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Approaches To Community Needs Assessment A Literature Review
1.
JournalofAdvanced Nursing, 1995,22,
721-730 Approaches to community needs assessment: a literature review JenniferRuth BillingsBSc(Hons) RGNRHVDPNS ResearchAssistant and Sarah Cowley BA Phi3 PGDERGNRCNTRHV FWT HVT Lecturer,Department of Nursing Studies, Kings CollegeLondon, London, England Acceptedforpublication1December1994 BILLINGSJ.R.&COWLEYS. (1995) Journal of Advanced Nursing 22, 721-730 Approaches to community needs assessment: a literature review In the light of the growing awareness of professionals in the community of the need to undertake health needs assessments of the population, this literature review sets out to explore, delineate and critically analyse the various approaches to community needs assessment, to facilitate a greater understanding of their strengths and weaknesses. The review commences by highlighting its complex nature, and attempting to define what is meant by 'needs assessment' f~om the differing perspectives of three dominant approaches, namely sociology, epidemiology and health economics. It continues by putting forward an argument for the use of the community health profile, being a multi-focal approach to needs assessment, combining quantitative with qualitative data, and proceeds with a discussion of strengths and weaknesses related to its compilation, in particular factors relating to reliability and validity of data sources. The consumer perspective is also reviewed, as are issues surrounding the ethics of data collection and problems concerning aggregation of the numerous data sources into meaningful policy. Throughout the review, issues are discussed with reference to the current political context in the United Kingdom. Equally important is the community nurse perspective, which is integrated into the arguments where appropriate. INTRODUCTION Needs assessment has always been a priority issue for those concerned with community health, but it was the publication of the Acheson report which led to a resurgence of interest, proposing as it did that directors of public health should be responsible for assessing the needs of their local populations (Department of Health and Social Security 1988}. Since this proposal, successive Department of Health (England} papers (1989a, 1989b, 1990, 1991, 1993} have broadened the professional scope Correspondence:JenniferB.Billings,DepartmentofNursing,King's CollegeLondon,CornwallHouseAnnexe,WaterlooRoad,LondonSE1 8TX,England. and application of needs assessment by reaffirming its importance as a means of determining the provision and extent of health care. As a result, this so-called 'needs-led' style of planning signals a departure from previous approaches, which were predominantly service-led (Stalker 1993). Community needs assessment has been defined simply as 'a description of those factors which must be addressed in order to improve the health of the population' (Harvey 1994). Although needs assessment was initially seen as the primary responsibility of potential purchasing and commissioning authorities, and necessary to inform the contracting process (Department of Health 1989c), com- munity provider units are now recognizing the important contribution they can make towards the identification of ©1995BlackwellScienceLtd 721
2.
J.R. Billings and
S. Cowley local population needs, particularly through the work of community nurses (Day 1992, Goodwin 1994). A recent report concerning the progress of the Health Visitor Marketing Project initiated by the National Health Service Executive (NHSE 1994) also emphasizes that purchasers recognize the central role potentially held by health visi- tors in accumulating information about health needs in the population, and require that this service be incorporated into service specifications. The ability to carry out a full assessment of the needs of individuals, families and communities is, however, not a new and fashionable marketing feature for community nurses, but has always been a central feature of community nursing practice, in recognition that an assessment of indi- vidual client need is fundamental to ensuring suitable ser- vice provision (Goodwin 1988). Indeed, the Council for the Education and Training of Health Visitors specified in 1977 that the search for health needs and a stimulation of their awareness were to be principle objectives within health visiting practice. Considering the challenges of today's practitioners, such as increasing social deprivation and poverty (Blaxter 1990), inequalities in health (Phillimore et al. 1994) and the growing morbidity and mortality from heart disease and AIDS (Department of Health 1991), these principles are as relevant today as they were for community nurses in the 1970s (Twinn & Cowley 1992). APPROACHES TO 'NEEDS' DEFINITIONS Assessment of health needs has been the subject of much inquiry over the past two decades, escalating in recent years due to the pressure of government legislation (Buchan & Gray 1990). The complex, multi-dimensional nature of needs assessment has been revealed, and those health care managers and practitioners who have launched into this field are realizing that the task is far from straight- forward. Defining what is meant by 'needs' is a case in hand. Orr (1985a) provides an initial interpretation that reveals the multiple meanings attached to the concept, defining need as 'social, relative and evaluative', social in being defined according to standards of communal life, relative in that its meaning will vary between people and societies, and evaluative in that it is based upon value judgements. The difficulties of