• Chapter 1: Needs Assessment, Part 1

    • Chapter 1: Needs Assessment, Part 1

    Vocabulary List



    Chapter One: Introduction to the Planning Process and Needs Assessment, Part 1

    Welcome to the beginning of your journey in learning some of the most fundamental skills used in any public health career. In a hypothetical situation, you are training as a local health education specialist, and your supervisor has assigned you to a major project, in which you will do the following:


    In the road map below, each of the major points along your journey is a major skill in the program planning process. You will learn about and practice each of these skills.

    A road map that goes from: Choose a Location, Planning Models, Assessment: Part 1, Assessment: Part 2, Goals and Objectives, Behavior Change Theory, Interventions, Budget, Marketing, Implementation, and ends at Evaluation.


    1. Choose a location: You will have to choose a location for your project. 

    1. Planning Models: Over the years, people have created systematic planning models with step-by-step processes to plan, create, and implement a program of this scale.  

    2. Needs Assessment, Part 1: Your first step is to identify the health needs within the community. Professionals are required to collect empirical data to show the most important issues; they can not just choose what they think are most important. Each individual’s needs will not be the same, but we can identify more prevalent needs to make significant health improvements for the community. This data can come from both primary and secondary data collection. In this class, you will only use secondary data—that is data that other people have collected already. 

    3. Needs Assessment, Part 2: Once the most pressing health issues in your community have been identified, you will need to break each one down into the underlying causes to help you prioritize. Two things need to be determined: how much is each health issue impacting your target population, and how changeable the issue is. Will the health promotion program being made have the capability to make a change on this health issue?

    4. Goals and objectives: Now that you know which health issue you are going to target, it is important to decide which changes need to be made. Setting specific goals and objectives will help you measure if you are successful or not. 

    5. Implementation: Implementation is a critical step. Before the program is started, you have to determine how you are going to run it. Who will be in charge of the program? Who will hire, train, and manage the staff? Where will you hold the program? These are critical questions that have to be answered. 

    6. Budget: Now you can start the administrative duties, including a budget. You have been given $100,000 to run your program over the course of the year. Where will that money go? Will that be enough? You won’t know until you create a budget showing the personnel, supplies, and equipment that will be needed. 

    7. Marketing Four Ps—Segmentation: The next step is to market the program. Advertising is  just one part of marketing. It will also include targeting your intended audience and crafting your message to be culturally appropriate. 

    8. Evaluation: One of the last steps is to evaluate the program and determine how successful your program has been. During the planning phase, you need to determine how the data will be collected to measure how your goals and objectives will be met. 

    Conclusion 

    All of these steps will be broken down so that you will do them one at a time over the next few weeks. No matter which career you eventually choose, these skills will be helpful.


    To begin the planning process, we will review the Health Promotion and Health Education professions and where they fit in the history of Public Health. We will also cover how program planners engage other stakeholders in coalitions to address health issues and how they determine health needs.


    Health Promotion

    The World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, n.d.-a)

    Public health work involves promoting the health of individuals and communities. Health promotion aims to empower communities to improve their health outcomes not just through focusing on individual behaviors, but also through addressing social and environmental forces. Health promotion accomplishes this through building healthy public policies, creating supportive environments, and strengthening community action and individual skills.

    The WHO has set Health Promotion priorities in these four areas:

    Health Education

    (RHIH, n.d.)

    One basic public health strategy is to educate the public by using classes or informal workshops. A good example are Community Health Workers who know the local people and work effectively with them. They are especially valuable in understanding cultural differences of the target groups.

    According to the National Commission for Health Education Credentialing in the US, Health Educators are responsible for eight main roles: (NCHEC, n.d.)


    Settings for Health Promotion

    (WHO, n.d.-b)

    Overview

    "Health is created and lived by people within the settings of their everyday life; where they learn, work, play, and love" (WHO, 1986, p. 4).

    Improving health can happen in many different settings. To build on the Ottawa Charter, the WHO presented Healthy Settings, a “Whole System” approach to health promotion, that encourages community participation, partnership, empowerment and equity.

