Public Health Skills: A Practical Guide for
Nurses and Public Health Practitioners.
By: mohammad sajjad lotfi

Introduction
– The assessment and identification of health need is a
process that helps:
1. Inform planning of health care for individuals and their
families, communities and the wider population.
2. It can be a powerful learning tool for local service
providers, presenting them with the rationale for re-
designing services to better target assessed needs of the
local population.

– In recent years interest in the assessment of
health care needs has increased because:
• the pattern of health service will frequently
reflect only partially the health needs of the
population that it is serving, and those with
the greatest need may receive least.
• Health needs assessment also provides a
method:
• Monitoring and promoting equity in the
provision and use of health services
• Addressing inequalities in health
‫که‬ ‫کوچکی‬ ‫جمعیت‬
‫دارد‬ ‫حداکثی‬ ‫استفاده‬
‫که‬ ‫انبوهی‬ ‫جمعیت‬
‫دارد‬ ‫حداقلی‬ ‫استفاده‬

1. Pressure on costs
2. Increasing willingness of politicians, managers
3. Public challenge of use healthcare service
To cause:
emphasis on the optimal allocation of scarce health care
resources.
– In order to establish a useful and effective program for a
specific target population, planners, policy makers and
health care practitioners must determine the needs and
wants of individuals and communities.
Introduction

– It is recognized that most clinical health
professionals are familiar with assessing the needs
of individual patients
needs assessment is now
undertaken by people
Traditionally, health needs
assessments have been
undertaken by public health
professionals

What is Health Needs Assessment?
– Health needs assessment (HNA) is defined as ‘a
systematic method for reviewing the health needs and
issues facing a given population, leading to agreed
priorities and resource allocation that will improve health
and reduce inequalities’

What is aim of Health Needs
Assessment?
– Aims of a health needs assessment (HNA) are:
1. To gather information to plan, and change services for
the better, and to improve health in other ways.
2. To build a picture of current services in order to
establish the baseline of existing services from

What is aim of Health Needs
Assessment?
which to determine what needs to be changed to meet the identified
health needs. Information gained from an HNA is the basis for
designing and implementing programmes of health and health care
that is, as far as possible, acceptable and accessible to the local
community and is based on evidence of cost-effectiveness. It is also the
primary means of allocating scarce health and public health resources
to individuals and communities with the greatest need.

What is aim of Health Needs
Assessment?
Stevens and Gillam (1998) highlighted five objectives of an HNA that
flow from these aims:
1. Planning:
2. Intelligence: gathering
3. Target efficiency
4. Involvement of stakeholders
5. Equity

What is equity means in Health
Needs Assessment?
– Equity is a difficult concept to analyse. It may help to differentiate between
horizontal and vertical equity:
1. Horizontal equity is concerned with the equal treatment of equal need
irrespective of socioeconomic background. This means that to be horizontally
equitable, the health care allocation system must treat two individuals with the
same complaint in an identical way.
2. Vertical equity, is concerned with the extent to which individuals who are
‘unequal’ should be treated differently (Sutton 2002). In health care it can be
reflected by the aim of unequal treatment for unequal need in order to achieve
equal health status; for example, higher health care investment in areas of
greatest socioeconomic need. These public health programmes are targeted to
the areas of highest socioeconomic deprivation.

Health, Health Need and Health
Care Need
– It is commonly accepted that the social and economic conditions
under which people live impact on the health status of a population.
– Hall and Elliman (2003) assert that in the 21st century social,
economic and environmental factors are more important than
biological disorders as causes of ill health.
– Health needs’ incorporates these wider social and environmental
determinants of health.

Health
– The World Health Organization’s definition holistic approach to
health:
– Health is a state of complete physical, psychological, and social
wellbeing and not simply the absence of disease or infirmity.
(WHO 1999)
– The World Health Organization defined the determinants of
health as: social gradient, stress, early life, social exclusion, work,
unemployment, social support, addiction, food and
transportation.

Health
– The socialization aspects of health should not be underestimated
and typically reflect the wide variations within communities
where both young and old live.
– People’s ideas and perceptions about health will be mediated by:
1. their own experiences
2. learnt patterns of behavior
3. key figures
4. from their lives through the home, family, school and work
environments.