operationalizing these notions for assessment purposes becomes apparent. In a broader perspective, sociologists, epidemiologists and health economists have each defined needs from their own standpoint. Generally, the sociological view is exem- plified by Bradshaw (1972), whose taxonomy of formative need, felt need, expressed need and comparative need remains cogent in health care, distinguishing as it does the important differences between needs as identified by pro- fessionals (normative) and those 'felt' by the individual. The influence of Bradshaw is also evident in community nursing, where the concept of need is perceived as per- sonal, subjective and variable (Orr 1985b, Twinn &Cowley 1992). This perspective does, however, raise issues concerning the difficulty of forming clear and comparable criteria for needs assessment. Buchan & Gray (1990) argue that qualitative definitions of need tend to be nebulous and of little help in determin- ing appropriate levels of service requirement. In a study of social welfare provision, for example, Thayer (1973) concluded that the taxonomy of need was a useful way to demarcate different approaches to assessment, but there was little methodological evidence to suggest that the concepts could be operationalized in a meaningful way. In general terms, however, health is a broad concept (Seedhouse 1986) and there would appear to be unlimited scope for people to consider themselves unwell. Traditional epidemiological approach The traditional epidemiological approach to needs assess- ment has been to use morbidity and mortality data to meas- ure the total amount of ill health in the community, and then use this information to set priorities for allocating resources between different diseases (Knox 1976, Ashley &McLachlan 1985). Need is thus defined in terms of lives lost, life years lost, morbidity, or loss of social functioning. Indicators of deprivation are used in a similar fashion, based upon census data. Variables such as numbers of single parents, elderly people living alone, families with pre-school children and ethnicity are measured, combin- ing social and material deprivation into a composite index. This ultimately provides a means of scoring and ranking areas according to their degree of relative disadvantages or affluence (Jarman 1984, Townsend et al. 1988). These approaches have the potential to provide valuable information about the need for health, but by focusing upon 'normative' or professionally defined need, there is the assumption that, once categorized, population groups are automatically in need of services, which may not be the case (Orr 1985a). This lack of specificity regarding the identification of the need for health care has also been highlighted by Stevens &Gabby (1991), who argue that the need for health care must be the focus of community needs assessment if service provision is to be effective. The health economists' contribution has been in contrast to previous perspectives, defining need within the context of cost-effectiveness and supply and demand. The main thrust of the argument is to emphasize that areas of needs are relative and can be 'traded off' against each other, given limited resources (Culyer 1976, Donaldson & Mooney 1991). With the assumption that the objective of health care policy is to maximize the contribution of health care resources to the health of the community, defined in terms of quality adjusted life years (QALYs), it is argued that more resources within the health care budget should be 722 © 1995 Blackwell Science Ltd, fournal of Advanced Nursing, 22, 721-730
3.
Community needs assessment allocated
to treatments with a low marginal cost per QALY and less to those with a high marginal cost per QALY gained. Bryan et al. (1991) give the example of expanding a community chiropody service whilst contracting home dialysis, as more QALYs would be produced without any increase in expenditure. Proponents of this approach state that it does not require any assessment of total needs, and that the key concept is getting the greatest benefit for each pound spent (Williams 1987). Although the economic viewpoint may rationalize service provision in a 'cut and dried' fashion, it is not difficult to imagine that the perspective has been strongly criticized for its unethical stance, neglecting as it does con- sumer views and issues relating to maintenance of quality of life in illness (Harris 1987, Loomes & McKenzie 1989). In addition to this, the economist viewpoint is difficult to grasp when little textual simplification is offered, which is particularly evident in Bryan et al.'s (1991) paper. For this reason, those health care professionals unfamiliar with the language may be overly critical or dismissive of the approach. Notwithstanding the ambiguities surrounding differing interpretations of need, defining what is meant by 'com- munity' and 'population' within this context also high- lights inconsistencies and lack of clarity when undertaking an assessment procedure. Briefly, with reference to com- munity, Orr (1985b) states that the various meanings and confusion surrounding the concept of community occur because it is used in a descriptive, evaluative and emotive manner, making precise definition arduous, a view shared by Benson (1976). Regarding population, community agencies are expected to set out the needs of the population they serve (Department of Health). Stalker (1993) questions whether the term refers to existing service users, potential service users, or the totality of residents in a region. THE COMMUNITY HEALTH PROFILE Thus, attempting to identify community needs within a population against this complex and multi-faceted