Assessment of health needs; the health visiting contribution to public health

Abstract

Health Visiting is targeting to health inequalities and quality of life in communities. Thus, Health Visiting profession is linked with public health and health promotion interventions in the community. Health needs assessment is a methodology that reviews population health issues in order to produce a set of recommendations for action to improve health outcomes. The methodology of health needs assessment which is described in this paper is determined as a useful tool for the everyday practice of Health Visitors. The use of structured tools is also discussed which have lead to suggestions for future research and Health Visitors' education. [PUBLICATION ABSTRACT]

Headnote

Abstract

Health Visiting is targeting to health inequalities and quality of life in communities. Thus, Health Visiting profession is linked with public health and health promotion interventions in the community. Health needs assessment is a methodology that reviews population health issues in order to produce a set of recommendations for action to improve health outcomes. The methodology of health needs assessment which is described in this paper is determined as a useful tool for the everyday practice of Health Visitors. The use of structured tools is also discussed which have lead to suggestions for future research and Health Visitors' education.

Keywords: health needs, needs assessment, public health, health visitors

Introduction

The concept of "need" is personal, subjective, variable and constantly changing (Cowley et al., 2000). On the other hand, the pragmatic view of "need" is about those things that are life sustaining, e.g. food, water, shelter and health care (Rowe, 2008). Moreover, Maslow's (1943) hierarchy of needs defines the needs of life, in an order in which needs have to be satisfied to enable individuals to reach their full potential (Thrower, 2002).

Bradshaw (1972) identified four main needs:

- normative; defined by experts,

- felt needs; perceived by the individual according to what he/she wants,

- expressed needs; expressed by the individual, and

- comparative needs; identified when one community is compared with another.

The idea of "health need" is relatively recent, particularly in respect of health promotion or public health. Health needs describes a community public health approach to the surveillance and assessment of the populations' health and wellbeing (Cowley, 2008). Health needs assessment aims to improve the health of a population and reduce health inequalities (Porter, 2005). According to W.H.O. (1998), equity in health means that people's needs guide the distribution of opportunities for well-being. Needs assessment is a priority for those concerned with community health (Billings & Cowley, 1995). Recoginising the health needs of people and communities leads to more flexible health services (Naidoo & Wills, 2000).

Public health is a social and political concept aimed at the improving health, prolonging life and improving the quality of life among whole population through health promotion, disease prevention and other forms of health intervention (W.H.O., 1998).

A public health approach means looking at health needs across a population, targeting inequalities and tackling causes of ill health (UK Department of Health, 2001) and applying into practice the principles of equity and social justice especially for those in greatest need (Rowe, McClelland and Billingham, 2001). Health visiting has been closely linked with preventive and public health issues (Dingwall, 1982).

Since every person has the right to health, Health Visitors take the responsibility to face the inequalities in health and health care through proper interventions (Cowley, 2007). Health Visitors, in their public health role, have an important role to play in searching for health needs and empowering vulnerable groups to use of available services (Twinn and Cowley, 1992). Health visiting has always been based on public health principles with a strong preventive emphasis (UK Department of Health, 2001) since the key to reduce health inequalities lies in providing preventive services (Colwey, 2007). Health visitors provide prevention services to individuals, families and groups in the community (Chalmers, 1993). Thus, searching for health needs and assisting in meeting them is a legitimate public health activity of health visiting (Porter, 2005). Since 1977, the Council for the Education and Training of Health Visitors specified that the search for health needs and a stimulation of their awareness were to be principle objectives within health visiting (Billings & Cowley, 1995).

The benefits of health needs assessment as identified by Cavanagh and Chadwick (2005) include: strengthened community involvement in decision making, improved team and partnership working, professional development of skills and experience, improved communication with other agencies and the public and better use of resources.

Health needs assessment and Health Visiting practice

Needs assessment is about change in order to bridge the gaps identified (Hooper & Longworth, 2002). Health needs assessment is a methodology that reviews population health issues in order to produce a set of recommendations for action to improve health outcomes (Rowe, 2008). The protection and improvement of the health of populations, communities and individuals are based on the collection of health and social information in order to draw up accurate profiles on the health needs of population (Porter, 2005).

