif- ferent approaches that inform the process and affect the types of data that might be gathered.
In attempts to capture the distinction between various approaches, three are commonly cited:
the epidemiological, comparative and corpo- rate approaches (Naidoo & Wills 2009). In addi- tion to these it is useful to consider asset-based (Macdowellet al. 2006) and empowerment-based approaches to needs assessment (Houston &
Cowley 2002).
An epidemiological approach uses largely quantitative-type data in order to create an accu- rate description of the size and nature of a health- related problem and its distribution around a community. It is less concerned with community perspectives of the issue and often begins with a specifi c topic to be explored. Having identifi ed the incidence and prevalence of a health prob- lem, the epidemiological approach goes on to identify the effectiveness and cost-effectiveness of current interventions for the problem and identifi es the current level of service provision.
As such, its focus remains on health care needs rather than health needs. Reliance on this approach has been criticised for its narrow problem-based focus and for failing to identify any potential solutions to the issues identifi ed (Robinson & Elkan 1996).
The comparative approach involves comparing the experience of poor health among one group with that of another, within or outwith the local- ity. If one group of people is not receiving a serv- ice or has poorer health outcomes than another group of people with similar demographic char- acteristics, the fi rst can be said to have an explicit need (Robinson & Elkan 1996). A corporate approach may include the use of epidemiological and comparative data but goes on to explore the views of key stakeholders such as local health professionals, managers, commissioners and in some cases, users and local people.
Some argue that seeking the views of local peo- ple as part of an HNA, while important, does not go far enough and that in order for any interven- tions that follow to be successful, the community should be involved in identifying and prioritis- ing their own needs as well as going on to iden- tify appropriate actions to address those needs.
As such, the empowerment approach seeks not to enable the community to identify the social context within which they experience health but also to explore their own health-creating poten- tial and capacity (Houston & Cowley 2002).
A further approach that needs to be consid- ered, and which can be seen to link into the empowerment framework, is that of the asset based model (Macdowell et al. 2006). The starting point of this approach is that assessment of need alone is not enough and that rather than tak- ing a defi cit approach which looks at what the community lacks, it should include an examina- tion of the extent to which facilitators of health exist within the community itself. It therefore includes an assessment of the effectiveness of local community networks, the level of social capital, degrees of community cohesion and other resources upon which health can be built.
It sees the community as a producer of health rather than being merely a consumer of services (Macdowellet al. 2006).
All of these approaches explore the needs of whole communities and current defi nitions of HNA emphasise this as a tool for population- based studies (Cavanagh & Chadwick 2005;
Hooper & Longworth 2002). However, the place of applying an individual approach should not be ignored in any discussion of HNA ( Jackson 2007; Naidoo & Wills 2009). The individual approach, while usually focused on a particular family or individual in order to determine need that will be responsive to health service inter- vention (Rowley 2005), can be an important ele- ment in building up a comprehensive picture of a community (Horne & Costello 2003).
Each approach is based on a different perspec- tive and refl ects different ways of conceptualis- ing and thinking about both health and health needs as well as their relationship to health care, service provision and public health strategies.
Overlap exists between all of these approaches and in reality a HNA may incorporate elements of more than one method of enquiry. Some argue that what is needed is a balance of epide- miological data and appraisal of socio-economic information with that of the community’s own
‘lived experience’ or perspective of health needs (Horne & Costello 2003). However, what is clear is that decisions about what approach to take will be informed by how both health and need are defi ned and perceived by those undertak- ing a HNA. These terms therefore need closer examination.
Perspectives of health and need For many, health is viewed in biomedical terms as the absence of disease and disability and is determined primarily by physiological factors.
A behavioural perspective, on the other hand, acknowledges the importance of this medical model but sees health as being infl uenced by the way in which people live their lives and there- fore recognises behavioural as well as physi- ological determinants. An alternate perspective on health is a socio-economic approach that sees health as being primarily infl uenced by the social and economic environment within which people live and the constraints and opportuni- ties such structural factors create.
Most professionals do not operate solely within the confi nes of just one of these per- spectives but are likely to be infl uenced by one perspective more than another (Sykes 2007).
However, the most dominant perspective held by any group leading an HNA will clearly infl u- ence the type of approach that is adopted. A position that incorporates a less biomedical model of health and acknowledges the socio- economic determinants of health will, for exam- ple, require the HNA team to adopt an approach that goes beyond the collection of epidemiologi- cal data and that explores both health and health care needs from multiple perspectives.
