Joumal of Advanced Nursing, 1995, 22, 721-730

Approaches to conmiunity needs assessment: a literature review

Jenmfer Ruth BiUmgs BSc(Hons) RGN RHV DPNS Research Assistant

and Sarah Cowley BA PhD PGDE RCN RCNT RHV FWT HVT Lecturer, Department of Nursing Studies, Kings College London, London, England

Accepted for pubhcation 1 December 1994

BILLINGS J R & COWLEY s (1995) Journal of Advanced Nursing 22, 721-730

Approaches to community needs assessment: a hterature review In the light of the growmg 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' from the diffenng perspectives of three dommant approaches, namely sociology, epidemiology and health economics It contmues by puttmg 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, m 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 aoid problems concerning aggregation of the numerous data sources mto meaningful pohcy 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 mtegrated into the arguments where appropnate

and applicabon of needs assessment by reaffirming its importance as a means of determmmg the provision and

Needs assessment has always been a pnonty issue for extent of health eare As a result, this so-ealled 'needs-led' those eoneemed with eommumty health, but it WEIS the style of planning signals a departure from previous publieabon of the Aeheson report whieh led to a approaehes, which were predommantly serviee-led resurgenee of interest, proposing as it did that direetors of (Stalker 1993) Community needs assessment has been pubhe health should be responsible for assessmg the needs defined simply as 'a desenption of those faetors whieh of their loeal populabons (Department of Health and must be addressed m order to improve the health of the Soeial Secunty 1988) Since this proposal, successive populabon' (Harvey 1994) Department of Health (England) papers (1989a, 1989b, Although needs assessment was imbally seen as the 1990, 1991, 1993) have broadened the professional scope pnmary responsibility of potential purehasing and

eommissiomng authonbes, and neeessary to inform the Correspondence fenniferR Billings Department of Nursing King's eonbraebng proeeSS (Deparbnent of Health 1989c), Com- CoUege London, Cornwall House Annexe Waterloo Road, London SEl mumty provider units are now recogmzing the unportant 8TX, England contnbubon they can make towards the ldentificabon of

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fR Billings and S Cowley

local population needs, particularly through the work of commumty nurses (Day 1992, Goodwm 1994) A recent report concerning the progress of the Health Visitor Markebng Project mibated by the National Health Service Executive (NHSE 1994) also emphasizes that purchasers recognize the central role potentially held by health visi- tors m accumulabng informabon about health needs in the population, and require that this service be incorporated into service specificabons

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 commumty nurses, but has always been a central feature of commumty 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 Traming of Health Visitors specified in 1977 that the search for health needs and a sbmulation of their awareness were to be principle objectives withm health visiting practice Considenng the challenges of today's practitioners, such as increasing social depnvabon and poverty (Blaxter 1990), inequalities m health (Philhmore et al 1994) and the growing morbidity and mortality from heart disease and ADDS (Department of Health 1991), these pnnciples are as relevemt today as they were for conununity nurses m the 1970s (Twmn & 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 govemment legislation (Buchan & Gray 1990) The complex, multi-dimensional nature of needs assessment has been revealed, and those health care managers and practiboners who have launched into this field are realizing that the task is far from straight- forward Defining what is meemt by 'needs' is a case in hand Orr (1985a) provides an initial mterpretabon that reveals the multiple meanings attached to the concept, defimng need as 'social, relative and evaluative', social m being defined accordmg to standards of communal life, relative m that its meaning will vary between people and societies, and evaluabve m that it is based upon value judgements The difficulbes of operationahzmg these notions for assessment purposes becomes apparent

In a broader perspecbve, sociologists, epidemiologists emd health economists have each defined needs from their own standpoint Generally, the sociological view is exem- plified by Bradshaw (1972), whose taxonomy of formabve need, felt need, expressed need and compeirabve need remains cogent m health care, distinguishing as it does the important differences between needs as identified by pro- fessionals (normabve) and those 'felt' by the individual The influence of Bradshaw is also evident in community

nursing, where tbe concept of need is perceived as per- sonal, subjecbve and vanable (Orr 1985b, Twmn & Cowley 1992) This perspective does, however, raise issues concerning the difficulty of forming clear and comparable cntena for needs assessment