Health is in a dynamic state of continuity and change, constantly being challenged, stressed, abused and even enhanced by genetic makeup and lifestyle, and the wider ecological environment (Watkinson, 2002). Hence, health needs assessment is a complex, interactive and continuous activity of the Health Visitors, they are holistic in nature, involving a focus on the whole situation, not a single problem or issue (Appleton and Cowley, 2008). Responsible for assessment of need and the prescription of a plan of action for clients, Health Visitors are intimately concerned with the delivery of that plan and the evaluation of the intervention (Porter, 2005). However, these interventions have to be realistically acceptable to the population and the priorities are those that can reduce health inequalities (Rowe, 2008).

Profiling represents a traditional health visiting practice that has changed little over the years, it is a key skill for Health Visitors and it allows them to build up a collection of data which identifies both the health and social needs of the public in which they work (Muir & Reynolds, 2009). It should be carried out in isolation, rather the underpinning philosophy of any profile should be the communication and collaboration required between professional groups and more importantly the individuals and groups of the community in question (Muir & Reynolds, 2009) as well as other local authorities (W.H.O., 2001).

Furthermore, Appleton and Cowley (2008) conclude that Health Visitor's assessments are holistic in nature, involving focus on the whole situation, not a single problem or issue. It has been shown that when Health Visitors make a professional judgement, they are influenced by their personal values and life experiences and it is likely to be influenced by their personality, cultural beliefs and attitudes as they draw on personal knowledge and prior experience in shaping their professional assessments (Appleton and Cowley, 2008).

When focusing on a particular population it is preferable to look at the context within they live, so as to determine the needs of the defined group more clearly.

For example, seeing the needs of employees whilst they are at work would limit the extend of preventive activities in which they might be engaged, whereas focusing on a wider community may give an indication of local leisure patterns, food behaviour and so on, all of which influence on health (Cowley, 2008). Cowley (2007) also supports that practitioners who are in daily contact with the most vulnerable and excluded populations often know best how to describe their real health needs. Furthermore, when working with minority ethnic groups, international comparisons are important in order to assess disease trends and treatment efficacy or service effectiveness (Cowley, 2008).

Needs are recordable and can be measured, observed and made explicit to some degree, for example, it is possible to assess someone's blood pressure, or their mobility, or whether they have postnatal depression, using a carefully developed and validated instrument. Such assessment tools give a good degree of inter-rater reliability, which means if two or more people take the measurement, they will reach the same conclusion (Cowley, 2008). Some needs are very obvious, particularly those associated with clear physical diagnoses (Cowley et al. 1995). On the other hand needs are also very variable and personal, for example, limited mobility in an order person, may result in different views of whether it is a problem or not, which means that needs are also subjective and changeable according to context (Cowley, 2008). However, there are other physical as well as social, emotional and mental health needs, which are more hidden, for example, clients may hide their needs or not reveal things that are worrying them because they cannot formulate the words (Cowley et al. 1995; 1996).

However, clinical guidelines in the UK have been criticised for their lack of validity and the fact that if they are used in practice by Health Visitors it could result in unmet needs remaining hidden (Appleton, 1997). Furthermore, Mitcheson and Cowley (2003) study conclude that the use of instruments was associated with a failure to either identify needs that were relevant to the client or to enable clients to participate in the process. In the same way, a structured questionnaire which was an aid for Health Visitors to assess health needs showed that this inflexible, structured approach that focuses on a list of pre determined needs, was found that it didn't allow a deeper sensitivity that the varied understandings and needs require of people from different ethnic background which will lead to an individualised approach to practice (Houston and Cowley, 2003). The same researchers concluded that a structured health needs assessment tool (Implemented in London) was unsuitable for routine use to determine the intensity of health visiting contacts and not effective for eliciting health needs (Cowley & Houston, 2003).