While the concept of need is acknowledged as an appropriate basis on which to make decisions (Hawtin & Percy-Smith 2007), as a concept, it is complex and contested. Bradshaw’s (1972)
taxonomy of need is often used to portray dif- ferent types of need:
● Normative need – needs as they are defi ned by experts and professionals based on research and evidence. These may change over time or according to different professional groups
● Felt need – needs as they are defi ned by indi- viduals and often associated with wants
● Expressed need – felt need that has become an action, seeking out some kind of resolu- tion to the need
● Comparative need – determined by compar- ing the situation of one individual or group to that of another with similar characteris- tics. If one group is lacking in any area this becomes defi ned as a need
This taxonomy provides a useful way of con- sidering the different perspectives that may emerge when exploring the needs related to a particular issue or population group from these different angles. Many thus argue that ‘need’ is a subjective concept that is both relative to both time and place (Robinson & Elkan 1996). This position creates dilemmas for the practitioner in reconciling the different conclusions that might be drawn form each perspective and may chal- lenge emergent decisions.
There is not, however, a consensus on the notion of need as a subjective concept. Doyal & Gough (1991), for example, argue strongly that there are in fact objective and universal needs. They argue that the key goal for all people is to participate in society fully and that to do this they have two basic needs: the need for physical health and the need for autonomy, including mental health and cognitive skills. These, Doyal & Gough argue, are not driven by subjective values or positioning and do not alter with time or place but relate to everybody. They are, as such, both objective and universal. Doyal & Gough identify a number of intermediate needs that need to be fulfi lled if the two ultimate needs are to be met, but again they argue that these are universal and objective. They acknowledge that the ways in which these needs can be met varies and can be met to different degrees or standards (Robinson & Elkan 1996).
A health economist perspective judges need against effectiveness, supply and demand (Billings 2002). Limited resources and the need to decide how to prioritise and allocate resources against competing demands is the key driver behind this position in a climate in which it is recognised that ever expanding health care needs cannot all be met in any health economy.
Comparisons of the costs and benefi ts of dif- ferent health interventions and the degree to which they can instigate change should, accord- ing to health economists, drive decision-making (Robinson & Elkan 1996). In such a model the ranking of need involves moral questions that cannot be dissociated from issues relating to eco- nomic drivers and value for money imperatives.
Tones & Green (2006) point out that given the debate about the concept of health and its determinants, and the lack of precise and agreed defi nitions of health needs, it should come as no surprise that there is not a consensus about the means by which health needs should be assessed. What is clear therefore is that in con- ducting a multi-agency partnership approach to HNA, discussion and clarifi cation of these terms, which is not without contention, is needed before a process can be agreed on.
Reasons for and benefi ts of conducting health needs assessments
When deciding if a HNA is required it is impor- tant to understand the benefi ts and reasons for undertaking such an assessment. Traditionally HNAs have been seen as a tool used by decision- makers to justify the provision of existing serv- ices or to obtain additional funding ( Jordan et al.
2002), but examination of their current use shows their benefi ts to be far more wide reaching.
As stated above, in many cases HNAs are a statutory requirement (DH 2007). However, not- withstanding this principle there is increasing rec- ognition of the benefi ts that effective HNAs can bring to individuals, their carers and to service commissioners. Understanding the needs and issues facing a community is clearly essential if services, public health interventions and health
protection programmes are to be effectively and appropriately planned, targeted and delivered.
In a climate of limited resources and compet- ing demands, there is a need to prioritise and to apply the principles of equity and social justice in decision-making and an HNA can provide the basis on which to do this (WHO 2001). The data also generate a baseline of information so that developments in services provision can be more rigorously evaluated and impacts and out- comes assessed.
HNAs can also provide an effective tool in challenging existing practice and in encourag- ing a broader view of how things can be done.
Reviews of Health Visitors’ experience of under- taking HNAs have shown, for example that they have not only resulted in a deeper knowledge of the community but have challenged the way existing services are delivered. Engagement with HNAs has also encouraged practitioners to engage in areas of practice that had not previ- ously been regarded as their role. Others changed their perception of role importance as evidenced by the fact that issues not previously seen as a priority were identifi ed as being important and things assumed to be a priority were shown not to be a major concern (Rowe & Carey 2004).
As well as being an important driver of the planning process, involvement in HNAs can enhance multi-agency working and facilitate an effective means of delivering coordinated and integrated responses to issues through the generation of improved communication and the development of a greater shared focus and understanding of priorities (Cavanagh &
Chadwick 2005; Horne & Costello 2003). The links between services and the interdependence that might exist between them can be usefully mapped out and clarifi ed through a partnership approach to HNA (Cowley & Houston 2003).