Buchan & Gray (1990) argue that qualitabve definitions of need tend to be nebulous and of little help m determin- ing appropnate levels of service requirement In a study of social welfare provision, for example, Thayer (1973) concluded that tbe 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 operabonahzed in a meanmgful 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

IVaditional epidemiological approach

The tradibonal epidemiological approach to needs assess- ment has been to use morbidity and mortality data to meas- ure the total amount of ill health m the community, and then use this information to set pnonbes 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 m a similar fashion, based upon census data Vanables such as numbers of single parents, elderly people living alone, famihes with pre-school children and ethnicity are measured, combin- ing social and material depnvabon into a composite index This ultimately provides a means of scoring and remkmg areas according to their degree of relative disadvantages or affluence (Jarman 1984, Townsend ef al 1988)

These approaches have the potenbal 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 ldenbfication 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 m contrast to previous perspectives, defimng 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 relabve and can be 'traded off' against each other, given limited resources (Culyer 1976, Donaldson & Mooney 1991) With the assumption that the objecbve of health care policy is to maximize the contnbution of health care resources to the health of the community, defined m terms of quality adjusted hfe years (QALYs), it is argued that more resources withm the health care budget should be

722 11995 Blackwell Science Ltd, foumal of Advanced Nursmg, 22, 721-730

Commamty needs assessment

allocated to treatments with a low margmal cost per QALY and less to those with a high mai^inal cost per QALY gamed Bryan et al (1991) give the example of expandmg a commumty chiropody service whilst contracbng home dialysis, as more QALYs would he produced without any mcrease m expenditure

Proponents of this approach state that it does not require any assessment of total needs, and that the key concept is getbng the greatest benefit for each pound spent (Williams 1987) Although the economic viewpomt may rationalize service provision in a 'cut and dned' fashion, it is not difficult to lmagme that the perspective has been strongly cnbcized for its unethical stance, neglecting as it does con- sumer views and issues relatmg to mamtenance of quality of life in illness (Hams 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 m Bryan et al's (1991) paper For this reason, those health care professionals unfamiliar with the language may be overly cnbcal or dismissive of the approach

Notwithstanding the ambiguities surrounding differing mterpretabons of need, defining what is meant by 'com- munity' and 'population' withm 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 m a descnptive, evaluabve and emotive manner, making precise definition arduous, a view shared by Benson (1976) Regardmg populabon, commumty agencies are expected to set out the needs ofthe populabon they serve (Department of Health) Stalker (1993) quesbons whether the term refers to existmg service users, potential service users, or the totality of residents m a region

THE COMMUNITY HEALTH PROFILE

Thus, attempting to identify commumty needs withm a population against this complex and mulb-faceted back- drop IS an enormous task for professionals However, an approach that is gaining increasing mterest and appli- cabon IS the development of an area or community profile, which mcorporates the sociological and epidemiological perspecbves outlined The concept is not new, and has been adopted cis part of determining social policy objec- bves m 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 m that It combines quanbtabve data, such as demographic infor- mabon, epidemiological data and indicators of depn- vation, with quahtabve data, such as informabon from health care professional caseloads and individual assess- ments (Richards 1991)

CoUaborabon between and amongst professional groups

and agencies in the community is strongly advocated (Twinn et al 1990, Cemik & Weame 1992) and is thought to have considerable benefits P^kham & Spanton (1994) state that commumty nurses can build local networks and alliances with groups and individuals, mcreasmg their understanding and awareness of local issues, and adapbng work pnonbes accordingly Advocates of the profile stress Its value m providing a comprehensive and rounded picture of populabon needs for health care, giving a more accurate indication for health service provision, and highlighbng mis-matches between need and health care delivery (Klein & Thomlinson 1987, Snee 1991, Cemik & Weame 1992)

