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Population-based needs assessment
POPULATION-BASED NEEDS ASSESSMENT Bringing Public Health to Midwifery Practice Eugene R. Declercq, PhD, MBA,Terry Jo V. Bichell, CNM,MPH,and Jill K. Center, BA, MPH ABSTRAC~F Midwives are accustomed to individualizing their care of women on the basis of an assessment of each client's health status. By expanding their focus of care to encompass treatment of a population group, midwives and other providers can adopt a public health perspective through use of a community needs assessment. The first steps in diagnosing and treating the health problems of a group require the same rigorous and systematic: examination of health indicators as does treatment of an individual. This article outlines the needs assessment process, identifies basic sources of information, and describes ways in which results can be presented. © 1997 by the American College of Nurse-Midwives. Since the 1970s, maternal and child health professionals have been using needs assessments to apply for funding to design new programs a n d / o r revise existing ones and to justify the opening or closing of clinics or hospitals (I). Increasing demands in recent years from public and private funding sources for provider accountability has encouraged the further use of needs assessments. Although much of the literature on needs assessment focuses on the question of how to identify a community's priority health issue systematically (2), this article focuses m o r e narrowly on how a certified nurse-midwife (CNM) or certified midwife (CM) might develop and use a needs assessment. As the health care system changes and midwives adapt to new roles in primary care, managed care, and independent practice, needs assessments can be used for a variety of purposes, including: • to make a case to health insurers a n d / o r managed care companies for the inclusion of midwifery care in their benefits package, • to convince a hospital or health maintenance organization (HMO) to fund a new practice, • to lobby for legislative change, and • to provide a decision-making tool for the individual practitioner(s) in situations such as opening a birth
Address correspondence to Eugene R. Declercq, PhD, MBA, Boston University School of Public Health, Department of Maternal and Child Health, 715 Albany Street, A206, Boston, MA 02118.
478 © 1997 by the American College of Nurse-Midwives Issued by Elsevier Science Inc.
center, adding an interpreter to staff, starting an outreach program for teen mothers, or advertising primary care services. DEFINITION OF NEEDS ASSESSMENT
Assessment has been identified as one of the three core functions in public health practice and is the building block for the other two functions (along with policy development and assurance) (3). A needs assessment is practical research culminating in a description of a specific group's health status, as well as the adequacy of resources available to that population. The process will enable a midwife to uncover an unmet health need or an underserved group within a community and use that information to design a solution to the identified problem. Health information about population groups can be both quantitative and qualitative. Qualitative data can come directly through personal interviews, surveys, or focus groups. Quantitative data sources can include existing data analyzed specifically for the needs assessment (eg, examining hospital records to identify infant readmission rates) or secondary sources, such as library resources, Internet sites, or research previously conducted by other community agencies. The c o n c e p t of " n e e d " may be expressed or valued differently depending on one's perspective. Generally, it implies that a community health problem exists that can be diagnosed and treated. A need was defined in Title XX legislation as " a n y identifiable condition which limits a p e r s o n or individual, or a family member in meeting his or her full potential. Needs are usually expressed in social, economic, or health refated terms and are frequently qualitative statements" (1). Kettner et al describe a need as either relative, normative, expressed, or perceived (1), and PeoplesSheps, et al (2) identify five categories of needs (Table I). A needs assessment is an attempt to quantify and understand a specific need within the community in an effort to target resources effectively to address that need. Although somewhat akin to market research, a needs assessment focuses on the need for services rather than the profitability of services (4). Additionally, the need
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may be related to barriers to, or the availability of, existing services, rather than the lack of services. Keppel and Freedman (5) described the following characteristics of services that can enhance or reduce their availability: proximity, accessibility, cost, affordability, acceptability, appropriateness, effectiveness, and ability to coordinate with other services. Often, the conclusion of a needs assessment may indicate that although proper services exist in a community, the services are not useful to, or used by, at-risk groups because of one or more of the characteristics just listed. TYPES OF NEEDS ASSESSMENTS
Needs assessments can be classified along several dimensions relating to source (internal versus external) and audience (private versus community). For example, an internal needs assessment might be commissioned by an HMO in an effort to decide whether staff midwives should provide expanded primary care services, whereas a state public health department may ask a local group
Eugene R. Declercq is associate professor and associate chairman for the Department of Maternal and Child Health at the Boston University School of Public Health. He teaches a course entitled "Assessing and AnalyzingMCH Systems,"in which students of maternal and child health learn the elements of needs assessment. Dr, Declercq has directed a number of populationbased needs assessments, including a recent community report,
The Health of Lawrence,Massachusetts, 1995: A Community Needs Assessment. In addition to his work as a maternal and child health policy analyst, Dr. Declercq is a childbirth educator and served as assistant editor of this home study series. Terry Jo V. Bichell is a 1997 graduate of the Maternal and Child Health Leadership Program at the Boston University School of Public Health, where she also completed her nurse-midwifery education and master of public health degree. She received her nursing degree in 1992 from the St. Louis University School of Nursing and her undergraduate degree in international health in 1984 from the Johns Hopkins University. Ms. Bichell's professional experience includes childbirth education, administration of an operation's research project on family planning in Africa, and an independent video production on a variety of health-related topics, including family planning, acquired immunodeficiency syndrome (AIDS), and women's health. Jill K. Center is a 1997 graduate of the Maternal and Child Health Leadership Program at the Boston University School of Public Health, where she also completed her master of public health degree. She received her undergraduate degree in English at Wake Forest University in 1992, attendance of which included a semester at the Worrell House in London, England. Ms. Center's professional experience in maternal and child health services administration includes her recent roles as clinical supervisor in the Department of Obstetrics and Gynecology, Harvard Pilgrim Health Care, Boston, Massachusetts, and assistant coordinator of Gynecology and Contraceptive Services, Planned Parenthood Clinic of Greater Boston, Brookline, Massachusetts.