back- drop is an enormous task for professionals. However, an approach that is gaining increasing interest and appli- cation is the development of an area or community profile, which incorporates the sociological and epidemiological perspectives outlined. The concept is not new, and has been adopted as part of determining social policy objec- tives in a locality (Glampson et al. 1975, Hubley 1982), and has been a requirement of health visitor training since the 1970s (Hunt 1982). The approach is appealing in that it combines quantitative data, such as demographic infor- mation, epidemiological data and indicators of depri- vation, with qualitative data, such as information from health care professional caseloads and individual assess- ments (Richards 1991). Collaboration between and amongst professional groups and agencies in the community is strongly advocated (Twinn et al. 1990, Cernik & Wearne 1992) and is thought to have considerable benefits. Peckham & Spanton (1994) state that community nurses can build local networks and alliances with groups and individuals, increasing their understanding and awareness of local issues, and adapting work priorities accordingly. Advocates of the profile stress its value in providing a comprehensive and rounded picture of population needs for health care, giving a more accurate indication for health service provision, and highlighting mis-matches between need and health care delivery (Klein & Thomlinson 1987, Snee 1991, Cernik & Wearne 1992). The potential contribution that community nursing information can make by the provision of explicit client- related experiential material via individual assessment and caseload data, is at present being fully exploited by its proponents in the nursing press (Gooch 1989, Drennan 1990, Day 1992, Goodwin 1992). Although the extent of profiling in practice has not been measured, studies are now emerging that give an indication of actual outcomes from caseload profiling, such as the construction of a general practice health strategy (Colin-Thome 1993) and health visiting strategy (Jackson 1989), the development of a weighting system for district nursing caseloads (Drennan 1990) and the identification of levels and types of nursing needed (Hugman &McCready 1993). In a family health needs study currently being undertaken by Cowley &Billings (1994a), a comprehensive community profile has been used to form the foundations of a semi-structured interview schedule for ascertaining client need. This infor- mation will subsequently be used to form a model for identifying health visiting service specifications for contracting. Community profiling, however, as with other approaches to community assessment, should not be viewed as a panacea for all ills. There are numerous issues associated with its compilation, some of which will be addressed. Although the above examples highlight the potential of the profile approach to needs assessment, the impact does not appear to be widespread. In reality, the time and resources needed to complete a profile would be beyond the scope of most hard-pressed practitioners (Twinn et al. 1990). From a research perspective, profiling is plagued with difficulties concerning the identification of an appropriate research design for data collection and analysis. In general, data are collected in an ad hoc manner, using what appears to be readily available infor- mation, and there is little description of how broad census data are aggregated with individual perspectives, which renders the derivation of findings, conclusions and ulti- mately action difficult to comprehend in some studies. Cowley & Billings (1994a) are, however, using a case study approach to profiling (Yin 1989), which allows for the development of a case description through a © 1995 Blackwell Science Ltd, Journal of Advanced Nursing, 22, 721-730 723
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S. Cowley pattern-matching of themes identified within the various data sources. This strategy allows for the complexity of community profile information to be described in terms of needs identification, and permits potentially meaningful aggregation of data across its differing methodological types. The dilemmas of data aggregation are further explored when discussing the consumer perspective. VALIDITY OF DATA SOURCES A further issue to consider is the validity of data sources for a community profile, as it would appear that the range of information obtained is rarely questioned for reliability or validity determinants. To illustrate this point, the use of 1991 census material to determine a range of population characteristics and circumstances is heavily recommended as a valuable source of data (Hubley 1982, Orr 1985a), but it has been identified that census variables such as age and ethnicity are not in themselves causes, nor necessarily indicators of need (Stalker 1993). Robinson (1985) and Orr (1985b) argue that such classifications may lend them- selves to professional stereotyping regarding needs assess- ment, rather than recognizing individual variation within the categories. Census data also continue to request information regard- ing the 'head of the house' upon which to base social class position. This is still largely completed as the male partner in a 'couple' household for most situations, despite differing economic activity between partners (Office of Population Censuses and Surveys 1992). McDowall (1983) highlights the shortcomings of this approach, particularly in relation to women. Firstly, most women now work, and not classifying them individually by their own occupation may conceal health hazards; and secondly, the earnings of working women may influence