The potential contnbubon that community nursing mformation 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 m 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 weighbng system for distnct nursmg caseloads (Drennan 1990) and the ldenbfication of levels and types of nursmg needed (Hugman & McCready 1993) In a family health needs study currently bemg undertaken by Cowley & Billings (1994a), a comprehensive commumty profile has been used to form the foundations of a semi-structured interview schedule for ascertaimng client need This infor- mation will subsequently be used to form a model for identifying health visibng 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 compilabon, 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 bme emd resources needed to complete a profile would be beyond the scope of most hard-pressed practiboners (Twinn et al 1990) From a research perspective, profiling IS plagued with difficulbes conceming the ldentificabon of an appropnate 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 descnpbon of how broad census data are aggregated with individual perspectives, which renders the denvabon of findings, conclusions and ulb- mately action difficult to comprehend m some studies

Cowley & BiUmgs (1994a) are, however, usmg a case study approach to profiling (Yin 1989), which allows for the development of a case descnpbon through a

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JR Billings and S Cowley

pattem-matchmg of themes identified withm the vanous data sources This strategy allows for the complexity of commumty profile mformation to be descnbed in terms of needs ldenUfication, and permits potenUally meaningful aggregation of data across its diffenng methodological types The dilemmas of data aggregaUon au-e further explored when discussmg the consumer perspecUve

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 rairely questioned for reliability or validity determmants To illustrate this point, the use of 1991 census matenal to determine a range of population charactenstics 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 m themselves causes, nor necessanly mdicators of need (Stalker 1993) Robmson (1985) and Orr (1985b) argue that such classifications may lend them- selves to professionai stereotyping regarding needs assess- ment, rather tham recognizing individual vatnation within the categories

Census data also contmue to request information regard- ing the 'head of the house' upon which to base social class position This IS still lairgely completed as the male partner m a 'couple' household for most situations, despite diffenng economic activity between partners (Office of Population Censuses and Surveys 1992) McDowall (1983) highlights the shortcomings of this approach, particularly m 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 secUons of the populaUon may be hidden or over- estimated using this classificaUon

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 (Osbom & Moms 1979), which was intended to be more in tune with the home environment of the child than occupaUonal 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- tribuUon of its results The present availability of small area population statisUcs (electoral ward and enumeraUon distnct) has facilitated planners in identifying need, but it does not assist the GP-attached practiUoner whose popu- laUon may span a wide geographical area with three or

four fomilies per ward (Young & Hajnaes 1993, Cowley & Billings 1994b) This ai^ument highlights the difficulUes aissociated with 'goodness of fit' of the vanous data sources, which is a recurrent obstacle regarding meammg- ful profile compilaUon However, the case study approach as previously described may overcome this problem to some extent

Further to this, the appairent under-representaUon of smgle people aged 16 to 44 m companson with the 1981 census has also caused speculaUon regarding the reliabihty of data m this group, particularly concerning potenUal poll tax evasion (Office of Population Censuses and Surveys 1992) This has obvious lmplicaUons concern- ing the accuracy of ldenUfymg needs Also, census data become very rapidly out-of-date, assuming that they were accurate m the first place, a feature that hounds all 'snapshot' populaUon information (Stalker 1993)

Social inequality and deprivation

Moving now to measures of social mequality and depn- vation — as stated most have been welcomed as an import- ant adjunct to esUmatmg the health of a populaUon (Whitehead 1987, Stalker 1993), but there are singular problems attached to their measurement For exaunple, 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 withm a housing estate, for example, that is situated m an area of relaUve affluence may be masked However, enumeraUon data fi-om the census may now largely overcome this problem, by giving specific house number information Whitehead (1987) remarks that some indices combine direct indicators of depnvaUon, such as overcrowding and unemplojrment, with indirect measures of numbers of people 'at risk' of deprivation (l e single- parent families or ethnic mmoriUes), where, as previously menUoned, not all people are deprived m these groups