Approaches that incorporate community per- spectives can effectively create a dialogue between service planners and the public and improve rela- tions between the two. When managed appropri- ately, an opportunity to express needs can create a sense of involvement in decision-making and a stake in the services and projects that fol- low. This can also include an assessment of the
community resources available to help address issues locally (Rawaf & Marshall 1999). If com- munity participation is taken to the level of gen- uine involvement in decision-making, it can also create an understanding among the community about how decisions are made and how compet- ing pressures have to be managed.
Finally, there are personal and professional benefi ts for those involved, particularly the opportunity to develop skills and to engage in personal and professional development. HNAs are a core public health skill, and involvement by community nurses can be an effective way of stepping out to refl ect on their role (Rowe &
Carey 2004) (Box 5.1) and develop a public health perspective of the population they serve, so enhancing their public health skills and function.
Box 5.1 Benefi ts of carrying out a health needs assessment
● Better understanding of the health and health care issues facing a community
● Better understanding of inequalities within a community
● Needs-led planning and development of interventions
● Needs-led prioritisation of issues
● Challenge existing practice and consider new ways of working
● More effective and equitable allocation of resources
● Contribute to effective partnership working
● Create shared understanding of need and priorities between partners
● Improved dialogue and understanding between community and decision-makers
● Identifi es capacity within community to address issues
● Community involvement in decision-making
● Development of public health skills of professionals
Challenges associated with health needs assessments
The benefi ts identifi ed above are dependent on the HNA being undertaken in a systematic and
rigorous way; this process is not without diffi - culties and challenges. Frameworks for carrying out HNAs increasingly stress the importance of analysing multiple layers of data acquired through multi-agency working (Cavanagh &
Chadwick 2005; DH 2007b; Hooper & Longworth 2002). The challenges of multi-agency work- ing are well documented (Atkinson et al. 2005;
Delaney 1994) and, in particular, include the diffi culty of achieving a shared language, com- munication diffi culties, agreeing perspectives of health and need, limited resources and con- fl ict over staff time and availability, allocation of roles and responsibilities, competing priorities and organisational culture and commitment.
Managing such challenges requires prior plan- ning and skilled management.
The effectiveness of HNA also rests in its abil- ity to infl uence strategic decisions. Yet there exists a danger that the target-driven culture of the health service with priorities already deter- mined centrally means that opportunities for fi ndings to truly drive locally relevant decisions are perhaps limited. An HNA is a complex and time-consuming process, which requires care- ful planning and the allocation of its own set of resources. Commitment to provide these skills and resources may not always be forthcoming and timescales may not match management pri- orities and deadlines (Cavanagh & Chadwick 2005; Macdowell et al. 2006). The time required to undertaken such a project also impacts directly on those involved in conducting the HNA. Community nurses, for example, may fi nd it diffi cult to prioritise this kind of work when still faced with their daily routine and direct care-related case load.
Assessing multiple layers and different types of data requires an acknowledgement that they may not all lead the assessor to a valid or reli- able conclusion. The competing perspectives of both need and the subjective experience of health means that, on some occasions compet- ing and sometimes confl icting conclusions may emerge (Raymond 2005). This may particularly be the case when using frameworks that seek to combine the epidemiological, corporate and community approaches to needs assessment.
The community perspective is increasingly accepted as an integral part of the HNA process but presents its own particular challenges. Care needs to be taken to avoid tokenism and there is a need to ensure that all sections of the commu- nity are represented. (A fuller discussion of the challenges of involving patients and public can be found in Chapter 24.)
The philosophy underpinning HNA requires refl ection and expects professionals to critically evaluate existing services, practice and norms.
For many this can in itself be a challenging process, particularly for those whose practice is well established. Resultant fi ndings arising from the assessment that require a fundamental shift in approach to practice can, in some cases be diffi cult to implement and organisational cultures and norms can act as a constraint to change (Rowe & Carey 2004). A specifi c set of skills is required to both carrying out and being involved in HNA, particularly those that seek a community perspective. Some of these skills are listed in Box 5.2.
Box 5.2 Skills required to carry out a health needs assessment
● Partnership working skills
● Community involvement and liaison skills
● Project management skills
● Research skills including the ability to gather and analyse new and existing data
● Communication skills (at both community and strategic levels)
● Planning skills
● Refl ective skills
The process of carrying out a health needs assessment
Robinson & Elkan (1996) advise that while it is important to acknowledge and explore the dif- ferent theoretical tensions that underpin any consideration of the assessment of health and need and the competing approaches to HNA that emerge from such deliberation, for practitioners,