    What is a setting? A setting can be anywhere people actively use and shape the environment. It is also where people create or solve problems relating to health by planning, implementing and evaluating health promotion programs. Examples of settings include schools, work sites, hospitals, cities, and even prisons.


    The History of Public Health

    (IOM, 2003)

    Throughout history, whenever people have lived together, there has been a need for public health. Ancient Romans built aqueducts to supply safe drinking water and dispose of waste. The earliest historical account of public health is in the Bible (Leviticus 11–20) where Moses gave the people rules for food safety.

    Some of the notable public health efforts in more recent centuries were vaccinations. Vaccines were first developed by the Chinese a thousand years ago and later introduced in Europe in 1796 by Edward Jenner for smallpox. In 1854, John Snow investigated a cholera outbreak in London and discovered it was spread by contaminated water. In his now-famous public health intervention, he chained the central pump to prevent use of its water.

    Such actions eventually led to developing public health associations, like in these examples:

    In the last two centuries, public health efforts have been used to:

    In short, public health efforts work to protect against environmental hazards, prevent the spread of disease, encourage healthy behaviors, and respond to disasters.


    Stakeholders in Health Promotion Programs

    (CTB, n.d.-a)

    A key element in the health promotion process is the involvement of stakeholders. Any intervention will be more effective if all stakeholders are engaged in the process and all their interests are addressed. 


    Who Are the Stakeholders? 

    Stakeholders include all who are affected or have an interest or a “stake” in a program.

    Primary Stakeholders are beneficiaries, those who stand to gain something from the program. Listed below are some examples of primary stakeholders:

    Secondary Stakeholders are those directly involved with beneficiaries, such as parents and family members, healthcare workers, community volunteers. Listed below are some examples of secondary stakeholders:


    Key Stakeholders 

    Government officials and policy makers can pass laws and regulations that may either fulfill the goals of the program or cancel them out. From local board members to state and federal agencies or legislators, they can make or break public health efforts. An advisory board of appointed professionals may offer guidance and support.

    Influencers are people that others listen to. They can be in respected positions such as church leaders, doctors, community organizers, and especially the media.

    Others with an interest:


    Why Involve Stakeholders? 

    In most cases, participation of as many stakeholders as possible and responding to their concerns will bring the greatest chance of success. Some advantages of identifying a wider list of stakeholders:


    When Should You Involve Stakeholders? 

    The earlier in the process stakeholders can be involved, the better.


    How to Identify Stakeholders 

    Evaluating the Stakeholder Process

    It is important to monitor how well stakeholders are involved in your effort. The stakeholders themselves should help evaluate what did and didn’t work to recruit and keep them.

    Keeping Stakeholders Involved

    New stakeholders may need to be brought in as time goes on. You have to maintain stakeholders’ and supporters’ motivation, keep them informed, and continue to find meaningful work for them to do if you want to keep them involved and active.


    Coalition Building

    (CTB, n.d.-b)

    Whenever community problems are too large for any one agency to solve, the best approach is to put together a coalition of groups and individuals to work together to achieve the goal. A coalition can be a powerful force for positive change in a community.

    Coalitions can work together in the short term or become permanent organizations with governing bodies and funding. Regardless of their size and structure, they exist to work together to reach specific goals.

    Coalitions are often formed to accomplish goals. Some examples of possible goals are listed below:


    How to Form a Coalition 

    It helps to start with a core group and pull in all necessary stakeholders, as well as opinion leaders, policy makers, and community members. Early in the process, the elements below must be addressed:

    As a coalition forms, it is essential to be inclusive and communicate well with all members. Acknowledge and take advantage of the diversity of coalition members.


    Social Determinants of Health (CDC, 2022)

    Social determinants of health are the conditions of daily life and the environment that affect the health and well-being of different groups. They are often some of the root causes of health disparities and inequities. These social determinants can either support or limit the health of a community or population. Social determinants of health are grouped into five domains: economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context. For example, racial and ethnic minorities may have more health problems due to:

    A pie chart labelled "Social Determinants of Health". The pieces of the pie chart are Health Care Access and Quality, Neighborhood and Built Environment, Social and Community Context, Economic Stability, and Education Access and Quality

    (CDC, n.d.)