Townsend et al (1988) have highlighted contradicUons between scores when mdices are monopolized by highly skewed vanables such as ethmcity, for example, the Depaatment of the Environment's (1983) and Jarman's (1984) indices discovered that the most deprived local authority areas were m London, with none m the north of Englamd Townsend et al's (1988) own observaUons record the converse to be more the case However, this problem may be overcome by choosing only indicators of matenal depnvaUon such as the proportion of households with no car, and unemployment (Townsend et ai 1985), by employing more sophisticated statisUcal techmques (Wagstaff et al 1991), or by using 'grass root' surveys to check and extend the statistical results (Thunhurst 1985)

Acquirmg epidemiological evidence hsts largely

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Community needs assessment

depended upon morbidity and mortality data Stevens & Gabby (1991) argue that an epidenuologically sound assessment of needs is a vital inclusion to any profile and the ulbmate 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, Patnck (1986) observes that these statisbcs have lost their importance m assessing a popu- lation's health He adds that this is parbcularly so when death rates are low, as by lmphcabon the majonty of the population remain alive in varymg states of health Wilson (1981) adds that the increase m chrome conditions and the development of medical treatments to prolong life, such as renal dialysis and insulin therapy, have contnb- uted to the decreasing value of this data

Thus informabon relating to the prevalence of disease would appear to have greater potential applicabon to needs assessment (Mays 1987) Stalker (1993), however, urges for morbidity rates to be translated with caution, supporting cntics of census and depnvabon data by statmg that incidence must not be confused with actual need Inconsistencies m measurement also abound, par- bcularly in relation to mental health McCollam (1992) discovered that incidences of mental health problems are obtained m a vanety of different ways, and that diffenng methods used m one area produced competmg perspec- bves of mental health prevalence On the other hand, Bebbington & Davies (1980) acknowledge the difficulbes in reaching consensus regarding cntena for measurement, and suggest that attempts to develop nabonal 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 mformabon can be hmited to the ability of hard-pressed pracbce staff to process and enter the data, and can vary between practices rendenng companson difficult (Cowley & Billings 1994b)

However, a lateral perspective that cnticizes the some- what iromc 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 setbngs or hospitals where a select group of the population with certain ahnormalibes and diseases are investigated Rijke goes on to argue that focusing upon disease groups to esti- mate populabon needs is not profitable, as very little is known in medical science ahout the natural history of diseases in the general public (Lorber 1980, Nelson & Ellenberg 1982) Rijke (1993) asserts that there is an assumpbon that the occurrence of a disease is determined by a causal factor(s), and that the elimination ofthe disease IS achieved by medical mtervenbon or lifestyle changes He a i^es that reducing certam factors does not necessanly lead to better health when applied to larger populabon groups, especially in relabon to cardiovascular disease (Coronary Dmg 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 pomts to factors such as autonomy, vitality and social suppmrt as being essenbal to the reduced frequency of physical com- plaints cmd illness, and maintenance of a sense of well- being (Rijke 1985, Antonovsky 1987, Rohe & Kahn 1987) Not only has this perspective profound implicabons for the nature of current health educabon and promobon pro- grammes, which work from a perspecbve 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, hy intimation, be enhanced rather than eroded

CONSUMER PERSPECTIVE

Having now debated some of the issues conceming the accumulabon 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 restncted m providing a picture of health needs, limited as It IS at present to the collecbon and collation of existing informabon from a service perspective (Peckham & Spanton 1994) Consultation, however, appears to be an aspect of planning that is attracting considerahle interest, offenng 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 bndgmg the gap hetween the 'micro' and 'macro' levels of health estimabon (Stalker 1993) Cnticism has been directed against health C£u« pro- fessionals for settmg the health agenda without consulbng 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 nobon of consul- tation about health needs The current wave of con- sumensm m health and social circles has, however, not occurred due to the sudden development of socially con- scious managers Phillips et al (1994) state that the govem- ment's policy of controlling public expenditure and encouraging a mixed economy of care has introduced a strong element of enterpnse culture into public service organizations Central policy thus demands greater choice and independence for service users, evidenced by their publications (Department of Health 1990, Nabonal Health Service Management Execubve 1992)