and improve the standard of living within the household. Difficulties with the unem- ployed, the elderly and children also occur, in that occu- pational class does not fully encapsulate the circumstances under which they live (Whitehead 1987). Thus the needs of large sections of the population may be hidden or over- estimated using this classification. Several alternatives have been put forward, such as Arber's (1987) household class, based upon the occupation of the spouse who is economically dominant, or the child- centred social index (Osborn & Morris 1979), which was intended to be more in tune with the home environment of the child than occupational class alone. Their use has not as yet been widely replicated and evaluated. A further difficulty regarding census data is the useful- ness to potential 'profilers' regarding the geographical dis- tribution of its results. The present availability of small area population statistics (electoral ward and enumeration district) has facilitated planners in identifying need, but it does not assist the GP-attached practitioner whose popu- lation may span a wide geographical area with three or four families per ward (Young & Haynes 1993, Cowley & Billings 1994b). This argument highlights the difficulties associated with 'goodness of fit' of the various data sources, which is a recurrent obstacle regarding meaning- ful profile compilation. However, the case study approach as previously described may overcome this problem to some extent. Further to this, the apparent under-representation of single people aged 16 to 44 in comparison with the 1981 census has also caused speculation regarding the reliability of data in this group, particularly concerning potential poll tax evasion (Office of Population Censuses and Surveys 1992). This has obvious implications concern- ing the accuracy of identifying needs. Also, census data become very rapidly out-of-date, assuming that they were accurate in the first place, a feature that hounds all 'snapshot' population information (Stalker 1993). Social inequality and deprivation Moving now to measures of social inequality and depri- vation -- as stated most have been welcomed as an import- ant adjunct to estimating the health of a population (Whitehead 1987, Stalker 1993), but there are singular problems attached to their measurement. For example, Jarman's (1984) score has been criticized for its bias towards using determination variables associated with the elderly (Thunhurst 1985). Foy et al. (1987) and Chase & Davies (1991) have pointed out that the aggregated data may hide large variations between smaller groups; the deprivation within a housing estate, for example, that is situated in an area of relative affluence may be masked. However, enumeration data from the census may now largely overcome this problem, by giving specific house number information. Whitehead (1987) remarks that some indices combine direct indicators of deprivation, such as overcrowding and unemployment, with indirect measures of numbers of people 'at risk' of deprivation (i.e. single- parent families or ethnic minorities), where, as previously mentioned, not all people are deprived in these groups. Townsend et al. (1988) have highlighted contradictions between scores when indices are monopolized by highly skewed variables such as ethnicity; for example, the Department of the Environment's (1983) and Jarman's (1984) indices discovered that the most deprived local authority areas were in London, with none in the north of England. Townsend et al's (1988) own observations record the converse to be more the case. However, this problem may be overcome by choosing only indicators of material deprivation such as the proportion of households with no car, and unemployment (Townsend et el. 1985), by employing more sophisticated statistical techniques (Wagstaff et aL 1991), or by using 'grass root' surveys to check and extend the statistical results (Thunhurst 1985). Acquiring epidemiological evidence has largely 724 © 1995 Blackwell Science Ltd, Journal of Advanced Nursing, 22, 721-730
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upon morbidity and mortality data. Stevens & Gabby (1991) argue that an epidemiologically sound assessment of needs is a vital inclusion to any profile and the ultimate development of the health service, focusing as it does on prevalence rates of death and disease. Although death rates are obviously a necessary concept for assessing disease, Patrick (1986) observes that these statistics have lost their importance in assessing a popu- lation's health. He adds that this is particularly so when death rates are low, as by implication the majority of the population remain alive in varying states of health. Wilson (1981) adds that the increase in chronic conditions and the development of medical treatments to prolong life, such as renal dialysis and insulin therapy, have contrib- uted to the decreasing value of this data. Thus information relating to the prevalence of disease would appear to have greater potential application to needs assessment (Mays 1987). Stalker (1993), however, urges for morbidity rates to be translated with caution, supporting critics of census and deprivation data by stating that incidence must not be confused with actual need. Inconsistencies in measurement also abound, par- ticularly in relation to mental health. McCollam (1992) discovered that incidences of mental health problems are obtained in a variety of different ways, and that differing methods used in one area produced competing perspec- tives of mental health prevalence. On the other hand, Bebbington & Davies (1980) acknowledge the difficulties in reaching consensus