1. Needs Assessment January 6 th 2011 Dr Jane Buxton

2. Consider what do we mean by need What is need? How is it different from want? What is demand? How does supply fit in the picture?

3. 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

4. Maslow’s hierarchy of needs (1954)

5. 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)

6. The Determinants of Health 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)

7. 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

8. A/B for URT viral infections Health promotion, some screening Waiting list e.g. TOP

9. Death rates UK Q. Why the decline?

10. Thomas McKeown 1979 Decrease mortality infectious disease E & W 1938-70 was not due to medical intervention alone –Nutrition –Living conditions –Birth spacing

11. Hans Rosling's 200 Countries, 200 Years, The Joy of Stats - BBC 4 http://www.youtube.com/watch?v=jbkSRLYSojo http://www.youtube.com/watch?v=jbkSRLYSojo How has life expectancy changed over time globally?

12. 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

13. 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.

14. 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?

15. Spiti Valley, India

16. Over 400 children (kindergarten – grade 10) Children stay in hostels, monitored by house mothers Closest hospital 8 km away

18. 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)

19. Spiti Project Needs Assessment YearActionKey findings/concerns 2006 Conversation with locals Lack of healthcare Conversation with partner NGO’s Transmission of illness in boarding schools Health screens  Anemia, dental caries, intestinal disease, and skin disease. 2007 Health screens 88% of children were anemic

20. Spiti Project Needs Assessment YearActionKey findings/concerns 2006 Conversation with locals Lack of healthcare Conversation with partner NGO’s Transmission of illness in boarding schools Health screens  Anemia, dental caries, intestinal disease, and skin disease. 2007 Health screens 88% of children were anemic

21. Spiti Project Needs Assessment YearActionKey findings/concerns 2006 Conversation with locals Lack of healthcare Conversation with partner NGO’s Transmission of illness in boarding schools Health screens  Anemia, dental caries, intestinal disease, and skin disease. 2007 Health screens 88% of children were anemic

22. Spiti Project Needs Assessment YearActionKey findings/concerns 2006 Conversation with locals Lack of healthcare Conversation with partner NGO’s Transmission of illness in boarding schools Health screens Anemia, dental caries, intestinal disease, and skin disease. 2007 Health screens 88% of children were anemic

23. Spiti Project Needs Assessment YearActionKey findings/concerns 2006 Conversation with locals Lack of healthcare Conversation with partner NGO’s Transmission of illness in boarding schools Health screens Anemia, dental caries, intestinal disease, and skin disease. 2007 Health screens 88% of children were anemic

24. Spiti Project: Anemia Integrated approach looking at linked causes Anemia Health screens Hemoglobin Measurement Blood smears

25. Researched all linked causes of anemia (as per WHO guidelines and resources) Community surveys & focus groups: –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

26. 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 Spiti Project: Anemia Integrated approach looking at linked causes

27. India project: anemia Integrated approach looking at linked causes Anemia Health screens Hemoglobin Measurement Blood smears Iron Supplementation Deworming Health Education Nutrition survey Infrastructure Hygiene Toothbrushing Handwashing Water Sanitation Greenhouses

28. Types needs assessment Subtypes/terminology –Rapid needs assessment –Health needs assessment –Community needs assessment

29. 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.).

30. 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

31. 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. 4 th ed. Green & Kreuter pub McGraw Hill

33. Population Health Community assessment/diagnosis –Identify determinants of health problem ↓ Intervention/program options –Appraise, decide, implement ↓ Evaluate

34. 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; Community assessment/diagnosis

35. 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 PM 10 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

36. 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

37. 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

38. 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?

39. 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

41. Context: micro/meso/macro Individual client Family Clinic/school/church Pop. Community Region Global Medical students Community intervention: Literature search

42. 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

43. 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

44. Qualitative vs. Quantitative

45. 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

46. 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

47. 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

48. 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

49. 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

50. Systematic sampling; e.g. every 8th Source: D. Coulombier, Epicentre

51. Source: MSF

52. 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

53. “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.

54. 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