    Many worldwide efforts address social determinants of health. It will require a whole community approach in which different sectors all work together to assure conditions for health. Changes will be required by individuals, communities, and nations. Partnerships will be needed among public health, community organizations, education, government, business, and civil society.

    Social determinants of health (SDOHs) contribute to health disparities. For example, people who don't have access to grocery stores with healthy foods have higher risks of heart disease, diabetes, and obesity — and lower life expectancy.

    Just promoting healthy choices won't eliminate health disparities. Instead, public health needs to take action with partners in education, transportation, and housing to improve the conditions in people's environments. 


    Health equity and health disparities 

    A basic principle of public health is that all people have a right to health. Health equity results when everyone can attain their full health potential and no one is prevented because of their social position. Health disparities refer to preventable differences in health conditions and health status among groups. Most health disparities affect groups that have been marginalized or excluded. They experience worse health, as well as less access to food, good housing, and health services. Health inequities are “avoidable inequalities in health between groups of people within countries and between countries” (CTB, n.d.-c)


    Ten Essential Public Health Services (CDC, 2023)


    This is an image showing The Ten Essential Public Health Services. For a more in-depth description, follow the link below to the appendix.

    Access the appendix for a description of this image

    What Are the Ten Essential Public Health Services? 

    The Ten Essential Public Health Services were adopted by the US Centers for Disease Control in 1994 and strongly emphasize the theme of prevention. They are worth reviewing while communities assess their public health status.

    1. Assess and monitor population health by collecting and interpreting health related data.

    2. Investigate, diagnose, and address health hazards and root causes, identifying emerging health threats and combating both infectious diseases and patterns of chronic disease and injury.

    3. Communicate effectively to inform and educate, including health promotion and social marketing efforts in your community.

    4. Strengthen, support, and mobilize communities and partnerships. Health professionals join with other community sectors in effective coalitions.

    5. Create, champion, and implement policies, plans, and laws. Review health-related laws and policies and advocate for changes as needed to promote optimal health for all.

    6. Utilize legal and regulatory actions. This may include enforcement of sanitary codes, protection of drinking water and clean air, and monitoring healthcare services and supplies.

    7. Enable equitable access for socially disadvantaged people. This should be done for clinical healthcare as well as culturally appropriate health education.

    8. Build a diverse and skilled workforce with effective training for public health professionals.

    9. Improve and innovate through evaluation, research, and quality improvement of health programs and community initiatives.

    10. Build and maintain a strong organizational infrastructure for public health, including ties with higher learning and research.



    The following Case Study illustrates how one agency addressed a health issue by planning and implementing an effective program.


    CREATING HEALTHY CHILD DEVELOPMENT AT THE MITUMBA INFORMAL SETTLEMENT, NAIROBI, KENYA

    Mary Amuyunzu- Nyamongo, African Institute for Health and Development

    (AIHD, n.d.)

    Urban informal settlements, more commonly referred to as “slums,” are home to almost one billion people globally, including one-third of those living in cities in developing regions. Such settlements provide some of the harshest conditions found in any collective living arrangement due to overcrowding, poor sanitation, and minimal access to essential resources. These conditions also result in stigmatization, social isolation, and discrimination. In Africa, people in urban settlements experience more morbidity and mortality than rural residents and have less access to health services. Children are hit hardest by these conditions, with five-year-olds and under mortality being 35% higher among children in Nairobi settlements than among children in rural Kenya.

    Mitumba, a Kiswahili term meaning “second hand” or “used,” is a Nairobi settlement of approximately 18,000 people that was established in 1992. Mitumba is smaller than other Nairobi settlements and, consequently, has received little attention or support from governmental or other organizations. In 2006, the African Institute for Health & Development (AIHD), with support from the U.S. Centers for Disease Control and Prevention, established a partnership with residents of Mitumba to undertake a pilot project to promote healthy child development. AIHD is a Nairobi-based, non-governmental organization (NGO) with a multidisciplinary staff that includes anthropologists, sociologists, economists, and education specialists. It was established in 2004 to conduct research, training, and advocacy on health and development issues.