regarding criteria for measurement, and suggest that attempts to develop national indicators would meet with limited success. A potentially valuable source of morbidity information is from GP practice data bases, but accuracy and availability of this information can be limited to the ability of hard-pressed practice staff to process and enter the data, and can vary between practices rendering comparison difficult (Cowley & Billings 1994b). However, a lateral perspective that criticizes the some- what ironic emphasis upon disease as a way of determin- ing health is offered by Rijke (1993). He states that most medical research has been undertaken in academic settings or hospitals where a select group of the population with certain abnormalities and diseases are investigated. Rijke goes on to argue that focusing upon disease groups to esti- mate population needs is not profitable, as very little is known in medical science about the natural history of diseases in the general public (Lorber 1980, Nelson & Ellenberg 1982). Rijke (1993) asserts that there is an assumption that the occurrence of a disease is determined by a causal factor(s), and that the elimination of the disease is achieved by medical intervention or lifestyle changes. He argues that reducing certain factors does not necessarily lead to better health when applied to larger population groups, especially in relation to cardiovascular disease (Coronary Drug Project Research Group 1980) and urges for a scientific approach to research which studies health rather than disease. To support his view, Rijke (1993) outlines research that has focused upon how people remain healthy. This points to factors such as autonomy, vitality and social support as being essential to the reduced frequency of physical com- plaints and illness, and maintenance of a sense of well- being (Rijke 1985, Antonovsky 1987, Rohe & Kahn 1987). Not only has this perspective profound implications for the nature of current health education and promotion pro- grammes, which work from a perspective of disease avoid- ance rather than health persistence, but it offers another dimension to the assessment of community and individual needs and service provision. Services such as health visit- ing that are able to provide the necessary skills to assess these qualities, and potentially augment their deficiencies through facilitating empowerment and networking (Drennan 1988), should, by intimation, be enhanced rather than eroded. CONSUMER PERSPECTIVE Having now debated some of the issues concerning the accumulation of health data for community profile compi- lation, the review will now focus upon obtaining the con- sumer perspective. The profile has been accused of being restricted in providing a picture of health needs, limited as it is at present to the collection and collation of existing information from a service perspective (Peckham & Spanton 1994). Consultation, however, appears to be an aspect of planning that is attracting considerable interest, offering a unique opportunity for the community to make their needs known and, theoretically, ensure that they are adequately addressed within plans (Clode 1992). It appears to be one means of bridging the gap between the 'micro' and 'macro' levels of health estimation (Stalker 1993). Criticism has been directed against health care pro- fessionals for setting the health agenda without consulting the public (Forrester 1991). Amongst the population (Richardson et al. 1992) and health care professionals (Higgens 1992), there appears to be increasing importance attached to the notion of consul- ration about health needs. The current wave of con- sumerism in health and social circles has, however, not occurred due to the sudden development of socially con- scious managers. Phillips et el. (1994) state that the govern- ment's policy of controlling public expenditure and encouraging a mixed economy of care has introduced a strong element of enterprise culture into public service organizations. Central policy thus demands greater choice and independence for service users, evidenced by their publications (Department of Health 1990, National Health Service Management Executive 1992). Reviewing the various approaches to consultation, Bowling (1992) highlights numerous ways in which this © 1995 Blackwell Science Ltd, Journal of Advanced Nursing, 22,721-730 725
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S. Cowley can be achieved, namely consumer feedback via forums and public meetings, and consumer representation on user-groups. Local interview, postal or telephone surveys of views and satisfaction surveys have also been used (Roberts & Magowan 1994). Bowling (1992) adds that observation techniques can also be applied in care settings where clients find difficulty in expressing views. The use of focus groups has also been advocated as a valuable method of exploring perceptions of need (Morgan 1993), and indeed has been enlightening when used in this con- text, indicating consumer awareness of their contributive strengths and limitations in the needs assessment process (Cowley et al. 1994). Methodological difficulties Consultation is, however, not without its methodological difficulties. Focus groups, for example, are generally characterized by small numbers, which raises questions regarding the ultimate reliability of the results, as evi- denced by Cowley et al.'s (1994) paper. To overcome this problem, some studies have used a combination of tech- niques to obtain a more comprehensive picture of con- sumer need (Judge &Solomon 1992). Also, the constraints of satisfaction surveys have long been recognized, relating particularly to the validity of current methods