including midwives to assess the extent and nature of adolescent pregnancy in their community. The audience for the assessment may be a single funder (eg, an HMO), a state or local commission (eg, when midwives systematically identify why there is a need to expand prescriptive authority), or the community-at-large, wherein the results are widely published (eg, the teen pregnancy study). A needs assessment may combine elements of each approach. An example of an i n t e r n a l l y g e n e r a t e d needs assessment might be a situation in which two newly graduated midwives plan to open a midwifery practice in their local community. Questions must be raised about both the feasibility of starting a new practice in that area and the characteristics of the mothers they would be serving. Their assessment should also involve listening to local opinion at a public hearing, reviewing community demographic, economic, and health data previously gathered by state and local agencies, and compiling natality statistics from the state public health department. Their research might show, for instance, that there are no midwives practicing in the area, that the percentage of births to teen mothers is twice as high as the statewide rates, and that only a third of local women are using area institutions for their obstetric care. As a result of this research, a practice model could be created to serve the needs of local women, especially teenagers. An example of an externally generated needs assessment is one that is developed in response to national concern about high infant mortality rates in urban areas. Midwives in a particular area might conduct a needs assessment in a neighborhood with a high rate of infant mortality. It might be found that although services for pregnant women are readily available, they are fragmented, with few agencies providing continuity of care to at-risk women in the form of a consistent one-provider-to-one-patient relationship. This approach was used recently by a small group of midwives in Boston, Urban Midwife Associates, who determined through a needs assessment that a new practice modeled on the conviction that continuity of care with a midwife in an independent private practice setting would be the best way to reach women in their area who were at higher risk for infant mortality (personal communication, Peggy Garland, CNM, MPH, June 18, 1997). IMPLEMENTING A NEEDS ASSESSMENT
The steps necessary for successful completion of a needs assessment generally include the following: 1) formulating a question, 2) reviewing the literature, 3) describing existing resources, 4) refining the question,
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TABLE I
Categories of Unmet Needs (2) Unmet Need
Definition
Measurement
Professional and consensusbased standards Demand for services
Recommended services not available
Compare target population to accepted standard such as Healthy People 2000 Numbers on waiting lists; actual use compared with capacity of services
Underserved population at risk Relative availabilityof services Perceptions
Numbers of people who seek relevant services and are not served Number of people at risk who do not receive services Equity of services available in two similar populations Services people say are needed to prevent health problems
5) collecting data (including secondary and primary data), 6)analyzing the results, and 7) presenting the results to the public.
Formulating the Question If the assessment question is generated internally, there usually will be greater control of its shaping and refinement; control of an externally generated question may be limited. A clear and concise definition of the problem and the study population is critical to determining the appropriate approach to use to produce a useful outcome from the needs assessment process. Most needs assessment questions will fit into one of the following areas: • What is the general health status of a population? (ie, How healthy are the people in my community?) • Does a specific population have a certain health problem? (ie, Are too few Hispanic mothers beginning prenatal care in the first trimester?) • Are there sufficient and correctly designed services to address a specific health problem or a specific community group? (ie, Are postpartum home visiting services available and in languages other than English?) • Are there barriers that prevent a certain group from accessing services? (ie, Do any maternity care providers speak Spanish?) After an initial literature review, the questions can be refined and reformulated and the best sources of data identified
The Literature Review A literature review prevents duplication of previous work, reveals others' attempts at solving similar prob-
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Estimate of population at risk compared with numbers who receive services Compare services available in two populations Qualitative surveys of providers and people at risk
lems, and enables refinement of the initial question. The literature collected should include current published articles concerning the clinical and public health nature of the problem, as well as unpublished material available from national, state, and local agencies. Among the questions to consider are the following: • What is the exact nature of the problem in the population of interest? • What is the recommended clinical approach to the problem? • Has any other organization in the community done a similar (or any) needs assessment? • What kind of related information has been gathered and to what purpose? • Are there any previously identified sources of information about the community? • Are there sources of information that have been overlooked? • How was the past information presented, and what was the response? After becoming familiar with the nature of the problem, a programmatic literature review should be done. This process may be unfamiliar to many midwives, even though they may have considerable experience with clinical literature reviews. A programmatic literature review simply describes and evaluates programmatic initiatives. For example, in addition to the Medline database of citations, an examination of HealthStar will provide citations of the published literature on service delivery, including health services, technology, administration, and research. Often program descriptions are available from the public (eg, Maternal and Child Health Bureau) and private (eg, Robert Wood Johnson Foundation) agencies that fund such initiatives. This research can reveal not only past attempts to address similar problems, but might identify potential funding sources
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for one's own program. Many funding sources maintain World Wide Web sites that can lead to the information sought. In performing the programmatic literature review, the following questions should be considered: • What private and government efforts have been made to address the problem? • If different approaches to the same problem exist, what are the sources of the conflict? • Are there local barriers to implementing the services described elsewhere? • Have the services reached their target populations? • What was the effectiveness of services available in other communities? This can be accomplished by examining "before and after" statistics, with an awareness of the limitations that may exist in the findings. • Do the conclusions correspond to the data?
Describing Existing Services The true definition of community-based needs is the difference between the services needed and those currently provided. Therefore, a needs assessment should include some description of what services exist and how accessible and appropriate they are to the population of concern. The source of information for this stage of research may be as simple as a series of phone calls to providers documenting hours of operation, willingness to accept new patients, links to insurers, and languages spoken by the providers. At the other extreme, this research may involve formal program evaluations of current services (6). There may be existing studies by community groups that can serve as a valuable resource, although care must be taken to assess the quality of such secondary studies.