On the other hand, literature supports that the process of assessing health needs is linked with the Health Visitors' professional judgement and their ability to prioritise the needs (Williams, 1997). Moreover, Mitcheson and Cowley (2003) recommend that Health Visitors should use the open style of needs assessment that has been shown to be effective and acceptable, rather than an approach based on a structured instrument. Whereas, in an empowerment approach to needs assessment and service provision, the use of a specific tool such as "Field of Words", showed that offering control and power to the client does nothing to diminish the role of the Health Visitor, instead it gives an opportunity to offer to clients what they really need (Houston and Cowley, 2002). Similarly, Appleton and Cowley (2004) recommend that Health Visitors question whether it is ever appropriate to attempt to replace professional judgement by the shifttowards greater adoption of general and invalid formal guidelines in health visiting practice.

Health needs assessment process

Undertaking health needs assessment requires careful preparation, access to relevant information and clear and effective communication across multidisciplinary teams (Jack and Holt, 2008).

In the first step, it needs to be answered why this health needs assessment is necessary (Hooper & Longworth, 2002). The first stage of identifying health needs is to decide which population is under consideration and define the population (Cowley, 2008). The population is defined by geography, gender, age, ethnicity, service user or issue (Porter, 2005). Community profiling is used to identify the strengths, weaknesses, needs and problems of a community, to make decisions about health services and to justify the allocation of resources (Jack and Holt, 2008).

The purpose and scope of the assessment follows, for example, if it is for service planning or evaluation (Cowley, 2008). The objectives need to be described and define the specific outcomes which are aimed to be achieved (UK Department of Health, 2001). Then the data that are readily available are identified (e.g. data from medical GP practice, census data, local public health department, local/national/international statistics) (Cowley, 2008). Data sources could include not only vital statistics, but behavioural risk survey (Rohrer, 2009). Finally, it is defined which data should be collected specifically for this assessment and the audit and monitoring of information (Cowley, 2008). Needs assessment methods include the use of data and information to present a case for health improvement, service change or investment in a health programme (Rowe, 2008). Health needs assessment process is summarised below (New Zealand Ministry of Health, 2000):

1. Set objectives

2. Collect data on the demand and need for health services

3. Analyse data

4. Evaluate

5. Prioritise

Community-based needs assessment has three main approaches: sociology, epidemiology and health economics (Billings & Cowley, 1995). Before profiling the health needs of a community at least three types of information are required:

- Information to describe the basic characteristics of the community (number of individuals, age, sex, etc)

- Information to describe and monitor the health status of the community

- Information on the determinants of health in the community (Porter, 2005).

Following the profiling, the second step is concerned with health priorities for intervention (UK Department of Health, 2001; WHO, 2001; Hooper & Longworth, 2002), according to the size of population, the effect on the population health, the effectiveness of the intervention, the appropriateness of the current services, the expertise and training of the health professionals for addressing the specific issue that is a priority (UK Department of Health, 2001).

The final and most important part of the community health needs assessment process is planning and implementing the actions that will address the priority health needs that have been identified (UK Department of Health, 2001). Reporting is a useful way for the outcomes evaluation later (WHO, 2001). After prioritising the actions specific interventions are planned (UK Department of Health, 2001). Thus, an action plan and an implementation plan are developed (Hooper & Longworth, 2002). For the planning process, appropriate preparation should be made, the definition of the goals and the expected outcomes and furthermore, the detailed description of the activities which will be implemented regarding what and when they will be implemented, as well as who will be involved (UK Department of Health, 2001). Finally, Elkheir (2007) stressing the importance of monitoring and evaluation suggests the following key questions to ask when undertaking an evaluation:

Process evaluation

- are the original aims and objectives being followed or still relevant?

- is everything proceeding as expected? If not, why not?

- what do service providers and service users think about the changes?

- what resources are being used? Are they adequate?

Outcomes evaluation

- have the aims and objectives of the changes been achieved?

- how many people have benefited from the changes, and what are their characteristics?

- are the people who are benefiting from the changes the same people you intended to benefit from it?

Health needs assessment of individuals and families

Regarding the health needs assessment of families, Appleton and Cowley (2008), have found that it is difficult for Health Visitors to articulate how they make an assessment; Many of their participants suggested some aspects of the process are undoubtedly automatic and as such they probably do things without recognising they are doing it. Far earlier, Chalmers (1993), found that Health Visitors used several processes to search out needs:

- Questioning. It was used when a Health Visitor had little information about the client situation and in order to help clients explore and understand their situation.