Reviewing the vanous approaches to consultabon. Bowling (1992) highlights numerous ways in which this

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JR BillmgsandS Cowley

ean be aehieved, namely eonsumer feedbaek via forums and pubhe meebngs, and eonsumer representabon on user-groups Local interview, postal or telephone surveys of views and sabsfaction surveys have also been used (Roberts & Magowan 1994) Bowling (1992) adds that observation techniques ean also be applied m eare settmgs where elients find diffieulty m expressing views The use of focus groups has also been advocated as a valuable method of explonng perceptions of need (Morgan 1993), and indeed has been enlightening when used m this con- text, mdicabng consumer awareness of their contnbubve strengths and limitations m the needs assessment proeess (Cowley efa7 1994)

Methodological difficulties

Consultation is, however, not without its methodological difficulties Focus groups, for example, are generally eharaetenzed by small numbers, which raises quesbons regarding the ulbmate reliability of the results, as evi- deneed by Cowley et al's (1994) paper To overeome this problem, some studies have used a eombination of teeh- niques to obtain a more eomprehensive pieture of eon- sumer need (Judge & Solomon 1992) Also, the eonstraints of sabsfaetion surveys have long been reeognized, relating parbeularly to tbe validity of eurrent methods of oper- abonalizing the eoneept of elient sabsfaetion (Avis 1994) A faetor eommon to all approaehes to consultation eon- eems reliability of sample seleetion Rodgers (1994) and Bowlmg (1992) suggest that, where researehers do not stnve to gam equity of response, there will be a tendeney for the more artieulate, less burdened consumer's voice to be heard loudest Consultation therefore has the potential to remforee inequalities m serviee provision, rather than address them

However, obtaining the views of 'quieter' secbons of the populabon has its constraints In a eommumty projeet based in Stirling, the needs of a sample of elderly people were obtained witb the aid of a sehedule (Hudson 1992) Pnor to the assessment, a 10-point quesbonnaire was eompleted by the referrer, mdieatmg the degree to whieh the elderly person was pereeived to be 'in need' Hudson (1992) doeuments the diffieulties expeneneed by elderly people, who found expression of need arduous and con- sistently hnked need to availability of resources This was m eontrast to the referrer's percepbons, which gener- ally identified mulbple needs among the sample regard- less of available serviee provision Further eomplieabons were revealed in this study regarding the tension between the carer's needs and those of the elderly person Decisions regarding whose needs would dnve the care plans thus became difficult The study highlights some important issues surrounding the complexibes of needs assessment, but it is lacking in det£ul regarding sample numbers, questionnaire and sehedule details, rendering

the researeh diffieult to appraise for methodologieal ngour

Onee data from the eonsumer have been eompiled by a chosen method, eonsiderabon must be given to their syn- thesis with broader health informabon mto loeal pohey, a diffieulty highlighted earlier In an analysis of eommumty plans, Riehards (1991) noted that while most emphasized the lmportanee of aggregation of data, few praebeal pro- posals for aehievmg it were made This beeomes mereasmg sigmfieant when eonsidenng the depth of informabon obtamed by eommumty nurses through mdividual needs assessment Ineorporabng sueh information mto meaning- ful poliey statements ean be onerous For example, unless the total population withm an area ean be targeted, bias may be an inevitable eonsequenee and 'felt' need never fully identified (Stalker 1993)

Conversely, rendering the needs of mdividuals mto meaningful eomponents for pohey determmabon may neeessitate a radieal aggregation of felt need, so a tnie pie- ture may n

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