Refining the Question Assessment of current services and completion of the clinical and programmatic literature review will result in a clearer sense of the nature of the problem to be addressed, the characteristics of the population to be served, and what, if any, approaches were used in the past to rectify the problem. The needs assessment must then focus on a very clearly defined target group. Target groups can be selected by demographic indicators (eg, age, race, ethnicity, religion), service areas (eg, the known patients of a health clinic), catchment area (eg, geographic locations such as neighborhoods, towns, or regions; all the streets along one bus route; a census tract; a school district), or by an identified need (eg, women at risk of abuse, teen pregnancy, exposure to environmental toxins). On the basis of
these considerations, the question can be further refined to reflect more accurately both the target community and the information needed to formulate a possible solution. Ultimately, the end result should be a refined question that is both relevant (Will anyone care?) and researchable (Is there an answer?).
Data Collection There are a variety of approaches to data collection. The two methods that are the most useful and feasible for a community-based needs assessment are qualitative primary data collection and secondary data collection. In general, primary data collection involves original research that addresses a specific question, whereas secondary data is information collected by someone else for their own purposes. The tradeoffs involved in each approach are obvious, with primary data collection preferred but usually much more costly and time consuming. Secondary data is often not precisely applicable to the specific question to be addressed. Given that the costs associated with most approaches to primary data collection typically make it beyond the reach of individuals or small groups, this discussion focuses on how to find and best use secondary data and integrate it with less costly, but valuable, primary data collection techniques. As discussed at length in a later section on analysis of results, standards of comparison are essential to any needs assessment. This point is noted here because analysis cannot be completed if the comparison data have not been collected. The availability of such comparison data may shape what local information is to be collected; because the comparison data were used to answer someone else's question, the available data may be in very different forms. For example, if a comparison was to be made between local teen pregnancy rates and state and national standards, there must be some degree of sensitivity as to how data are reported at those levels. Healthy People 2000 standards (7) seek to reduce pregnancies "among girls aged 17 and younger," citing a target of 50 per 1,000 girls, whereas a Massachusetts report on adolescent pregnancy in the state presented birth rates for 15-19 year olds (8) and local data reported the actual number of births to women less than 20 years and less than 18 years old (8). None of these figures are comparable with each other as they stand, and although adjustments can be made to enable reasonable comparisons, it is the researcher's responsibility to plan and collect the information that will facilitate those comparisons.
Qualitative and quantitative data. Many different modes of inquiry can be used to gain an understanding
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of a particular issue or need. This is nowhere better understood than in the context of a midwife's practice. In assessing a client, a midwife considers multiple types of information and uses a variety of skills to elicit information from a client to better understand her needs and assess her health. A prenatal assessment consists of a blending of empirical, or quantitative information such as weight, fundal height, urinalysis, and other measurable, quantifiable data with qualitative information gleaned from answers to a series of open-ended questions, such as "What kind of support do you have from your partner/family/friends?" and "Tell me about your concerns with this pregnancy." An appropriate assessment of the client's well-being and health depends on the use of both methods of information gathering. Using these methods of inquiry is also valuable as a means of identifying, defining, and articulating a population need. Michael Quinn Patton (9) reinforces this idea, suggesting, "because qualitative and quantitative methods involve differing strengths and weaknesses, they constitute alternative, but not mutually exclusive, strategies for research." Quantitative data offer a summary of trends and patterns, and qualitative data usually provide information about fewer cases in more detail than statistical data. In general, the advantage of using quantitative data is that it can provide limited information about a large number of people, identify trends in the health status of given populations, and provide data that are appropriate for statistical and comparative analysis.
Primary quantitative data. The most common form of primary quantitative data collection are surveys of public opinion. These can be very valuable, particularly if they are well-constructed, because they can provide insights into individual opinions, which can then be analyzed along a number of dimensions (eg, demographic characteristics). Unfortunately, a well-designed and implemented survey is also very costly and generally beyond the means of individuals; therefore, their strengths and weaknesses will only be briefly summarized here. For those interested in using surveys in their community, The Survey Kit (Sage Publications) is a valuable and relatively inexpensive tool (10). Surveys can be used to collect information from a large sample of the population and may be conducted via telephone interview, face-to-face interview, or self-administered questionnaire. For example, a group of midwives n~lay want to know if there is a need for their services among women in an adjoining community and may choose to use a combination of quantitative and qualitative methods to address the question. With some variations, survey methods could be used to collect
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qualitative data (often based on open-ended questions) or quantitative data (more likely relying on closed-ended questions). As in the case of a clinical assessment, the way a survey is constructed and the questions worded in a needs assessment will have a profound effect on the value of the data gathered. If a personal or telephone public opinion survey is used, the issue of who comprises the sample, as well as the size of the sample, is crucial to the validity of the results. If the goal of the survey is to generalize the findings to all women in the community, the sample selected must be representative of this population and must be of sufficient size for the variable studied (eg, 4 0 0 + , depending on sampling technique) for the data to be considered valid. Selecting a randomized sample is the best way to ensure that there is no bias in the selection of participants in the survey. It should be noted that the same considerations concerning survey sampling apply to studies that rely on a sample of hospital or provider records. For those who are unfamiliar with this method of research, it may be wise to hire a consultant for assistance in drawing the sample, developing the survey tool, and analyzing the results. Care should also be taken in the design of the survey tool to phrase questions in language that will be easily understood by the respondents and not to include biased questions that lead the respondent to certain desired answers (11). A mail survey may seem like a useful compromise because it is less costly; however, it is often a false savings. Mail surveys involve questions of sampling (results are determined by who chooses to send in a response; thus, it cannot be determined if those who returned a questionnaire have opinions comparable to the population of interest) and validity (it cannot be determined who actually completed the survey and under what circumstances). Additionally, if the respondent does not understand a question, it cannot be clarified for them. Mail surveys are typically shorter, involve few open-ended questions and must, as Bourque and Fielder (12) note, "stand alone," as no probes or follow-up questions are possible. Mail surveys require more care than may initially be understood and are most valuable when used as a complement to other forms of data collection.