- Using illustrations from other client situation. Health Visitors used illustrations in order to help them open up needs or problems which they identify or suspect are present.

- Normalising. This approach was used to explore potential needs and help clients acknowledge them was to normalise the occurrence of needs or problems and create an environment for disclosure and effective collaborative intervention.

- Assigning homework. Health Visitors were giving to their clients some type of homework.

- Assessing and intervening while searching. Health Visitors often used multiple processes, while they were searching out one health need, she frequently was assessing other potential needs and intervening to promote health at the same time.

- Responding to "cues". Health Visitors used their previous professional experiences and their own life experiences to cue them that something in the situation was "not quite right".

It is also argued that self-rated health is the ultimate bottom line impact measure for public health and it is supported that selfrated health impact focuses on issues that matter to people, they focus on local risk factors that are more relevant for community health planning (Rohrer, 2009). Self-rated health impact is ideal for identification of health inequalities (Subramanian & Ertel, 2009) and it does not require that health agencies conduct their own surveys (Rohrer, 2009). Furthermore, focus groups can be used to determine the needs of individuals (Tipping, 1998) and to highlight the differences and similarities between different groups of clients (Hibbard & Jewett, 1996). Since focus groups may not be representative of the target group, they should used alone a s a method if enough groups are conducted to ensure saturation of the data (Tipping, 1998).

Discussion

This paper has described the health needs assessment as a process and vital tool for everyday practice of Health Visitors. Health needs assessment is vital to public health services and health care for better health outcomes in the community. Health Visitors although they play the main role in assessing peolpe's health needs, they should work multi-disciplinary in providing the proper care for promoting health and hence, accomplish the aims set for each case.

Health Visitors, using the methodology of health needs assessment, target tackling health inequalities and promoting health for individuals, families and community in general, which are the goals of Public Health. The process of health needs assessment has been described in a practical approach in order to provide the knowledge and skills needed for Health Visitors.

Health Visitors have been through years of their practice used subjective methods through their professional judgements in order to assess the needs of individuals and families. On the other hand, objective information is used for assessing the needs of bigger groups of people, through available data or specifically designed surveys. Health Visitors in that way have managed to provide the adequate health care needed.

However, a more structured way that can be universal and culturally sensitive should be developed in order to aid also inexperienced Health Visitors. Thus, studies on this topic which will provide useful implications for health visiting will be welcomed from the Health Visitors. Future studies need to consider the criticism of previous published studies and apply them in their research questions.

Furthermore, Health Visitors, should not only be familiar with the terms regarding health needs assessment, but be very well educated on this subject on a practical level during their graduate studies and continuing education can be used a booster for the implementation of evidence based practice.

References

References

Appleton J. V. (1997) Establishing the validity and reliability of clinical practice guidelines used to identify families requiting increased health visitor support. Public Health, 111: 107-113.

Appleton J. V. & Cowley S. (2004) The guideline contradiction: health visitors' use of formal guidelines for identifying and assessing families in need. International Journal of Nursing Studies, 41: 785-797.

Appleton J. V. & Cowley S. (2008) Health visiting assessment - unpacking critical attributes in health visitor needs assessment practice: a case study. International Journal of Nursing Studies, 45: 232- 245.

Billings J. R. and Cowley S. (1995) Approaches to community needs assessment: a literature review. Journal of Advanced Nursing, 22: 721-730.

Bradshaw J. (1972) The concept of human need. New Society, 19: 640-643.

Cavanagh S. and Chadwick K. (2005) Health needs assessment: a practical guide. (online) Available at: http://www.nice.org.uk/media/150/35/Health_ Needs_Assessment_A_Practical_Guide.pdf [assessed: 19.10.11].

Chalmers K. I. (1993) Searching for health needs: the work of health visiting, Journal of Advanced Nursing; 18: 900-911.

Cowley S. (2007) Principles of British health visiting. Rev Esc Enferm USP, 41: 756-761.

Cowley S. (2008) The search for health needs. In: Cowley S. (Ed.) Community Public Health in Policy and Practice, A sourcebook, Bailliere Tindall Elsevier, UK.

Cowley S. & Houston A. M. (2003) A structured health needs assessment tool: acceptability and effectiveness for health visitng. Journal of Advanced Nursing 43(1): 82-92.

