Better Focusing on Our Problems: Needs Assessment & the Planning Process William M. Sappenfield, MD, MPH MCH EPI Program Consultant Division of Reproductive Health, CDC Needs Assessment Training Course AMCHP Preconference Skills Building Workshop Atlanta, GA – December 8 th & 9th

Acknowledgements n Mary D. Peoples-Sheps, Anita Farel, & Mary Rogers n South Carolina Department of Health and Environment Control (DHEC) n CityMatCH Urban MCH Data Use Institute n Greg Alexander & Donna Peterson

Act I Public Health Planning Cycle

Being Effective in Public Health Assessment Capacity & Strategies Plan Evaluation Monitor Implement Plan Do

Being Effective in Public Health? Capacity &

Being Effective in Public Health Assessment Capacity & Strategies Plan Evaluation Monitor Implement Plan Do

Health Problem: Late PNC Entry South Carolina

Needs Assessment n Underreporting of prenatal visits n Physicians not starting to 2nd trimester n Late entry into the WIC program n Problem recognition by Community n Transportation & child care barriers n Unintended pregnancy

Potential Strategies n Underreporting of prenatal visits –Vital registration manual –Clerk training –Health department record transfer –Physician record transfer –Standardized prenatal care record –Physician & hospital education –Monthly reporting system –Hospital standards –Incentive awards

Chosen Strategies n Underreporting of prenatal visits –Vital registration manual –Clerk training –Health department record transfer –Physician record transfer –Standardized prenatal care record –Physician & hospital education –Monthly reporting system –Hospital standards –Incentive awards

Being Effective in Public Health Assessment Capacity & Strategies Plan Evaluation Monitor Implement Plan Do

Health Problem: Late PNC Entry South Carolina

So Why Doesn’t It Happen? n Over-commited staff n Lack of political will n Committed to present activities n Previous planning failures n Limited expertise n Insufficient resources n Competing priorities/desires

Being Effective in Public Health Assessment Capacity & Strategies Plan Evaluation Monitor Implement Plan Do Who? What? When?Where? How? Resources?

Act II Needs Assessment

Being Effective in Public Health Assessment Capacity & Strategies Plan Evaluation Monitor Implement Plan Do

Definition of Needs Assessment Systematic collection and examination of information

Definition of Needs Assessment Systematic collection and examination of information to make decisions

Definition of Needs Assessment Systematic collection and examination of information to make decisions to formulate a plan

Definition of Needs Assessment Systematic collection and examination of information to make decisions to formulate a plan for the next steps leading to public health action.

Definition of Needs Assessment Systematic collection and examination of information to make decisions to formulate a plan for the next steps leading to public health action.

Needs Assessment Qualities n Conceptual n Visionary n Systematic n Resourceful n Pragmatic n Action-oriented n Cohesive

Types of Needs Assessment... n Community--Healthy Communities n Population--Title V (MCH) n Health Systems--Emergency Response n Program--Title X (Family Planning) n Health Services--Prenatal Clinic Location n Health Problem--Infant Mortality

Needs Assessment Phases  Health problem identification and measurement  Prioritization of health problems  Analysis of a particular health problem  Assess potential strategies to address targeted aspects Part 1 Part 2

Needs Assessment Phases  Health problem identification and measurement  Prioritization of health problems  Analysis of a particular health problem  Assess potential strategies to address targeted aspects. Part 1 Part 2

What is a health problem? n Community perception? n Health status measure? n Risk Factor? n Health Service Deficiency? n Measurement? n Comparison?

Problem Identification & Verification n Stakeholders n Partners n Reports n Available Data Purpose: Search & compile

Problem Definition n Extent n Duration n Expected future course n Variation Purpose: Define, describe & validate

Types of Prioritization n Group consensus n Voting n Criteria-based rating n Q sort Purpose: Build consensus/support

Q-Sort Procedure: Priority Log Sheet for 25 MCH Needs 5th 4 th 5 th 6 th 3 rd 4 th 5 th 6 th 7 th 2 nd 3 rd 4 th 5 th 6 th 7 th 8 th 1 st 2 nd 3 rd 4 th 5 th 6 th 7 th 8 th 9 th

Part 1: Identification & Prioritization Selection Criteria n Magnitude of the problem n Trend n Severity/consequences n Perceived preventability n National/state goals n Agency capacity n Political/community acceptability