Secondary quantitative data. Secondary data refer to data already collected, organized, and analyzed, which may or may not be published. Secondary data are often inexpensive to obtain and already available, resulting in a significant savings of time, personnel, and money. Secondary data may be the only available option to researchers who lack the resources to initiate a major community-wide study dedicated to their question. A
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good place to begin a needs assessment is with a review of secondary data pertaining to the topic of study as a means of exploring the scope and depth of the need the investigator is researching. Secondary data are available in many forms, and depending on the specific information necessary for the formulation of a needs assessment, much or all of the data needed may have already been collected. The major advantages of using secondary data are that such use is generally less expensive than conducting original surveys and studies, it may provide informarion on entire populations or at least much larger samples than data collected by an individual, and the data are available much more quickly, enabling the investigator to respond rapidly to requests for a profile of needs in a community. The major problems with secondary data are availability and applicability. The data might not be accessible (eg, in insurance company records) or typically, may not be organized in a way that directly addresses the target question. For example, statewide data on sexually transmitted diseases may be available but might not be organized at a community level; community data may exist but not be broken down by age or ethnicity; or the categories available do not necessarily coincide with the researcher's question (eg, a question about adolescent sexuality is addressed only by existing data about juniors in the local high school). Likewise, a question about the outcomes of planned home births in an area may lead to birth certificate data, which in most states combine planned and unplanned home births. There may also be questions of timeliness (How long ago were the data collected? What changes to the community have occurred in the meantime? How were the data collected?). Secondary data may be accessed through hard copy resources or more recently, through a variety of Internet and electronic sources. Ideally, a refined question should address a perceived need and not be a function of what data are available; however, reality often dictates compromises depending on what can be known with existing resources. There are several possible sources for data providing information about the characteristics of national and local populations. These data sources may include information about demographic trends, vital statistics, health history, service availability, service utilization, maternal and infant morbidity and mortality, and nutrition status. With any data source, it is important to bear in mind its particular strengths and weaknesses and how they affect the credibility of the needs assessment being developed (Table 2). Primary qualitative sources. Using data from a variety of sources and methods of inquiry can strengthen a
needs assessment. Methods for primary qualitative data collection include the use of key informant interviews, focus groups, and in-depth interviews with clients and the public. Depending on the investigator's skills, financial resources, and time frame for obtaining the data, one or more of these methods may be used to support the definition of need for the population to be served or studied. Qualitative methods rely on the researcher's ability to collect information about people's experiences, thoughts, opinions, and understanding of a given topic. This mode of inquiry usually involves the researcher's observations and interviewing of subjects involved in or related to the topic of study (perhaps a particular program or organization). One of the strengths of this type of inquiry is the support it provides a researcher seeking to learn about an issue in depth, in a way that exclusive use of quantitative methods often does not allow. The validity of qualitative data relies mainly on the researcher's skill as an interviewer, as opposed to the construction of the interview tool (as in collection of quantitative data). Through the use of the following techniques and information, a midwife may apply a w~riety of methods to obtain information to be effectively used in a needs assessment.
Key informant interviews and in-depth interviews with clients and the public. Key informant interviews involve solicitation of information from carefully selected experts or other individuals knowledgeable about the issue or need being studied. Questions may be phrased to elicit open-ended, "yes/no", or multiple-choice responses. AIthough this type of data source can enhance understanding of an issue or problem, it is also important to bear in mind that key informants may have their own biases and prejudices that might emerge during the interview. A comparison of data collected from several key informant interviews can enhance the quality and depth of the data collected. By using a similar format, a midwife interested in providing a specific service may conduct interviews with current clients or members of the community to assess the need or desire for the service. Focus groups. Focus groups are a method of collecting qualitative data from a carefully chosen population who are led by an individual skilled in facilitating group discussions (13). As Krueger (13) notes, "The focus group is a special type of group in terms of purpose, size, composition and procedures. A focus group is typically composed of seven to 10 participants who are selected because they have certain characteristics in common that relate to the topic of the focus group." The goal is to elicit the views and
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opinions of each member of the group in an e{fort to emerge from the meeting with a deeper understanding of the issue of interest. One of the unique and most intriguing aspects of conducting research using this method is the p h e n o m e n o n of the group yielding a richer and more complex set of data than the sum of its parts. The effect of asking questions in a group setting as opposed to questioning several people individually can result in responses building on each other; however, it is also important to acknowledge that this group dynamic may result in "group think" and thereby stifle individual ideas or opinions. A midwife may choose to conduct a focus group as a means of collecting qualitative data to support a needs assessment. For example, a midwife who wants to begin a new practice may attempt to assess the need for a midwifery practice in several communities by assembling focus groups in the target areas. The group setting may be used to introduce questions about the group's attitudes, knowledge, and experiences with midwives. This essential information would be more difficult to obtain through quantitative methods of inquiry. The members of the group may offer information that supplements equally important data about women's access and use of available health care providers. Utilization data may show that although most women in the community have adequate access to providers, utilization rates are low. A focus group may help to illuminate the reasons for such a discrepancy. The midwife may ascertain that several women are not comfortable with the available providers and would prefer to seek care from a midwife, a provider who speaks their language, a provider whose specialty is specifically women's health, or a female provider. Although the quantitative data may show an adequate number of accessible providers, a need for a new midwifery practice may be supported by the qualitative data obtained from a focus group in which the participants were able to articulate in depth their needs for the type of provider with whom they would be most comfortable and most likely to see regularly for care. ANALYSIS OF RESULTS