    The goal of the Mitumba project is to facilitate empowerment processes with mothers of children under the age of five to improve health; these processes include increased access to health information, safety, and early child development opportunities. The project follows general principles of community-based participatory research (CBPR), fully engaging mothers of under-five children, community health workers, and community leaders throughout the entire project period. CBPR goes beyond simply educating people, which usually involves interventions imposed on communities by outsiders, to an approach inspired by the Brazilian community organizer Paulo Freire. In his 1968 work, Pedagogy of the Oppressed, Freire describes a process which actively involves community members and organizations in developing the capacity to improve their own political and economic circumstances, as well as their health and well-being. Communities are encouraged to take control of their situations and to collectively improve them through cycles of planning, action, and evaluative reflection. The rationale is that the beneficiaries must drive the improvement and promotion of their own health with effective and sustainable strategies if significant long-term change is to take place.

    To help all residents and the AIHD gain clarity about living conditions in Mitumba, a 10-day social mapping project was conducted with youth and adults to understand community resources and boundaries. Mothers took part in surveys and focus group discussions to identify community conditions and norms affecting maternal and child health. In interviews, key informants provided insight into community issues and challenges. Participatory processes informed the design of the questionnaires as well as efforts to assure respondents of confidentiality.

    The findings revealed that Mitumba has three narrow roads passable by car during non-rainy seasons, six narrow paths for foot traffic, four churches, one school, and no health facilities. Housing structures are small and crowded: in 68% of the households, 3 to 5 people share a single 10' _ 10' room for both cooking and sleeping; only occasionally does the living space include a toilet. Most houses are made of metal sheeting and plastic, and have dirt floors. Water, available from community taps, is purchased at high prices and is mostly unclean because the vendors who supply the water use low quality pipes. Toilets, constructed by landlords, are shared by large numbers of people, poorly maintained, and often full. Children are not allowed to use them because of these conditions and because the holes are too big, creating safety concerns. Consequently, most children eliminate their waste on the open ground, causing serious sanitation problems. The sole community school in Mitumba has six classrooms, none of which have doors, windows, desks or books. The nearby city council school does not accept children from settlements. Some children attend private schools but most families cannot afford the fees.

    Some 65% of the mothers in Mitumba have received primary education and 35% a secondary education. Most residents engage in casual labor in industrial areas or construction sites. Women work in nearby wealthy households, although more than half were unemployed at the time of the baseline study. Poor economic conditions limit access to safe, affordable child care when mothers work or run errands. Young children (0–3 years) are usually left with neighbors who are not obligated to feed or clean them; older children (3–5 years) are usually left outside of the locked house. Children are often seen looking for food, loitering around neighboring houses, or sleeping on the ground when their mothers are away. Mothers reported that the major concerns facing young children include lack of food (20%) and diseases (42%), including malaria, respiratory infections, and diarrhea and vomiting. Due to lack of access to health services and limited economic resources, mothers stated that when their children are sick they frequently rely on chemists (pharmacies) and drug vendors who often sell inadequate or inappropriate remedies. Thus, 20% of households reported at least one child having died.

    With this information, organizers held a consensus-building forum with mothers to identify and prioritize their needs and to enable them to think of homegrown, practical approaches they could adopt and implement without stretching their scarce resources. The community decided upon three initiatives: establishing a day care center (the core project), soliciting support for the community school, and working with youth to enhance their ongoing activities and to open new horizons for them. Together, these initiatives support the overall goal of improved child health while also increasing skills and capacities among various groups in the community.

    For example, the mothers stated that they wanted their children nurtured in a home environment staffed by older mothers with experience and training in child care and development. They identified two such mothers from the community, potential locations, and determined how much they could afford per child. The community members and AIHD jointly planned the intervention. They included a signed memorandum of understanding that defined roles and responsibilities for each group, in order to develop commitment and to safeguard against potential misunderstandings. They constructed the day care by refurbishing and expanding an existing facility.