of oper- ationalizing the concept of client satisfaction (Avis 1994). A factor common to all approaches to consultation con- cerns reliability of sample selection. Rodgers (1994) and Bowling (1992) suggest that, where researchers do not strive to gain equity of response, there will be a tendency for the more articulate, less burdened consumer's voice to be heard loudest. Consultation therefore has the potential to reinforce inequalities in service provision, rather than address them. However, obtaining the views of 'quieter' sections of the population has its constraints. In a community project based in Stirling, the needs of a sample of elderly people were obtained with the aid of a schedule (Hudson 1992). Prior to the assessment, a 10-point questionnaire was completed by the referrer, indicating the degree to which the elderly person was perceived to be 'in need'. Hudson (1992) documents the difficulties experienced by elderly people, who found expression of need arduous and con- sistently linked need to availability of resources. This was in contrast to the referrer's perceptions, which gener- ally identified multiple needs among the sample regard- less of available service provision. Further complications were revealed in this study regarding the tension between the carer's needs and those of the elderly person. Decisions regarding whose needs would drive the care plans thus became difficult. The study highlights some important issues surrounding the complexities of needs assessment, but it is lacking in detail regarding sample numbers, questionnaire and schedule details, rendering the research difficult to appraise for methodological rigour. Once data from the consumer have been compiled by a chosen method, consideration must be given to their syn- thesis with broader health information into local policy, a difficulty highlighted earlier. In an analysis of community plans, Richards (1991) noted that while most emphasized the importance of aggregation of data, few practical pro- posals for achieving it were made. This becomes increasing significant when considering the depth of information obtained by community nurses through individual needs assessment. Incorporating such information into meaning- ful policy statements can be onerous. For example, unless the total population within an area can be targeted, bias may be an inevitable consequence and 'felt' need never fully identified (Stalker 1993). Conversely, rendering the needs of individuals into meaningful components for policy determination may necessitate a radical aggregation of felt need, so a true pic- ture may never be explicated. However, focusing upon small groups within a locality, such as corers or families of physically challenged children, may converge areas of need in a more meaningful way (Richards 1991, Morris & Lindlow 1993). This latter argument highlights a concern regarding the ethical consequences of needs assessment. To elaborate, a consideration of the ethical issues involved in obtaining information about a community, both from statutory and informal sources, appears to be largely absent from the literature (Cowley 1993). This 'invasion of privacy' becomes of increasing significance if a large percentage of the population from which data are being obtained will not benefit from any service provision (Orr 1985b). Coupled with this, the often perceived unequal relation- ship between professionals and recipients of care (Becker 1967, Dunnell & Dobbs 1983, Orr 1983) may mean that clients are placed in uncompromizing situations concern- ing the revelation of personal details for the purposes of a profile. This is particularly evident when viewing the very personal components of the individual assessments, evi- denced by questions relating to intimate physical and sexual components (Bell 1993). A balance must therefore be achieved between a desire to locate and provide for unexpressed needs and the right of citizens to maintain their privacy (Pinker 1982). Notwithstanding methodological and ethical issues, further contradictions to this approach to needs assess- ment are evident. For example, the financial costs are con- siderable (Richardson et aI. 1992), and the depth of information obtained will ultimately depend upon the methods employed. As there is no 'minimum standard' to be achieved, cost-restrictions may limit areas to obtaining superficial consumer data only, whilst still fulfilling government recommendations. Rodgers (1994) argues that the Citizen's Charter (HMSO 1993) is a case in hand; with 726 © 1995 Blackwell Science Ltd, Journal of Advanced Nursing, 22, 721-730
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'vague promises and relaxed standards' it may leave the organization with a comfortable feeling that the issues are being addressed. The fact that public consultation may be nothing more than 'tokenism' in some areas has been suggested by Wistow et al. (1992). In their analysis of 22 English com- munity care plans, it was discovered that, where consul- tation had been employed, methods differed considerably across regions. Importantly, the extent to which the results of the exercises had influenced the completed strategy documents and service specifications was far from clear, nor were there distinct evaluative accounts ofhow satisfac- tory the process had been. Respondents in Cowley et al.'s (1994) study were not uniformly convinced that their views were respected, either at an individual level, or as part of a service planning exercise. Indeed, Richardson et al.'s (1992) findings support this 'powerlessness' per- spective and highlight the consumer's dilemma, by indi- cating that most respondents in their survey