There are three terms that are essential to understanding analysis of data from a needs assessment: comparison, comparison, and comparison. The research process usually involves one of three basic designs, and all involve some form of comparison: I. Experimental design (comparison of subjects randomly assigned to an experimental or a control group) 2. Time series (comparison of the same population over time)
3. Cross-sectional (comparison between similar groups at one point in time) Most needs assessments involve some form of time series or cross-sectional analysis~ as well as comparison to external standards (eg, Healthy People 2000); experiments are uncommon in field settings and are, thus, of limited value here. In any comparison, it is critical to ensure that the data being compared are sufficient and actually comparable, as demonstrated by the case of different "adolescent" age groups cited earlier. Equally important in many community studies is the problem of population size. For example, there may appear to be an alarming finding that the infant mortality rate in a community has jumped from 6.0 to 8.0 per thousand births (a 33% increase) in the past year, but in a community with 500 annual births, that represents a change of one infant death. If there were a substantial fall in the number of births, it may represent no change at all in the actual number of infant deaths. If a rare event (eg, an infant death or disability) in a small population is being studied, it is sometimes preferable to combine years for purposes of comparison (eg, compare average infant mortality rates for 3-year periods rather than single years) to reduce the effects of random variation on the data. A second overriding concem in the analysis stage of a needs assessment is to ensure that correlation is not confused with causation (14). Finding a relationship between two events (opening of a midwifery s e ~ c e and a fall in community infant mortality) is a necessary, but not sufficient, condition to determine that one caused another, although such a finding may seem entirely plausible. Time Series
The simple question, "Are we doing better than before?" is at the heart of time series analysis. Have infant mortality, breast cancer, teen births, and sexually transmitted diseases in the community increased or decreased during the past 5 years? There are several important questions to ask in looking at data over time: • Has the form of measurement changed in the time studied? (eg, the national standard certificate of a live birth was revised in 1989 with a change in key categories) • Has the population studied changed over that time? (eg, a long-term increase in the incidence of low birth weight in a city may be less the result of changes in care and more a function of an increasing number of at-risk mothers in the community) • Is there a long enough period to determine a trend? If teen births increase for three consecutive years, is there a trend? Perhaps, but more information is needed to discern a trend. Unfortunately, the longer
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the data period used, the more likely the two concerns cited earlier will become more prominent. Cross-Sectional Analysis
Many needs assessments involve some form of crosssectional analysis, comparing comparable groups with each other. This may involve comparisons with other similar communities, or breakdowns of a general population into smaller parts in an attempt to isolate a problem. The validity of the conclusions drawn from this approach will depend on the extent to which the groups compared are truly comparable. Are the two towns used in the comparison really alike? Are adolescents in one part of a large city similar to those in another?
External Standards
"In determining that individuals or groups have a need, it is important to evaluate existing conditions against some societally established standards. If the community is at or above those standards there is no need; if it is below those standards, there is need" (7). The most notable effort to establish standards for health outcomes has been the Healthy People 2000 project (7), which includes 14 targets to be achieved in maternal and child health by the year 2000. These targets serve as goals and they provide an outside, credible standard to present to the community. Many state health departments are also measuring state performance on a number of indicators, with a movement toward reaching consensus on a set of standard indicators in maternal and child health (15).
PRESENTATION OF RESULTS
Results are presented as part of the decision-making process and are instrumental in the subsequent steps of setting priorities, goals, and objectives (16). Before presentation of results, the following questions should be considered: • Who is the audience for the needs assessment? • What is their interest in the data? Is this a presentation or a confrontation? • What is their level of methodologic sophistication? (eg, will they expect a discussion of statistical significance or will the discussion bore them?) • What kind of comparisons are most effective, relevant, and convincing for this audience? • How should the information be presented? • If it is a community report, what materials should be prepared for the media?
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Although data may be presented in a variety of methods, the use of graphic presentations in tables, graphs, or charts can be particularly effective. These can be created by hand or (preferably) through the use of a computer program (eg, PowerPoint: Microsoft Corporation; Redman, WA). Time series data can be especially powerful in a graph that illustrates either a clear trend or involves a presentation of "before and after" data that shows substantial change associated with a key event (eg, the rate of infant mortality was rising before the establishment of a new birth center, and since its opening it has dropped). As noted earlier here in the analysis section, showing the correlation between two events does not prove causality, but a "before and after" time series is a powerful means by which to focus a discussion. The purpose of the needs assessment will determine its written style and depth; most begin with a brief executive summary of the important findings, an organization of results into major sections, an explanation of the methodology used to collect the data, results presented in graph format (preferably with the actual data available in the text or in an appendix), and carefully referenced sources. The format should be appropriate to the expected audie n c e - b e they neighborhood groups, granting agencies, legislators or your own organization. The information should be organized so that the audience will be able to visualize the most important comparisons of data, both in table and chart format. A valuable reference for presentation of information in altemative formats is Wallgren et al's Graphing Statistics and Data (17). RECOMMENDATIONS
