Chapter 6. Identifying health promotion needs and priorities
Concepts of need78
Need, demand and supply79
Identifying health promotion needs79
Finding and using information81
Assessing health promotion needs83
Setting health promotion priorities84
This chapter begins with an analysis of the concept of need. This is accompanied by an overview of essential factors for you to consider when identifying health promotion needs. These include the scope and boundaries of professional remits; the difference between reactive and proactive choices and the importance of placing the people who are the targets and users of health promotion at the centre of the needs identification process. This discussion is supplemented with an exercise on the user friendliness of services. In the next section on finding and using health information, types and sources of information are identified and exercises included on gathering and applying information. This is followed by a framework for assessing health promotion needs, with a case study and an exercise. In the final section there is a focus on priority setting, with exercises on analysing the reasons for health promotion priorities and on setting priorities.
Many organisations at different levels have a role in identifying public health needs, including those needs that can be addressed by health promotion interventions. These range from international agencies, such as the World Health Organization (WHO), national organisations, such as government departments, to organisations at local level, such as primary care trusts (PCTs).
See Chapter 4 for information on the range of agencies with a public health and health promotion role, Chapter 7 for national and local health strategies, and Chapter 16 for making and implementing national and local health strategies.
The focus in this chapter is on the need for interventions undertaken by health promoters working with individual clients, families, groups and communities.
Identifying the people who are intended to benefit from health promotion activities (sometimes called target groups) is a complex process. These people may be referred to as users, which imply they use health promotion services such as smoking cessation groups. In some cases people receive help that they may or may not use, for example receiving advice and information leaflets. Alternatively, people may be called consumers, customers, clients or patients if they are receiving their health promotion via medical services, such as a coronary rehabilitation service. Positive action may be necessary to ensure that everyone has equal access to services and can benefit from them.
Going one stage further and identifying and prioritising people’s needs is also a complex and difficult process. Needs may exceed the finite resources available to meet them so difficult choices may have to be made.
Before looking further at how the needs of the users and receivers of health promotion can be met, it is worth considering what is understood by a need.
Concepts of Need
It is useful to think of need in terms of:
• the kinds of health problems which people experience or are at risk from
• the requirements for a particular kind of health promotion response
• the relationship between health problems and the health promotion responses available.
Bradshaw’s (1972) taxonomy of need was established many years ago but it is still very useful in distinguishing between four different kinds of need.
1. Normative Need – Defined by the Expert
Normative need is a need defined by experts or professionals according to their own standards; falling short of those standards means that there is a need. For example, a dietitian may identify a certain level of nutritional knowledge as the desirable standard for her client and defines a need for nutrition education if her client’s knowledge does not reach that standard. This normative need is based on the judgements of professional experts, which may lead to problems. One is that expert opinion may vary over what is the acceptable standard, and the values and standards of the experts may be different from those of their clients.
2. Felt Need – Wants
Felt need is the need that people feel; it is what they want. For example, a pregnant woman may feel the need for (and want) information about childbirth. Felt needs may be limited or inflated by people’s awareness and knowledge about what could be available: for example, people will not feel the need to know their blood cholesterol level if they have never heard that such a thing is possible or know about the potential risk of high blood cholesterol levels to health.
3. Expressed Need – Demands
Expressed need is what people say they need; it is felt need that has been turned into an expressed request or demand. Commercial weight-control groups and exercise classes are examples of expressed need; they are provided in response to demand.
Not all felt need is turned into expressed need or demand. Lack of opportunity, motivation or assertiveness could all prevent the expression of a felt need. Lack of demand, therefore, should not be equated with lack of felt need.
Expressed needs may conflict with a professional’s normative needs. For example, a patient may express a need for a course of individual professional counselling as a result of experiencing a mental heath problem, but the resources may not be available for this type of health promoting service and normative needs and priorities may be focused on other types of interventions to promote mental health.
4. Comparative Need
Comparative need for health promotion is defined by comparison between similar groups of clients, some in receipt of health promotion and some not. Those who are not are then defined as being in need. For example, if Company A has an employee health policy covering stress at work and the provision of healthy food choices in the staff canteen and Company B does not, it could be said that there is a comparative need for health promotion in Company B. This assumes that the health promotion in Company A is desirable and ideal, which of course it may not be.