Part 1: Identification & Prioritization Real Selection Criteria n State or agency political will n Current program priority n Currently funded activity n Fits current staffing/resource patterns n People available to work on the issue n Important issue to the heart

Matrix of MCH Problems CriteriaWeightLBWPeri HIVSmoking Magnitude2 Trend2 Severity3 Preventable2 Goal1 Capacity3 Acceptable1

Clear Scoring Criteria Magnitude n Low incidence/prevalence n Moderate in some subgroups n Moderate in all groups n High in some subgroups n High in all groups

Matrix of MCH Problems CriteriaWeightLBWPeri HIVSmoking Magnitude22 x 42 x 12 x 4 Trend22 x 42 x 12 x 2 Severity33 x 33 x 43 x 2 Preventable22 x 22 x 42 x 3 Goal11 x 3 Capacity33 x 13 x 3 Acceptable11 x 2 1 x 3

Act III Problem-Oriented Needs Assessment

Needs Assessment Phases  Health problem identification and measurement  Prioritization of health problems  Analysis of a particular health problem  Assess potential strategies to address targeted aspects. Part 1 Part 2

Problem Precursors Consequences Before After Problem Map: Basic Components

Direct: Secondary: Tertiary: Teen Pregnancy Initiation of Sexual Activity Continuation of Sexual Activity Use of Contraception Problem Precursors

Direct: Secondary: Tertiary: Teen Pregnancy Initiation of Sexual Activity Continuation of Sexual Activity Use of Contraception Problem Precursors Access to Confidential Services Partner Age Disparity Unsupervised Activities

Direct: Secondary: Tertiary: Teen Pregnancy Initiation of Sexual Activity Continuation of Sexual Activity Use of Contraception Problem Precursors Access to Confidential Services Partner Age Disparity Unsupervised Activities After School Programs Social Norms Health Policy

Direct: Secondary: Tertiary: Teen Pregnancy Initiation of Sexual Activity Continuation of Sexual Activity Poor School Connectedness Life Goals Poor Family Connectedness Access to Confidential Services After School Programs TV/Movies & Music Parenting Knowledge Sex/Contraceptive Education Social Norms Partner Age Disparity Parental Beliefs & Behaviors Unsupervised Activities At Risk Educational Programs Youth Unemployment Use of Contraception Abuse Peer Group Sex/Contraceptive Knowledge Family Income Risk Behaviors Racism Role Models Acceptable Method Problem Precursors Health Policy

Direct: Secondary: Tertiary: Teen Pregnancy Abortion Problem Consequences Live Birth Fetal Death

Direct: Secondary: Tertiary: Teen Pregnancy Abortion Problem Consequences Live Birth Fetal Death Abortion Consequences LBW/Prematurity School Delay or Drop Out

Direct: Secondary: Tertiary: Teen Pregnancy Abortion Problem Consequences Live Birth Fetal Death Abortion Consequences LBW/Prematurity School Delay or Drop Out Impaired Economic Productivity

Direct: Secondary: Tertiary: Teen Pregnancy Abortion Live Birth School Delay or Drop Out Economic Difficulties Poor Growth Environment Limited Family Support Social Support Day Care Subsidy Medicaid Support Child Neglect Slowed Development Repeat Pregnancy Abortion Consequences Limited Maternal Skills Limited Father Involvement Impaired Economic Productivity Poverty Cycle LBW/Prematurity Medical Complications Problem Consequences Fetal Death

Need for Services n Standards--Professional or Consensus n Demand--Waiting Lists n Population at Risk--At Risk Not Using n Relative--Population Comparisons n Perceptions--Reported Needs

Direct: Secondary: Tertiary: Teen Pregnancy Initiation of Sexual Activity Continuation of Sexual Activity Use of Contraception Problem Precursors Access to Confidential Services Partner Age Disparity Unsupervised Activities After School Programs Social Norms Health Policy

n Many causes & risk factors n Many levels of influence n Different opinions--causes & solutions n Vast scientific knowledge n Stacks of local data Why Do You Need A Problem Map?

Simple Map to Show You Where to Go!