A needs assessment is both a process of data collection about a community and a written and often public report of the findings. In general, the final product is akin to a "SOAP" (subjective, objective, assessment, plan) note, combining subjective and objective findings into an overall assessment. An assessment of the needs of the community should be derived from the findings and support the development of a plan that, while drawing on general knowledge through the literature review, is specifically attuned to the local community's needs. Just as a written history of patient contact is crucial to patient care, so the written needs assessment is central to addressing a community's health needs. Midwives should use needs assessments to assist their decision-making and identify populations that may be underserved in their practice or the community as a whole. Needs assessments can be particularly valuable in justifying service provision to vulnerable populations, as many of these services are publicly funded and require needs assessments to justify fund-
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ing proposals. Also, m a n y of these groups are relatively small and need very specialized services including outreach, translation, and other innovative a p p r o a c h e s that midwives are especially suited to incorporate into health care provision. A needs assessment m a y identify m a n y services that are in place but can also describe existing barriers to certain groups. For example, a needs assessment can describe local provider service hours and locations and also reveal a lack of transportation to those locations at those times. The assessment can then provide justification for a proposal to add or c h a n g e locations, e x p a n d service hours, or add a transportation van. Three major problems should be considered in conducting a needs assessment (1). The first is that current m e t h o d s are useful only for deriving estimates, and decision makers often prefer greater precision. Such expectations are unrealistic because studies of h u m a n behavior can seldom be precise and estimates are of considerable value in identifying service gaps and providing targets. The second is the problem of data availability; typically, a lack of resources m e a n s the ideal data are not available or are not specific to the particular planning issue in question, therefore, existing data sources should be used creatively and their limitations expressed. The third problem is that of creating expectations. As a needs assessment is conducted, it may create a desire for a service or make public what had been a latent p e r c e p t i o n of need in the community. It is, therefore, important to prevent unrealistic expectations as interviews are designed and to analyze the data in light of a possible bias toward the p r o p o s e d p r o g r a m (1). A needs assessment is both a research process and a written document that carefully and often publicly documents a problem. The literature review about other programs and strategies also may identify possible solutions to the problem. Needs assessment sources should be traceable and accurate, and the literature search should include all relevant prior knowledge about the target group, with some type of comparison made to put the information in a larger context. As midwives begin providing more primary care services to existing caseloads and consider opening or expanding their practices to include underserved populations, a needs assessment is a vital step in determining both the necessity and the demand for services, as well as a way of presenting a potential program to local officials, grant makers, or insurers. In a managed care environment, midwives will need to justify systematically not just the quality of their care
but also the demand for their services. For midwives, needs assessments will become an increasingly valuable tool in systematically building the case for expanded and more effective practices.
Preparation of this article was supported in part by grant #MCJ259501 from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services.
REFERENCES
1. Kettner PM, MoroneyRM, Martin LL. Designingand managing programs: an effectivenessbased approach. NewburyPark (CA):Sage Publications, 1990. 2. Peoples-Sheps M, Farel A, Rogers M. Assessment of health status problems: self-instructional manual. Washington (DC): Maternal and Child Health Bureau, 1996. 3. Institute of Medicine. The future of public health. Washington (DC): Academic Press, 1988. 4. Collins-FuleaC, editor. An administrative manual for midwifery services. 2nd ed. Washington (DC): American College of Nurse-Midwives, 1996. 5. Keppel KG, Freedman MA. What is assessment? J Public Health Manage Prac 1995;1:1-17. 6. Fink A. Evaluation fundamentals: guiding health programs, research, and policy. Newbury Park (CA): Sage Publications, 1993. 7. Department of Health and Human Services (US). Healthy people 2000. Washington (DC): U.S. Department of Health and Human Services, 1991. 8. Massachusetts Department of Public Health. Adolescent births: a statistical profile, Massachusetts, 1994. Boston: Department of Public Health, 1996. 9. Patton MQ. Qualitative evaluation and research methods. 2nd ed. NewburyPark (CA): Sage Publications, 1990. 10. FinkA. The surveykit. Thousand Oaks (CA):Sage Publications, 1995. 11. Work Group on Systems Development. Needs assessment for improved systems of care. Arlington (VA):National Center for Education in Maternal and Child Health, 1994. 12. BourqueLB, Fiedler EP. How to conduct self-administered and mail surveys. Thousand Oaks (CA): Sage Publications, 1995. 13. Krueger RA. Focus groups: a practical guide for applied research. 2nd ed. Thousand Oaks (CA): Sage Publications, 1994. 14. BlalockHM. Theory construction. EnglewoodCliffs (NJ): Prentice-Hall, 1969. 15. Klerman L, Rosenbach M. Needs indicators in MCH planning. Washington (DC): National Maternal and Child Health Clearinghouse, 1984. 16. TimmreckT. Planning, program development and evaluation. Boston: Jones and Bartlett, 1995. 17. Wallgren A, Wallgren B, Persson R, Jorner U, Haaland J. Graphing statistics and data. Thousand Oaks (CA):Sage Publications, 1996.
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ADDITIONAL SUGGESTED READING Aikins Murphy P. Interpreting research for clinical practice. J Nurse Midwifery 1988;33:249-51. Aikins Murphy P. Clinical epidemiology: applying science to the art of nurse-midwifery. J Nurse Midwifery 1992;37:219-21. Cheadle A, Wagner E, Koepsell T, Kristal A, Patrick D. Environmental indicators: a tool for evaluating community-based health-promotion programs. Am J Prev Med 1992;8:345-50. Farel A. Needs assessment in MCH Programs. In: Wallace H, Nelson RP, Sw~eney PJ, editors. Maternal and child health practices. 4th ed. Oakland (CA): Third Party Press, 1994. Fine A. Indicators for accountability: an overview of recent developments. Washington (DC): Data Analysis and Information Resource Management Branch, Maternal and Child Health Bureau, HRSA, 1996. Helms W, Isaacs M. Review of needs assessment approaches. Technical assistano~ memorandum. Washington (DC): Alpha Center, 1991. Ireys H. Blueprint for needs assessment: contributing to a system of care for children with special needs and their families. Baltimore: Johns Hopkins University Children's and Adolescent Health Policy Center, 1995. Kahn, C. Picking a research problem: the critical decision. N Engl J Med 1994;330:1530-33.