Need, Demand and Supply
Over time, there has been debate over need, demand, supply and quality of health services and other public sector services that relate to health promotion, such as education. Levels and quality of service can vary across the country, and between GPs and hospitals even in the same neighbourhood, resulting in what has been termed as a postcode lottery (Kiss 2006). The need for services may be similar or different, but supply is unevenly distributed and this results in significant health inequalities (see, for example, Jaffa (2003) in relation to mental health services, Cockcroft (2007) in relation to cancer care, and the BBC (2009) reporting variation in health visitor provision).
If demand outstrips supply it means that people do not always get the access to the health services they want, or that health professionals believe they need. This issue of uneven provision also applies to health promotion services, with different levels of provision in different geographical areas (Scriven 2002, DoH/WAG 2005). The Institute of Healthcare Improvement (IHI) has a range of tools to ensure that demand matches supply (www.ihi.org), but nonetheless the problem arises because the health services and other public bodies have a finite pot of money to spend, so they have to prioritise. This can result in rationing (Campbell 2007, Klein 2007). To overcome the problems associated with rationing, the 2008 NHS Next Stage Review (DoH 2008a) endorsed NHS funding within personal health budgets. This new initiative of giving personal health budgets to the general population (for more detail see DoH 2009b) coincides with an NHS Confederation report Personal Health Budgets: the Shape of Things to Come (NHS Confederation 2009) which suggests that direct payments could result in enhanced health outcomes and positively change the nature of the patient–professional relationship. The scheme is currently in a pilot phase so its effect on the supply and demand for health promotion services is not yet known.
Measures to address the uneven supply and quality of health services have also included publication of national standards, in the form of the national service frameworks (NSFs) that set out the pattern and level of service which should be provided for major care areas such as mental health and disease groups such as cancer (www.dh.gov.uk). Local services are required to work towards these standards. National bodies also have a role in ensuring that the best value-for-money services and treatment are provided fairly wherever people live. The Care Quality Commission (www.cqc.org.uk) is responsible for ensuring good-quality services in the NHS, and the National Institute for Health and Clinical Excellence (www.nice.org.uk) provides the evidence for clinical practice and health promotion.
Identifying Health Promotion Needs
How does a health promoter set about identifying people’s needs? There are three key areas it is useful to think about first: the scope and boundaries of your job; the balance between being reactive and proactive in your work; and the extent to which you are putting your clients first. Each of these is addressed in turn.
For some practitioners the task of identifying needs has already taken place. For example, dental hygienists working in a dental surgery with individual patients already have the clearly identified task of educating patients in oral hygiene. But they may want to think carefully about how they can make their service as person centred and user friendly as possible. And they will certainly have to identify and respond to the individual needs of each patient.
Other workers, however, have more choice and scope in the range of health promotion activities they can undertake. Health visitors and community workers may have considerable scope, but the degree of autonomy they have will vary according to the policy of their managers and the resources available. All health promoters will need some competency in being responsive to the health promotion needs of their clients, and will need to be clear about the boundaries of their work: which health promotion activities are within their remit to undertake and which are not, however desirable they may be. For example, a family planning nurse may be asked to undertake sex education with young people in schools, but is this within the boundaries of her job?
Reactive or Proactive?
It is useful to make an initial distinction between being reactive and being proactive when identifying needs. Being reactive means responding or reacting to the needs and demands that other people make. Pressure from vested interest groups and the media may introduce bias into how needs are perceived, and produce pressure to react. Being proactive means taking the initiative and deciding on the area of work to be done. It may include rejecting the demands of other people if these do not fit existing policies and priorities.
See Chapter 3, section on analysing your aims and values: five approaches.
Being reactive or proactive can be related to the approaches to health promotion, which were discussed in Chapter 3. Using a client-directed approach means being reactive to consumers’ expressed needs, whereas using a medical or behaviour change approach probably means being proactive. This is particularly true of preventive medical interventions such as immunisation campaigns. In practice, there is usually a balance to be struck between being reactive and proactive.
Putting Users’ Needs First
It is important to ask the questions about whose needs should come first, the users or the providers of health promotion. There may be conflict between the two: for example, users may want a family planning service to be open on Saturdays to improve access but providers are unable to supply this service because of difficulties in getting staff to work at weekends. However, numerous international policy directives, such as the seminal Ottawa Charter (WHO 1986), and national strategies such as Choosing Health (DoH 2004), have emphasised the need for more people-centred health promotion.