What Is A Problem Map? n Oriented around a health problem n Shows causes & solutions n Shows consequences n Consensus of opinions, knowledge, & and information n Defines boundaries of what is known n Provides a map for use

Steps for Making A Problem Map n Obtain community thoughts n Review scientific information n Obtain & review local information n Develop consensus n Determine gaps in information n Determine potential actions n Develop an action plan

Bill's Steps for Problem-Oriented Needs Assessment Theoretical Framework Gather Readily Available Information Frame and Choose Critical Questions Choose and Develop Methods Analyze and Answer Your Questions Summarize Your Problem Present the Results

Gather… n Other Needs Assessments n Available Reports n Key Data People n Key Community People

Frame & Choose Critical Questions n What Are Remaining Questions? n What is Gained By Answering the Question? Do Something Different? n Can the Question Be Answered? n What Will It Cost? n Will It Be Part of the Big Picture?

Bill's Steps for Problem-Oriented Needs Assessment Theoretical Framework Gather Readily Available Information Frame and Choose Critical Questions Choose and Develop Methods Analyze and Answer Your Questions Summarize Your Problem Present the Results

Summarize the Findings!!! n Problem statement n Trends n Individual contributors n Community contributors n Individual strengths n Community strengths

Definition of Needs Assessment Systematic collection and examination of information to make decisions to formulate a plan for the next steps leading to public health action.

Being Effective in Public Health Assessment Capacity & Strategies Plan Evaluation Monitor Implement Plan Do

Needs Assessment Debates n Qualitative or Quantitative n Assets or Problems n Assessment or Surveillance n One Time or Ongoing n Ourselves or Contract n Science or Art n Performance or Pretty

Act IV Linkage of Assessment to Planning

n What are objectives? n Where do objectives come from?

Problem Analysis Access to poison by children Ingestion of poison Death from poison consumption Program Hypothesis Reduce child poison deaths Reduce poison consumption Provide childproof containers

Program Hypothesis Reduce child poison deaths Reduce poison consumption Provide childproof containers Problem Analysis Access to poison by children Ingestion of poison Death from poison consumption

n What is a program hypothesis? n How do objectives form a program hypothesis?

Program Hypothesis Goal Policy Program Operational Activities of the program Change in characteristics of recipients Change in health status of recipients Change in health of community

Program Hypothesis Goal: A broad statement of desired health status which does not have to be measured. All of the objectives must be state in measurable terms. Policy: A specific, measurable statement about the desired extent of improvement in a health status problem. Program: A specific, measurable statement of desired change in knowledge, behavior, biomedical measures or other intermediate characteristics that are expected to occur. Operational: A specific, measurable statement of an activity to be carried out by the program or intervention.

Program Hypothesis Goal: A broad statement of desired health status which does not have to be measured. All of the objectives must be state in measurable terms. Policy: A specific, measurable statement about the desired extent of improvement in a health status problem. Program: A specific, measurable statement of desired change in knowledge, behavior, biomedical measures or other intermediate characteristics that are expected to occur. Operational: A specific, measurable statement of an activity to be carried out by the program or intervention. NumberTimingControlAvailable

n What are the qualities of a good objective?

Good Objectives n Connected to the problem analysis n Straight forward n Measurable n Available n Baseline and target measures n Time period

Direct: Secondary: Tertiary: Teen Pregnancy Initiation of Sexual Activity Continuation of Sexual Activity Use of Contraception Problem Precursors Access to Confidential Services Partner Age Disparity Unsupervised Activities After School Programs Social Norms Health Policy

n What are the advantages and disadvantages of defining a program by its objective?

n Early prenatal care n More prenatal visits n Better medical care n Better nutrition n Better weight gain n Less smoking n Less substance abuse n More stable social situation n Less stress n Less prematurity/LBW n Outreach visits n Clinic visits n Home visits n Services provided n Completed referrals n Medicaid enrollment n WIC enrollment n Deliveries Train and monitor staff Clinic staff: n Outreach n Medicaid and WIC enrollment n Early enrollment n Risk assessment n Care Plan n Tailored Services based on plan n Interpretation n Follow up n 3 Clinic Sites n OBs n Advanced Nurse P. n Nurses n Nurse Case Managers n Nutritionists n Social Workers n Health Educator n Substance Abuse Counselors n Outreach workers n Interpreters n Administrative Staff Low income pregnant women who receive early risk-appropriate prenatal services will receive: n Early continuous care n Risk-based health care plan n Tailored medical care n Tailored health ed n Tailored health intervention/services Changes in the target population Products of the program Key actions of program staff and clients The resources needed to deliver the program Theoretical assumptions about why a program works OutcomesOutputsActivitiesInputsAssumptions Target Population: Uninsured or Medicaid Pregnant Women in Low SES Communities Columbus Health Department Perinatal Program