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Paine L, Greener D. Nurse-midwives speak out on research: results of the 1987-88 needs assessment survey, part 2. J Nurse Midwifery 1989;34:66-70. Peoples-Sheps M, Farel A, Ahluwalia I. Needs assessment: resource handbook. University of North Carolina at Chapel Hill, Chapel Hill (NC): Department of Health and Human Services (US), Maternal and Child Health Bureau, 1996. Peoples-Sheps M, Farel A, Rogers M. Health services needs assessment: self-instructional manual. University of North Carolina at Chapel Hill, Chapel Hill (NC): Maternal and Child Health Bureau, 1996. Strobino D. Child health needs assessment: a review of data sources to measure child health status. Baltimore: Johns Hopkins University Children's and Adolescent Health Policy Center, 1995. Varkevisser C, Pathmanathan l, Brownlee A. Designing and conducting health systems research projects. Health systems research training series, vol 2. Ottawa (Canada): IDRC, Marketing and Distribution Unit, 1991. Wigton A, Grason H. Child health systems primary care assessment. Baltimore: Johns Hopkins University Children's and Adolescent Health Policy Center, 1995. Work Group on Systems Development. Needs assessment for improved systems of care. Arlington (VA): National Center for Education in Maternal and Child Health, 1994
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Address correspondence to Eugene R. Declercq, PhD, MBA, Boston University School of Public Health, Department of Maternal and Child Health, 715 Albany Street, A206, Boston, MA 02118.
478 © 1997 by the American College of Nurse-Midwives Issued by Elsevier Science Inc.
center, adding an interpreter to staff, starting an outreach program for teen mothers, or advertising primary care services. DEFINITION OF NEEDS ASSESSMENT
Assessment has been identified as one of the three core functions in public health practice and is the building block for the other two functions (along with policy development and assurance) (3). A needs assessment is practical research culminating in a description of a specific group's health status, as well as the adequacy of resources available to that population. The process will enable a midwife to uncover an unmet health need or an underserved group within a community and use that information to design a solution to the identified problem. Health information about population groups can be both quantitative and qualitative. Qualitative data can come directly through personal interviews, surveys, or focus groups. Quantitative data sources can include existing data analyzed specifically for the needs assessment (eg, examining hospital records to identify infant readmission rates) or secondary sources, such as library resources, Internet sites, or research previously conducted by other community agencies. The c o n c e p t of " n e e d " may be expressed or valued differently depending on one's perspective. Generally, it implies that a community health problem exists that can be diagnosed and treated. A need was defined in Title XX legislation as " a n y identifiable condition which limits a p e r s o n or individual, or a family member in meeting his or her full potential. Needs are usually expressed in social, economic, or health refated terms and are frequently qualitative statements" (1). Kettner et al describe a need as either relative, normative, expressed, or perceived (1), and PeoplesSheps, et al (2) identify five categories of needs (Table I). A needs assessment is an attempt to quantify and understand a specific need within the community in an effort to target resources effectively to address that need. Although somewhat akin to market research, a needs assessment focuses on the need for services rather than the profitability of services (4). Additionally, the need
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may be related to barriers to, or the availability of, existing services, rather than the lack of services. Keppel and Freedman (5) described the following characteristics of services that can enhance or reduce their availability: proximity, accessibility, cost, affordability, acceptability, appropriateness, effectiveness, and ability to coordinate with other services. Often, the conclusion of a needs assessment may indicate that although proper services exist in a community, the services are not useful to, or used by, at-risk groups because of one or more of the characteristics just listed. TYPES OF NEEDS ASSESSMENTS
Needs assessments can be classified along several dimensions relating to source (internal versus external) and audience (private versus community). For example, an internal needs assessment might be commissioned by an HMO in an effort to decide whether staff midwives should provide expanded primary care services, whereas a state public health department may ask a local group
Eugene R. Declercq is associate professor and associate chairman for the Department of Maternal and Child Health at the Boston University School of Public Health. He teaches a course entitled "Assessing and AnalyzingMCH Systems,"in which students of maternal and child health learn the elements of needs assessment. Dr, Declercq has directed a number of populationbased needs assessments, including a recent community report,
The Health of Lawrence,Massachusetts, 1995: A Community Needs Assessment. In addition to his work as a maternal and child health policy analyst, Dr. Declercq is a childbirth educator and served as assistant editor of this home study series. Terry Jo V. Bichell is a 1997 graduate of the Maternal and Child Health Leadership Program at the Boston University School of Public Health, where she also completed her nurse-midwifery education and master of public health degree. She received her nursing degree in 1992 from the St. Louis University School of Nursing and her undergraduate degree in international health in 1984 from the Johns Hopkins University. Ms. Bichell's professional experience includes childbirth education, administration of an operation's research project on family planning in Africa, and an independent video production on a variety of health-related topics, including family planning, acquired immunodeficiency syndrome (AIDS), and women's health. Jill K. Center is a 1997 graduate of the Maternal and Child Health Leadership Program at the Boston University School of Public Health, where she also completed her master of public health degree. She received her undergraduate degree in English at Wake Forest University in 1992, attendance of which included a semester at the Worrell House in London, England. Ms. Center's professional experience in maternal and child health services administration includes her recent roles as clinical supervisor in the Department of Obstetrics and Gynecology, Harvard Pilgrim Health Care, Boston, Massachusetts, and assistant coordinator of Gynecology and Contraceptive Services, Planned Parenthood Clinic of Greater Boston, Brookline, Massachusetts.