The core values that would be embedded in people-centred health promotion are:
• the central role of the individuals, family and community in any process of health development
• equity and nondiscrimination.
The implications of these values are clear. People have the right to participate in making decisions about their health and should be enabled to do so. The needs, wants and expectations of individuals, families and communities should be respected by health promoters and influence priority setting and the delivery of health promotion services. You can measure how user friendly your services are by undertaking Exercise 6.1.
Find out about some services available locally, designed for the public, staff and/or health students (whichever is relevant to you) that aim to promote health or prevent ill health. The public library, human resources department of your employer, NHS trust or local council, for example, may be able to provide information about what services are available. These could include swimming facilities, exercise classes, the resources and information service of your local Public Health and Health Promotion Departments or an NHS walk-in centre.
Select one of these, appropriate and acceptable to you, and visit it. Make notes about what happens and how to make a service responsive to its users.
See also the section on working for quality in Chapter 8 for information on quality in health promotion services.
▪ Is it easy to find out that the service exists?
▪ Is it easy to locate, with clear signposting where needed?
▪ Is public transport easily available/is there easy access for parking your car?
▪ Are the opening times convenient to you?
▪ If there is a charge for the service, is it affordable and good value for money?
▪ How are you welcomed at reception? Are you given all the information you need? Do you feel at ease? Are the staff friendly?
▪ What do you think about the environment – is it safe, clean and comfortable?
▪ What do you think about the quality of the service you received? Do you have any ideas about how it could be improved? Will you use this service again?
▪ What have you learnt as a service user which you can now apply to health promotion practice?
These values suggest that key characteristics of people-centred health promotion might include the following:
For individuals, communities and population groups:
• Access to clear, concise and intelligible health information and education that increase health literacy and enable needs to be expressed.
• Equitable access to health including treatments, and psychosocial support.
• Development of personal skills which allow control over health and engagement with healthcare systems: communication, mutual collaboration and respect, goal setting, decision making, problem solving, self-care.
• Supported involvement in health decision making, including health policy.
For health promotion practitioners and specialists:
• Holistic understanding and approach to health improvement.
• Respect for people and their decisions.
• Recognition of the needs of people seeking to improve their health.
• Professional and personal skills to meet these needs: competence in promoting health, communication, mutual collaboration and respect, empathy, responsiveness, sensitivity.
• Commitment and adherence to quality, evidence-based and ethical practice.
• Team work, collaboration and partnership across disciplines and with clients.
(Adjusted from www.wpro.who.int)
Let us now return to the central question: how are needs for health promotion identified?
Finding and Using Information
The starting point for defining health promotion needs is information of various kinds from a range of sources. If you are gathering information on a local area for the first time, it would be helpful to share the work, and the findings, with colleagues. For example, health visitors may have done a neighbourhood profile as part of their training; the public health department in the local PCT will probably have health data on the local population. Gathering and updating all these different kinds of information is an ongoing project for every health promoter and sharing the task is a more efficient use of time. Working with colleagues needs to done in conjunction with establishing links with local people, in order to ensure the active participation of users and receivers.
There are a number of different kinds of information you can access when identifying need.
Epidemiology is the study of the distribution and determinants of disease in communities. Epidemiological data indicate how many people are affected by a health problem, how many people die from a particular health problem, and who are most at risk within sex, age, ethnic, socioeconomic, occupational or geographical groupings or perhaps by taking account of factors such as weight, smoking or physical activity levels.
Detailed discussion of the sources and limitations of epidemiological data is outside the scope of this book, but for excellent texts on epidemiology see Bonita et al (2007) and Gordis (2008). The important point to make here is that epidemiological data provide essential information on the health of the population, the causes and risk factors related to ill health and in doing this, the potential for prevention and health promotion.
Mortality and morbidity data are collected nationally, and some data are also available on a regional and local basis. Mortality data are concerned with causes of death; morbidity data with types of illness and disability. Mortality data are derived from death certificates; morbidity data from a wide range of sources, including medical records, sickness absence certificates, child health records, returns of notifiable diseases, disability registers and many others. In addition, surveys such as the government’s General Household Survey (GHS) (www.statistics.gov.uk) and those carried out for research purposes provide a considerable amount of health information.