    The floors were cemented, fences were added, and walls were painted with bright colors and murals of story book characters. Fifteen mothers attended a training session to learn how to make toys and other items needed for the center. Additional sessions focused on nutrition, developmental needs and health and safety issues. Within a few weeks, the day care center reached full capacity, with 20 children, and the partnership began discussing the development of additional centers.

    Additional Activities

    Community members also stressed the importance of education for the growth of individuals, communities, and the nation at large. Current educational conditions in Mitumba make it difficult for the children to learn and thus fully participate in the world. During meetings with community members, the school chairman, and teachers, the partnership identified the need to construct a fence around the school to ensure safety; obtain access to desks, textbooks, and writing materials; secure windows and doors; and pipe water in for personal hygiene and food preparation. The group developed a proposal to seek city council sponsorship.

    Another serious problem in Mitumba is the lack of employment for youth, which contributes to alcoholism, drug abuse, prostitution, and single parenthood. Using an approach similar to that adopted by the mothers, a partnership was established with Tuff Gong, a community youth group in existence since 2004 that has been involved in environmental cleanliness, HIV and AIDS education, and football activities. Members started monthly cleanups, but no longer have the equipment necessary to continue. The partnership is seeking funds to support their activities. Evaluation activities for the pilot phase of the Mitumba project include review of the registers used to record implementation activities; before-and-after photography; periodic, informal discussions with the community members; and end-of-project surveys.


    (Lightly edited from “Community Interventions on Social Determinants of Health: Focusing the Evidence,” by Marilyn Metzler, Mary Amuyunzu-Nyamongo, Alok Mukhopadhyay, and Ligia de Salazar. In McQueen, D and C. Jones C, editors. Global Perspectives on Health Promotion Effectiveness. New York: Springer, 2007.)


    Needs Assessment, Part 1: Gathering Information

    The first step of the planning process is the needs assessment. We can’t simply choose a health issue at random; we need to use credible data to show us what health issues are problems within our community.

    Here is an example of data available about some prevalent health issues. 

    A chart and maps depicting the findings of Mental and Substance use disorders mortality. See the appendix for a more in-depth description.

    Access the appendix for a description of this image

    Notice that we aren’t just gathering data about the most common causes of death. We are also looking at morbidity or the health issues that are not causing death but are upsetting the quality of life of the target population. 

    During the first part of the needs assessment, our job is to identify these health issues and collect data that will help us understand the underlying causes of each health issue. 


    Why Assess Both Needs and Resources? 

    Needs can be defined as the gap between what is and what should be. Resources, or assets, can include individuals, organizations, buildings, or anything that can be used to improve the quality of life. The mother in Chicago who volunteers to organize sports for neighborhood children after school, the Kenyan farmers' cooperative that helps farmers buy seed and fertilizer, the library that provides Internet access, the walking path where city residents can exercise -- all are resources that enhance community life. Every individual is a potential community asset.


    A Plan for Assessing Local Needs and Resources 

    1. Recruit a planning group that represents all stakeholders and mirrors the diversity of the community. 


    2. Determine what data is already available. Here are some commonly used sources of existing data. These link to external sources.


    3. Determine what other information you need. Finalize the questions you'll ask your informants, as well as the questions you hope to answer with the assessment. 


    4. Decide what methods you'll use for gathering information. Choose among many methods of gathering assessment data. Some possibilities are listed below:


    5. Decide who will collect data. Who will do the work of interviewing, surveying, or carrying out whatever other strategies you've chosen to find information? 


    Participatory Approaches to Planning Community Interventions

    (CTB, n.d.-d)

    Who Should Be Involved in a Participatory Planning Process? 

    There should be strong and effective representation for everyone involved, including the following:

    TARGETS OF CHANGE

    The people whom the intervention is intended to benefit. There are two groups to be considered:

    AGENTS OF CHANGE

    People who make policy or influence public opinion. They can help or block an intervention by their support or opposition.