felt they were unable to influence decisions in health care, despite wel- coming the opportunity. Studies are now emerging that document participant's frustration at the lack of feedback and positive action following consultation (Southampton and South West Hants Health Commission 1993). Paradox It is within this context that the true paradox of community needs assessment occurs. Critics of the community care reforms have argued that without a substantial increase in resources, assessment of needs, however it is undertaken, becomes an almost meaningless exercise, since the ser- vices and support required by the population will not be available (Cornwell 1992, Jack 1992). The more compre- hensive the assessment, the more inevitable the possibility that a plethora of social needs will be revealed that providers are unable to act upon, resulting in universal disillusionment (art 1985b, Twinn et al. 1990). Cheetham (1991), whilst urging local authorities to use the results of assessment as a means of exposing uninet need and 'social ills', acknowledges the political risks involved if the shortfall between planned services, needs identified and resources available were laid bare. Phillips et al. (1994) add that for care agencies to fully encompass the notion of consumerism is to make demands that both the public and professionals are unable to meet. It is there- fore not surprising that superficial data collection and interpretation may become the preferred option. FURTHER CONSIDERATIONS IN NEEDS ASSESSMENT Thus, whilst the consumer perspective is becoming a necessary focus of needs assessment within a locality, investigation into its components has revealed consider- able methodological and political restraints. Indeed, the whole issue of community needs assessment, arguably a fundamental component of 'care in the community', appears to necessitate substantial and disproportionate resource allocation on the part of community agencies. Little guidance for undertaking this task within policy documents and the literature is apparent and, although policy appears to have largely pinned its hopes upon greater collaboration between community agencies and consumers, health care professionals are becoming increasingly unsure about their own organization's ability to realize this potential (Higgens 1992). Indeed, Stalker (1993) points out that the changes required on the part of community agencies to undertake this task, in terms of activity and skills, are often under-estimated and only fully realized once assessment is underway. For example, training staff is essential to facilitate their transition from 'assessor' to 'assessed' (Hudson 1992), and in helping them to cope with the cultural shift of power to the consumer (Higgens 1992), a change that cannot occur overnight. Also, as the ultimate approach to needs assessment may depend upon the prevailing philosophy of a locality, vari- ations between districts may render cross-comparison impossible. It could be argued that effective nationwide implementation of 'care in the community' may thus be problematic to audit. Selecting the most suitable approach is only the first step, and Cheetham (1991) emphasizes the importance of consideration in this initial stage, as future community plans may hinge upon comprehensive and sound community needs assessments. But, as Stevens & Gabby (1991) point out, producing facts and figures to pro- vide a comprehensive picture, coupled with staff training and development, are lengthy procedures, in contrast to the headlong rush to agree contracts. They continue by declaring the fear that needs assessment is being put to one side, and that the logical sequence of needs identifi- cation, service specification and contracts may be reversed. CONCLUSION In conclusion, this literature review has attempted to debate definable, methodological, ethical and contextual factors surrounding community needs assessment, high- lighting the multi-dimensional difficulties surrounding its compilation. The issues raised have been projected within the current political climate, and have recognized its strongly influential nature concerning community needs assessment. This arena served to highlight the inherent paradoxes and dilemmas within the needs assessment pro- cedure. It has also attempted to highlight the potentially vital position of community nurses regarding data sources, which has yet to be fully recognized and taken advan- tage of. In general, it must be stated that needs assessment literature tended to be characterized more by assumptions, © 1995 Blackwell Science Ltd,Journal of Advanced Nursing, 22, 721-730 727
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S. Cowley predictions and for the most part, speculative rhetoric, rather than sound evaluative research, due possibly to its emergent nature. However, the difficulties associated with community needs assessment, coupled with its continued high political profile, dictate to a large extent the protrac- ted but welcome appearance of needs assessment deliber- ation within health-related literature, necessary to increase awareness among professionals in the community involved in these processes. References Antonovsky A. (1987) The salutogenic perspective -- towards a new view of health and disease. Advances 4(3), 47-55. Arber S. (1987) Gender and class inequalities in health: under- standing the differentials. In Inequalities in Health within Europe (Fox A.J. ed.), Gowar, Aldershot. Ashley J. & McLachlan G. (1985) Mortal or Morbid? A Diagnosis of the Morbidity Factor. Nuffield Provincial Hospitals Trust, London. Avis M. (1994) Satisfying solutions: a review of issues in measur- ing patient satisfaction. Paper presented at the RCN Annual Research Conference, Hull, April. [Available from Royal College of Nursing, London.]