Health
– Housing, income, employment and access to goods and services,
including health services, have all been recognized as important
components of health.
– The preferred model of the determinants of health, states is
1. Dynamic
2. Interactive
3. Adopting
a life course approach to health status, recognizing the complexity of
the interplay between antenatal, early and later life influences on the
development and maintenance of health and disease.

Health
– Dahlgren and Whitehead (1991) have described the factors affecting
health in a ‘rainbow model’

Health needs and health care needs
– This wider definition allows us to look beyond the confines of the
medical model based on health service provision, to the wider
influences on health.
– The health needs of a population will be constantly changing, and
many will not be amenable to medical intervention.

Health needs and health care needs
– Meeting health need is not the exclusive responsibility of the health
sector, but is rather the responsibility of multiple sectors and involves
ongoing collaboration between health, education, housing,
employment and welfare sectors.
– Health care visitor may need to advocate for patients where multiple
external factors are impacting on their health – for example a health
visitor may advocate for a family living in substandard
accommodation which is impacting on the physical health of the
children.

Health; Government or People
– There is currently a significant debate around the responsibility of
the individual to make ‘healthy’ choices. In July 2006, Tony Blair
urged the nation to take more responsibility for its own health.
– In the second of a series of major speeches on domestic policy, the
then prime minister argued that the government cannot make
decisions for people in a bid to improve their wellbeing: The
government can’t be the only one with the responsibility if it’s not the
only one with the power. The responsibility must be shared and the
individual helped but with an obligation also to help themselves.

Health; Government or People
– Blair also stated that: Our public health problems are not, strictly
speaking, public health questions at all. They are questions of
individual lifestyle – obesity, smoking, alcohol abuse, diabetes,
sexually transmitted disease. They are the results of millions of
individual decisions, at millions of points in time. The issue of
individual responsibility has become a topic of national debate and is
likely to continue to be so into the future.

Need, Demand and Supply
– Need is a critical concept in the pursuit of efficient health care and is
equally critical to the development of services that are equitable
(Mooney et al. 2004).
– In health care, need has a variety of meanings that may change over
time, so it is not surprising that different groups of health
professionals refer to ‘needs assessment’ in very different ways
(Jordan & Wright 1997).
– It is important to recognise the different perspectives illuminating the
relationship between the concepts of need, and health care needs
(Asardi-Lari et al. 2003)

Need
– In a sociological environment, divided ‘need’ into four types:
1. Normative need – distinguished by professionals, such as accination;
2. Felt need – wants, wishes and desires;
3. Expressed need – vocalized needs or how people use services;
4. Comparative need –needs arising in one location may be similar for
people with similar sociodemographic characteristics living in another
location.
– Bradshaw’s taxonomy of need creates a definition which is more
practical for health service research workers.

– his taxonomy of need was constrained because of inherent
problems with the concept of need.
– This issue is yet to be resolved as there is still no consensus as
to what constitutes ‘need’. The most widely presented definition
of need favored by economists is ‘the ability of people to
benefit from health care provision’, in other words, ‘need’ exists
only if there is a ‘capacity to benefit’ from a particular health
care service.

Need, Supply and demand
– Need is defined as the ability to benefit from health care, i.e. a
measurable change in health status attributable to the
intervention.
– Demand is what people ask for. It is not necessarily what they
need. GPs and consultants have a key role as gatekeepers in
controlling demand.
– Supply, that is the health care interventions and services that
are available to the population. This will depend on the interests
of health professionals, the priorities of politicians and the
amount of money available.

Need, Supply and demand
– Need, demand and supply overlap and this relation is important to consider
when assessing health needs

health care need
– The term ‘health care need’, according to Wright et al. (1998), can be used to
describe”
– a population’s need for the provision of particular health care services and those
that can benefit from health care (health education, disease prevention,
diagnosis, treatment, rehabilitation, end of life care).
– Most doctors will consider needs in terms of the health care services that they
can supply. Patients, however, may have a different view of what would make
them healthier – for example, a job, decent housing or access to affordable
leisure facilities.
– There needs to be some consideration of the effectiveness, including cost-
effectiveness, of services in which an investment is being considered. Because
available resources in all health care systems are finite, and demand will always
outstrip supply, prioritization of health service purchasing is necessary.

Approaches to Health Needs
Assessment
– Wright et al. (1998) state that a comprehensive HNA involves an:
1. Epidemiological (quantitative)
2. Qualitative approach
to determining priorities, and should incorporate different
perspectives :
1. Clinical
2. Cost-effectiveness
3. Patients’.