    Policy makers

    (CTB, n.d.-e)

     

    Influential people in the community


    INTERESTED MEMBERS OF THE COMMUNITY


    Collecting Information About the Problem - Primary and Secondary Data Processes

    (CTB, n.d. -f)

    Quantitative information and data analysis provide a concrete approach for assessing, planning, and implementing community projects. It helps us compare community problems across geographic regions and across periods of time. 

    Collecting New Information 

    Primary data is information that you collect yourself. Although the information you need is often already available, sometimes you need to create it yourself. Methods of primary data collection include:

    Secondary Data is information that others have collected. With access to the internet, countless sources are available for statistics on health conditions. One drawback is that we need to evaluate the accuracy of secondary data and ensure we use only reliable sources.

    Secondary Source Examples:



    References


    AIHD. (n.d.). African Institute for Health and Development. An Africa where people live in dignity. https://www.aihdint.org/

    CDC. (2022). Social Determinants of Health at CDC. Centers for Disease Control and Prevention. https://www.cdc.gov/about/sdoh/index.html

    CDC. (2023). 10 Essential Public Health Services. Center for Disease Control and Prevention. https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html

    CDC. (n.d.) Social Determinants of Health. Healthy People 2030. Centers for Disease Control and Prevention.  https://health.gov/healthypeople/priority-areas/social-determinants-health

    CTB. (n.d.-a) Chapter 7, Section 8. Identifying and Analyzing Stakeholders and Their Interests. (n.d.). Community Tool Box. https://ctb.ku.edu/en/table-of-contents/participation/encouraging-involvement/identify-stakeholders/main

    CTB. (n.d.-b) Chapter 5, Section 5. Coalition Building I: Starting a Coalition. (n.d.). Community Tool Box. https://ctb.ku.edu/en/table-of-contents/assessment/promotion-strategies/start-a-coaltion/main

    CTB. (n.d.-c). Chapter 2, Section 17. Addressing Social Determinants of Health in Your Community. Community Tool Box. https://ctb.ku.edu/en/table-of-contents/overview/models-for-community-health-and-development/social-determinants-of-health/main

    CTB. (n.d.-d) Participatory Approaches to Planning Community Interventions. Community Tool Box. Chapter 18, Section 2. https://ctb.ku.edu/en/table-of-contents/analyze/where-to-start/participatory-approaches/main

    CTB. (n.d.-e). Chapter 33, Section 10. General Rules for Organizing for Legislative Advocacy. Community Tool Box. https://ctb.ku.edu/en/table-of-contents/advocacy/direct-action/legislative-advocacy/main

    CTB. (n.d.-f) Chapter 3, Section 4. Collecting Information About the Problem. Community Tool Box. https://ctb.ku.edu/en/table-of-contents/assessment/assessing-community-needs-and-resources/collect-information/main

    IOM. (2003). Institute of Medicine (US) Committee on Educating Public Health Professionals for the 21st Century. History and Current Status of Public Health Education in the United States. Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century. https://www.ncbi.nlm.nih.gov/books/NBK221176/

    NCHEC. (n.d.). National Commission for Health Education Credentialing. Responsibilities & Competencies. https://www.nchec.org/responsibilities-and-competencies

    RHIH. (n.d.). Rural Health Information Hub. Health Education. RHIhub. https://www.ruralhealthinfo.org/toolkits/health-promotion/2/strategies/health-education

    WHO. (1986). The Ottawa Charter. World Health Organization. https://intranet.euro.who.int/__data/assets/pdf_file/0004/129532/Ottawa_Charter.pdf

    WHO. (n.d.-a). Health Promotion. World Health Organization. https://www.publichealth.com.ng/world-health-organizationwho-definition-of-health/

    World Health Organization. (n.d.-b). Healthy Settings. World Health Organization. https://www.who.int/teams/health-promotion/enhanced-well-being/healthy-settings


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    Access it online or download it at https://books.byui.edu/pubh_390_readings_2nd_edition_/chapter_1_needs_assessment_part_1.