. Becker H. (1967) Whose side are we on? Social Problems 14, 241. Bebbington A.C. & Davies B. (1980) Territorial needs indicators: a new approach. Journal of Social Policy 9(2), 145-168. Bell I. (1993) Less impertinence, more partnership. Health Visitor 66(10), 370-372. Benson J. (1976) The concept of community. In Talking About Welfare (Timms N. & Watson D. eds), Routledge & Kegan Paul, London. Blaxter M. (1990) Health and Lifestyles. Routledge, London. Bowling A. (1992) "Local Voices' in Purchasing Health Care:An Exploratory Exercise in Public Consultation on Priority Setting. Needs Assessment Unit, St Bartholomew's Hospital Medical College, London. Bradshaw J. (1972) The concept of social need. New Society 30, 640-643. Bryan S., Parkin D. & Donaldson C. (1991) Chiropody and the QALY: a case study in assigning categories of disability and stress to patients. Health Policy 18, 169-185. Buchan H. & Gray J.A. (1990) Needs assessment made simple. Health Service Journal, 100, 240-1. Cernik K. & Wearne M. (1992) Using community health profiles to improve service provision. Health Visitor 65(10) 343-345. Chase H.D. &Davies P.R.T. (1991) Calculation of the underprivi- leged area score for a practice in inner London. British Journal of General Practice February pp. 63-66. Cheetham J. (1991}Community care: bridging the gap. Community Care, 870, 24-25. Clode D. (1992) Best laid plans. Community Care, 39th April. Colin-Thome D. (1993) The public health nurse: a new model for health visiting? Primary Care Management 3(5) 4-6. Coronary Drug Project Research Group (1980) Influence of adher- ence to treatment and response of cholesterol in the coronary drug project. New England Journal of Medicine, 303, 1038-41. Cornwell N. (1992) Assessment and accountability in community care. Critical Social Policy 36 (4052) 42-52. Council For the Education and Training of Health Visitors (1977) An Investigation into the Principles of Health Visiting p.9. Council for the Education and Training of Health Visitors, London. Cowley S. (1993) Skill mix: value for whom? Health Visitor 66(5) 166-8, 171. Cowley S. & Billings J.R. (1994a) Family health needs project report. Unpublished report, Primary Health Care Development Fund, Kings College London, London [Available from Department of Nursing, King's College London.]. Cowley S. &Billings J.R. (1994b) A community profile of Hastings: Phase 1 of the family health needs project. Unpublished report, Primary Health Care Development Fund, Kings College London, London. Cowley S., Bergen A., Young K. & Kavanagh A. (1994) The chal- lenging nature of needs assessment in primary health care. Paper presented at the Fourth International Primary Health Care Conference, London. [Available from Department of Nursing, King's College, London.] Culyer A. J. (1976) Need and the National Health Service. Martin Robertson, London. Day L. (1992) Promoting the health visiting profession. Health Visitor 65(8), 270-272. Department of Environment (1983) Urban Deprivation: Information Note no. 2 From the Inner Cities Directorate. HMSO, London. Department of Health (1989a) Working For Patients. HMSO, London. Department of Health (1989b) Caringfor People: Community Care in the Next Decade and Beyond. HMSO, London. Department of Health (1989c) The Role of the District Health Authority. HMSO, London. Department of Health (1990) Caring for People: Implementation Document -- Assessment and Case Management. HMSO, London. Department of Health (1991) The Health of the Nation. HMSO, London. Department of Health (1993) Implementing Community Care: Population Needs Assessment, Good Practice Guide. HMSO, London. Department of Health and Social Security (1988) Public Health in England: The Report of the Committee of Enquiry Into the Future Development of the Public Health Function. HMSO, London. Donaldson C. &Mooney G. (1991) Needs assessment, priority set- ting and contracts for health care: an economic view. British Medical Journal 303, 1529-1530. Drennan V. (1988) Health Visitors and Groups: Politics and Practice Heinemann Nursing, Oxford. Drennan V. (1990) Gathering information from the field. Nursing Times 86(39), 46-48. Dunnell K. &Dobbs J. (1983) Nurses Working in the Community. HMSO, London. Forrester P.H. (1991) Assessing health information needs. In Promoting Choice: Consumer Health Information in the 1990s. Consumer Health Information Consortium, Loughborough University, Loughborough. Foy C., Hutchinson A. & Smythe J. (1987) Providing census data for general practice. 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A., Scott T. & Thomas D.N. (1975) A Guide to the Assessment of Community Needs and Resources. National Institute of Social Work, London. Gooch S. (1989) The health visitor's influence: imperatives for change. Nursing Standard 25 October, 4-5. Goodwin S. (1988) Whither health visiting? Keynote speech to the Health Visitors' Association Annual Study Conference. Health Visitors' Association, London. Goodwin S. (1992) Community nursing and the new public health. Health Visitor 65(3), 78-80. Goodwin S. (1994) Purchasing effective care for parents and young children. Health Visitor 67(4), 127-129. Harris J. (1987) QALYifying the value of life. Journal of Medical Ethics 13, 117-123. Harvey J. (1994) Assessment of Population Health Needs. Paper presented at the RCN Public Health Conference, London, July. RCN, London. Higgens R. (1992) Consumerism and participation. Senior Nurse 12(5), 3-4. HMSO (1993) Citizen's Charter (ref. CM 2290). HMSO, London. Hubley J. 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