Approaches to Health Needs
Assessment
– This approach must also balance
1. Clinical
2. Ethical
3. Economic considerations of need
– In practice three types of needs assessment have been described:
1. Epidemiological
2. Comparative
3. Corporate

Epidemiological
– Epidemiological statistics measure the total amount of ill
health in the community, for example mortality and morbidity
statistics.
– Indicators of deprivation are used to identify groups of people
who may experience social and economic disadvantage, for
example unemployment rates.
– enable the government to target resources to those most in
need.

Epidemiological approach
– The epidemiological approach to HNA has three elements:
1. determining the incidence and/or prevalence of the health
problem;
2. identifying the effectiveness (and cost-effectiveness) of
existing interventions for the problem;
3. identifying the current level of service provision.
– This combination of epidemiological (health status assessments) and
evidence (effectiveness/cost-effectiveness) has also been described as
an evidence-based approach to HNA.

Comparative approach
– Comparative need is defined as existing where the population of one
area has a lower uptake of a particular intervention than that of
another area, after adjustment for any differences in age or other
population characteristics.
– These could be cross-national comparisons, for example comparing
England with other countries in Europe, or comparisons at a more
local level or comparing the service provision in one town or locality
with another that has similar demography.

Corporate approach
– The corporate approach involves the systematic collection of
the expert knowledge and views of informants on health care
services and needs.
– In the context of the NHS, this corporate approach has been
widely used, and was encouraged in the 1989 health reforms and
the emphasis on partnership and collaboration in the 1997
White Paper.

Approaches to Health Needs
Assessment
– Each of these approaches requires a considerable
amount of resources and can be time intensive.
– A comprehensive needs assessment usually involves
a combination of all three approaches.

Approaches to Health Needs
Assessment
– An alternative model, rapid appraisal, offers certain advantages in
such circumstances.
– This is a multidisciplinary approach that incorporates flexibility
and innovation and which draws extensively on the views of the
local community.
– It involves using key informants to build up a community health
profile.
– This approach has been used to enhance community involvement in
developed countries.

Information pyramid
– Information is collected on nine issues, in an ‘information
pyramid’

– Bottom layer: structure and composition of the community and how
it is organized.
– Second layer: concerned with socioeconomic influences on health.
– Third layer: looks at resources in the community, including their
accessibility and acceptability.
– Top layer: looks at national, regional and local health policies.
– This information, taken together, can then inform current service
provision, identify the views of local residents and stakeholders, and
make recommendations for health improvements.
Information pyramid

service-related assessment of need
– There are other contemporary approaches to service-related
assessment of need; these include:
1. social services assessments
2. individual health care needs assessment
3. population and client group surveys
– increasing focus on strategies for assessing needs which allow the
use of multiple data sources to interpret the diverse and wide
ranging needs that are found within the community.

– Assessment of need for health care, using whichever of these models
is appropriate, is a prerequisite for the optimal allocation of
resources.
– The advantages and disadvantages of these approaches are
summarized.

– Epidemiology approach
– Advantages: Gives overall figures of numbers likely to have specific
problems (e.g. cancer, depression, hypertension) Relatively quick and easy,
can be done from a desk top Identifies the broad range of clinical conditions
and their likely prevalence Systematic and objective
– Disadvantages: Assumes uniform prevalence, although can be weighted
(crudely) for known risk factors, e.g. deprivation. Can tend toward medical
rather than social needs This approach is only possible for some conditions,
where there is straightforward means of identifying those with clinical
indications Frequent lack of existing local epidemiological data and lack of
evidence for certain interventions Carrying out new epidemiological work is
also costly and time consuming
– Source of information: ONS surveys of morbidity/ mortality Hospital
episode statistics Compendium of clinical and health indicators Census data
Screening data Public health observatories, www.swpho.org.uk, National
statistics, www.statistics.gov.uk Neighbourhood statistics,
www.statistics.gov.uk

Comparative approach
– Advantages: Sets local service provision against national norms Good for
identifying inequalities. Uses existing data and multiple sources of information
– Disadvantages: Relationship unclear between provision, utilization of services
and actual need assumes that the intervention rate in the area where it is higher
is the correct one – fails to take account of differences in disease prevalence
rates or of previous treatment
– Source of information: Prescribing data GP practice based data (disease
registers), Hospital activity data, Screening uptake data/vaccination uptake, car
ownership, employment, age profiles, housing tenure, self-reported limited
illness Indices of deprivation