Cowley S., Bergen A., Young K. & Kavanagh A. (2000) A taxonomy of needs assessment, elicited from a multiple case study of community nursing education and practice. Journal of Advanced Nursing, 31(1): 126-134.

Cowley S., Bergen A., Young K., and Kavanagh A. (1995) Exploring needs assessment in community nursing. Health Visitor, 68: 319-321.

Cowley S., Bergen A., Young K., and Kavanagh A. (1996) Identifying a framework for research: the example of needs assessment. Journal of Clinical Nursing, 5: 53-62.

Dingwall R. (1982) Community nursing and civil liberty. Journal of Advanced Nursing, 7: 337-346.

Elkheir R. Y. M. (2007) Health needs assessment: a practical approach. Sudanese Journal of Public Health, 2(2): 81-88.

Hibbard J. H. & Jewett J. J. (1996) What type of quality information do consumers want in a health care report card? Medical Care Research and Review, 53(1): 28-47.

Houston A. M. & Cowley S. (2002) An empowerment approach to needs assessment in health visiting practice. Journal of Clinical Nursing, 11: 640-650.

Houston A. M. & Cowley S. (2003) Health needs assessment in the health visiting service and the impact on the ethnic community. International Journal of Nursing Studies, 40: 85-94.

Jack K. & Holt M. (2008) Community profiling as part of a health needs assessment. Nursing Standard, 22(18): 51-56.

Mitcheson J. & Cowley S. (2003) Empowerment or control? An analysis of the extent to which client participation is enabled during health visitor/client interactions using structured health needs assessment tool. International Journal of Nursing Studies, 40: 413-426.

Naidoo J. & Wills J. (2000) Health Promotion. Foundation for Practice, Bailliere Tindall Elsevier, UK.

New Zealand Ministry of Health (2000) Health needs assessment for New Zealand: an overview and guide. (online) Available at: http:// www.moh.govt. nz/moh.nsf/82f4780aa066f8d7cc2570bb006b5d4d/a 164e4b64ff48b71cc2569bb00073904/$FILE/HNAo verview.pdf [assessed: 09.10.11].

Porter E. (2005) Public health and health visiting. In: Robotham A. and Frost M. (Eds) Health Visiting. Specialist Community Public Health Nursing, Elsevier Churchill Livingstone, UK.

Rohrer J.E. (2009) Use of Published Self-rated healthimpact studies in community health needs assessment, Journal of Public Health Management Practice, 15(4): 363-366.

Rowe J. (2008) Planning public health strategies. In: Cowley S. (Ed.) Community Public Health in Policy and Practice. A sourcebook, Bailliere Tindall Elsevier, UK.

Rowe A., McClelland A. & Billingham K. (2001) A pack for practitioners. In: Community Health Needs Assessment. An introductory guide for the family health nurse in Europe, W.H.O., Copenhagen.

Subramanian S.V. & Ertel K. (2009) Self-rated health may be adequate for broad assessments of social inequalities in health. International Journal of Epidemiology, 38(1): 319.320.

Tipping J. (1998) Focus groups: a method of needs assessment. The Journal of Continuing Education in the Health Professions, 18: 150-154.

Thrower C. (2002) Understanding ourselves. In: Hogston R. & Simpson P.M. (Eds.) Foundations of Nursing Practice, Making the Difference, Hogston R. & Simpson P.M. Palgrave, Great Britain.

Twinn S. & Cowley S. (1992) Principles of Health Visiting: A re-examination. Health Visitors' Association, London.

UK Department of Health (2001) The Health Visitor and School Nurse Development Programme. Health Visitor Practice Development Resource Pack, London.

Watkinson G. (2002) Promoting health. In: Hogston R. and Simpson P. M. (Eds) Foundations of Nursing Practice, Palgrave, Great Britain.

Williams D. (1997) Vulnerable families: a study of health visitors prioritization of their work. Journal of Nursing Management, 5:19-24.

W.H.O. (1998) Health Promotion Glossary, WHO, Geneva.

WHO (2001) Community Health Needs Assessment. An introductory guide for the family health nurse in Europe, Copenhagen.