Overview

The first phase in health promotion planning is an assessment of what a client or population group needs to enable them to become healthier. Health care usually takes the individual as its starting point. Public health concerns the health and welfare of people in groups. Practitioners do not assess individuals in isolation from the communities in which they live. As we have seen in previous chapters the health experiences of individuals are affected by where they reside. The local knowledge of practitioners about the range of local services, facilities and networks is an important part of needs assessment. Within a neighbourhood there will be people in settings such as schools and workplaces and population groups with specific health needs. Practitioners need to know how to assess individuals, how to manage their care and how to encourage healthier lifestyles. They also require an understanding of people’s ways of life and the health problems and opportunities they experience and they need to know how to use this understanding to assess the needs of people in groups systematically. The term needs assessment describes the process of gathering information. It has been defined as a ‘systematic method of reviewing the health needs and issues facing a given population leading to agreed priorities and resource allocation that will improve health and reduce inequalities’ (Cavanagh & Chadwick 2005). The purpose of health needs assessment at national, regional or local level is twofold:

1. To identify which actions to improve health should have greatest priority

2. To choose which particular groups or communities should have priority and so help in targeting interventions and commissioning services.

Recognition of the right to participate in defining health needs and health care was acknowledged in the 1978 World Health Organization (WHO) Alma Ata Declaration, and one of the underlying principles of Health For All is community participation (WHO 1985).

National Health Service (NHS) reforms have emphasized the participation of local people in setting priorities, signalling a philosophical shift from a paternalistic medical model to a participatory consumer-led model. This chapter considers the ways in which local health needs are assessed and applied in planning for health promotion. It should be read in conjunction with Chapter 3, which outlines the principal sources of information about health status.

Defining health needs

The concept of need is widely used but often not well understood. People may believe they ‘need’ a new coat because someone observed that their old one is worn out, or because it looks old compared to other people’s coats, or simply because they would like one. A need may thus be something people want or something that is lacking in comparison to others.

BOX 18.1

How would you distinguish between a need, a want and a demand?

There are two different understandings of what constitutes a health need. It can be seen as:

1. A subjective, relative concept which is judged by an expert or professional and is influenced by whether the need can be met

2. An objective and universal concept which is a fundamental right.

BOX 18.2

Make a list of 10 important human needs:

• Are some more fundamental than others?

• Are these needs relative to a particular country or are they universal?

Economists tend to avoid the use of the term needs altogether, arguing that it is overlaid with emotion and what is really meant by a health need is actually a matter of people’s wants and demands, and these are limitless (Cohen 2008). Identifying health needs is therefore a question of identifying priorities.

An alternative view is that there are universal needs. Maslow’s hierarchy of needs (Maslow 1954) suggests that all human needs are in fact health needs (Figure 18.1).

Figure 18.1 Maslow’s hierarchy of needs.

For a person to be self-actualizing, physical, social and emotional needs must be met. Doyal & Gough (1992) have similarly argued that the ultimate goal of human beings is to participate fully in society and to do this the basic needs for physical health and for autonomy must be met. These needs are not relative to a particular country or period of time but are fundamental rights and include the prerequisites for health – peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity (WHO 1986). But these needs are not undisputed. How healthy do people have to be before we can say that their needs have been met? Bradshaw (1972), in a widely used taxonomy, distinguished four types of health and social need:

1. Normative needs, as defined by experts or professional groups

2. Felt needs, as defined by clients, patients, relatives or service users

3. Expressed needs, when felt needs become a demand

4. Comparative needs, identified when people, groups or areas fall short of an established standard.

Normative needs

Normative needs are objective needs as defined by professionals, who also identify the ways in which these needs can be met. A normative need reflects a professional judgement that a person or persons deviate from a required standard. This may be against some external criteria such as occupational or legal requirements. Thus the manager of a restaurant is in need of training because she has not completed a course in food hygiene. Or it may be that a person deviates from what is defined by medical staff as the range of ‘clinically normal’ physiological indicators.

BOX 18.3

Normative need: child development

A health visitor decides that, according to a growth chart, an infant has failed to gain weight for some time and has fallen below the third centile. She deems the infant to be in need of supplementary feeding and suggests this is done by additional bottle-feeding. Yet expectations of child development vary according to the place and time. This infant would not be regarded as failing to thrive in the USA or in pre-war UK.

Normative needs are not absolute or objective ‘facts’ – they reflect the judgement of professionals which may be different from that of their clients. Health care workers will judge a need relative to what they are able to provide. The ability to judge normative needs also contributes to the notion of professionalism and the authority and status of professionals.

Felt needs

Felt needs are what people really want. They are needs identified by clients themselves which may relate to services, information or support which can be termed service needs. Moves towards bottom-up approaches in health and social care have meant a greater acceptance of service users’ views. (Chapter 6 in our companion volume (Naidoo & Wills 2005) discusses some of the policy drivers to patient and public involvement.) Needs may be limited by the perceptions of an individual. Individuals may not believe themselves to be in need simply because they do not know what is available in terms of treatment or services.

This is an example of a need identified by professionals. No consultation was involved. The intervention was planned in the expectation that it would result in a saving of GP time, not as part of a programme to prioritize infertility. The intervention was poorly presented with no marketing, and no attempt to make it accessible for clients.

Expressed need

Expressed need arises from felt needs but is expressed in words or action – it has become a demand. Thus clients or groups are expressing a need when they ask for help or information, or when they make use of a service. Expressed need is often used to measure the adequacy of service provision, even though it is not a comprehensive or complete measure. There are also objective needs which exist but are not expressed. Only a proportion of patients make contact with health services and they are merely the tip of an iceberg of potential need, as illustrated in Figure 18.2.

Figure 18.2 Iceberg of health care needs.

Sometimes people will use a service because it is all that is available, even if it does not adequately meet needs. The best example of expressed need (and unmet demand) is the waiting list. Some needs are not expressed, perhaps because of an inability or unwillingness to articulate the need. This could be due to language difficulties or a lack of knowledge. Expressed needs should not be taken as an indicator of demand because they also exclude needs which are felt but not expressed. Tudor Hart’s inverse-care law has been of vital importance in showing that just because a service or treatment is used less does not mean that it is needed less (Tudor Hart 1971). Those who could most benefit from a service are often those least likely to use it. People may express different needs, and there is a tendency to listen to those with loud and powerful voices, such as views which come from an established group or views which appear to express a popular need. Responding to expressed needs may also therefore have the effect of increasing inequalities in service provision.

Comparative needs

Individuals or groups are said to be in need if their situation, when compared with that of a similar group or individual, is found wanting or lacking with regard to services and resources. For example, if a person with schizophrenia in area A was living in sheltered accommodation and receiving day care, but in area B this was not available, we would say that schizophrenics in area B were in need. In the NHS, although people may be assessed to be in absolute need (normatively), in practice comparative needs assessment will often dictate whether their needs will be met. Areas may be compared on the basis of provision of services or length of waiting lists to see if the health needs of their populations are being met. In a sense, then, comparative need is about equity. It is about equal provision for equal need. This kind of analysis of need does, of course, assume that those in receipt of a service are receiving adequate provision and that their needs are being met.

Bradshaw’s work (1994) is useful in showing that different groups in society hold different definitions of need. We can see that needs are not objective and observable entities to which we must just match our interventions. The concept of need is a relative one and is influenced both by values and attitudes and by other agendas.