Corporative approach
– Advantages: Involves local health care providers and local people responsive
to local concerns and fosters local ownership of the issues
– Disadvantages: If carried out in isolation may determine demands rather
than needs and stakeholder concerns may be influenced by the political
agenda Risks legitimizing existing patterns of care that may have little
rational basis
– Source of information: Sources of information for this methodology can be
drawn from any of the other three approaches – using local/ national
quantitative data and qualitative data such as focus groups/interview and
surveys

Rapid Appraisal
– Advantages: Good for community profiling Highly participative
Good qualitative Information
– Disadvantages: Does not generate statistics for planning
purposes Subjective may raise local expectations
– Source of information: Local informants Local information/
reports – practice profiles, community directories Semi
structured interviews Questionnaires Focus groups Observation
of community

– A combination approach is more
likely to reflect reality, however,
than using one method alone

Health Needs Assessment: Practical
Approaches
– There is no single best way of assessing the needs of a
particular target population in a local area.
– The methods that you use will be completely dependent
upon who your target population is, and what you want to
find out about that population.

Health Needs Assessment: Practical
Approaches
– The HNA population can be identified:
1. geographic location – e.g. living in deprived neighborhoods
or housing estates;
2. settings – e.g. schools, prisons, workplaces;
3. social experience – e.g. asylum seekers, specific age groups,
ethnicity, sexuality, homelessness,
4. drug/alcohol use;
5. experience of a particular medical condition – e.g. mental
illness, coronary heart disease, cancer.

Health Needs Assessment: Practical
Approaches
– A target population can also be identified through a
combination of main and subcategory groups, e.g. children
under 5 years living in a deprived neighborhood.
– Levels of HNA range from individual contact between the
health care professional and the client, to local, national and
international assessment of population health needs.

Framework for Assessing the Health Needs
of a Population
– Various tools and guides have been produced by individuals and
organizations in recent years to assist practitioners undertaking
HNAs.
– Cavanagh and Chadwick (2005) have produced a revised
practical guide Health Needs Assessment based on the work of
Hooper and Longworth (2002) outlining a five step process to
undertake an HNA.

– This framework has been recognized as a flexible, systematic
process that has been well tried, tested and refined over several
years and provides practitioners with a consistent process for
undertaking an HNA
– It is important to recognise that the process seldom follows a
linear path through the steps and, in essence, an HNA can be
approached in much the same way as doing a jigsaw, so that
different pieces are put together to give a complete picture of
local health

Community health needs
assessment
Community HNA is a process that:
1- describes the state of health of local people;
2- enables the identification of the major risk factors and causes of
ill health;
3- enables the identification of the actions needed to address these.
– A community HNA may not be a one-off activity but can be a
developmental process that is added to and amended over time. It
should not be an end in itself but a way of using information to
plan health care and public health programmers in the future.

The steps of a community HNA are
as follow
1. Profiling: the collection of relevant information that will inform the
community HNA about the state of health and health needs of the
population, and analysis of this information.
2. Deciding on priorities for action.
3. Planning public health and health care programmes to address the
priority issues.
4. Implementing the planned activities.
5. Evaluation of health outcomes.
– These stages correspond to the Cavanagh and Chadwick (2005)
five-step process

Individual/Patient Health Status
and Health Needs Assessment
– The distinction between individual needs and the wider needs of
the community is important to consider when assessing needs.
Commonly, the health status of patients is evaluated according to
clinical tests, for example blood tests, scans and X-rays.
– In recent years there has been an increasing interest in evaluating
the health status of patients through self-completed responses to
questions about health status.

Individual/Patient Health Status
and Health Needs Assessment
– There are important contributions that the individual health
assessment record can make to two important population-based
tasks
1. The management of groups of individuals in a population in
order to provide care directly to each individual
2. The management of information about a population in order to
understand the population itself for purposes

– The individual health assessment is now being designed to bring
together information from many sources and incorporate it into a
consistent single record.
– Such single assessment processes are well positioned to provide
information and to identify circumstances requiring action that
spans providers. Furthermore, the information can also be used
collectively to give health and social care information regarding
neighborhoods and communities and to assist in community
needs assessment and health care planning.

reference

Thanks a lot