including midwives to assess the extent and nature of adolescent pregnancy in their community. The audience for the assessment may be a single funder (eg, an HMO), a state or local commission (eg, when midwives systematically identify why there is a need to expand prescriptive authority), or the community-at-large, wherein the results are widely published (eg, the teen pregnancy study). A needs assessment may combine elements of each approach. An example of an i n t e r n a l l y g e n e r a t e d needs assessment might be a situation in which two newly graduated midwives plan to open a midwifery practice in their local community. Questions must be raised about both the feasibility of starting a new practice in that area and the characteristics of the mothers they would be serving. Their assessment should also involve listening to local opinion at a public hearing, reviewing community demographic, economic, and health data previously gathered by state and local agencies, and compiling natality statistics from the state public health department. Their research might show, for instance, that there are no midwives practicing in the area, that the percentage of births to teen mothers is twice as high as the statewide rates, and that only a third of local women are using area institutions for their obstetric care. As a result of this research, a practice model could be created to serve the needs of local women, especially teenagers. An example of an externally generated needs assessment is one that is developed in response to national concern about high infant mortality rates in urban areas. Midwives in a particular area might conduct a needs assessment in a neighborhood with a high rate of infant mortality. It might be found that although services for pregnant women are readily available, they are fragmented, with few agencies providing continuity of care to at-risk women in the form of a consistent one-provider-to-one-patient relationship. This approach was used recently by a small group of midwives in Boston, Urban Midwife Associates, who determined through a needs assessment that a new practice modeled on the conviction that continuity of care with a midwife in an independent private practice setting would be the best way to reach women in their area who were at higher risk for infant mortality (personal communication, Peggy Garland, CNM, MPH, June 18, 1997). IMPLEMENTING A NEEDS ASSESSMENT
The steps necessary for successful completion of a needs assessment generally include the following: 1) formulating a question, 2) reviewing the literature, 3) describing existing resources, 4) refining the question,
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TABLE I
Categories of Unmet Needs (2) Unmet Need
Definition
Measurement
Professional and consensusbased standards Demand for services
Recommended services not available
Compare target population to accepted standard such as Healthy People 2000 Numbers on waiting lists; actual use compared with capacity of services
Underserved population at risk Relative availabilityof services Perceptions
Numbers of people who seek relevant services and are not served Number of people at risk who do not receive services Equity of services available in two similar populations Services people say are needed to prevent health problems
5) collecting data (including secondary and primary data), 6)analyzing the results, and 7) presenting the results to the public.
Formulating the Question If the assessment question is generated internally, there usually will be greater control of its shaping and refinement; control of an externally generated question may be limited. A clear and concise definition of the problem and the study population is critical to determining the appropriate approach to use to produce a useful outcome from the needs assessment process. Most needs assessment questions will fit into one of the following areas: • What is the general health status of a population? (ie, How healthy are the people in my community?) • Does a specific population have a certain health problem? (ie, Are too few Hispanic mothers beginning prenatal care in the first trimester?) • Are there sufficient and correctly designed services to address a specific health problem or a specific community group? (ie, Are postpartum home visiting services available and in languages other than English?) • Are there barriers that prevent a certain group from accessing services? (ie, Do any maternity care providers speak Spanish?) After an initial literature review, the questions can be refined and reformulated and the best sources of data identified
The Literature Review A literature review prevents duplication of previous work, reveals others' attempts at solving similar prob-
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Estimate of population at risk compared with numbers who receive services Compare services available in two populations Qualitative surveys of providers and people at risk
lems, and enables refinement of the initial question. The literature collected should include current published articles concerning the clinical and public health nature of the problem, as well as unpublished material available from national, state, and local agencies. Among the questions to consider are the following: • What is the exact nature of the problem in the population of interest? • What is the recommended clinical approach to the problem? • Has any other organization in the community done a similar (or any) needs assessment? • What kind of related information has been gathered and to what purpose? • Are there any previously identified sources of information about the community? • Are there sources of information that have been overlooked? • How was the past information presented, and what was the response? After becoming familiar with the nature of the problem, a programmatic literature review should be done. This process may be unfamiliar to many midwives, even though they may have considerable experience with clinical literature reviews. A programmatic literature review simply describes and evaluates programmatic initiatives. For example, in addition to the Medline database of citations, an examination of HealthStar will provide citations of the published literature on service delivery, including health services, technology, administration, and research. Often program descriptions are available from the public (eg, Maternal and Child Health Bureau) and private (eg, Robert Wood Johnson Foundation) agencies that fund such initiatives. This research can reveal not only past attempts to address similar problems, but might identify potential funding sources
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for one's own program. Many funding sources maintain World Wide Web sites that can lead to the information sought. In performing the programmatic literature review, the following questions should be considered: • What private and government efforts have been made to address the problem? • If different approaches to the same problem exist, what are the sources of the conflict? • Are there local barriers to implementing the services described elsewhere? • Have the services reached their target populations? • What was the effectiveness of services available in other communities? This can be accomplished by examining "before and after" statistics, with an awareness of the limitations that may exist in the findings. • Do the conclusions correspond to the data?
Describing Existing Services The true definition of community-based needs is the difference between the services needed and those currently provided. Therefore, a needs assessment should include some description of what services exist and how accessible and appropriate they are to the population of concern. The source of information for this stage of research may be as simple as a series of phone calls to providers documenting hours of operation, willingness to accept new patients, links to insurers, and languages spoken by the providers. At the other extreme, this research may involve formal program evaluations of current services (6). There may be existing studies by community groups that can serve as a valuable resource, although care must be taken to assess the quality of such secondary studies.
Refining the Question Assessment of current services and completion of the clinical and programmatic literature review will result in a clearer sense of the nature of the problem to be addressed, the characteristics of the population to be served, and what, if any, approaches were used in the past to rectify the problem. The needs assessment must then focus on a very clearly defined target group. Target groups can be selected by demographic indicators (eg, age, race, ethnicity, religion), service areas (eg, the known patients of a health clinic), catchment area (eg, geographic locations such as neighborhoods, towns, or regions; all the streets along one bus route; a census tract; a school district), or by an identified need (eg, women at risk of abuse, teen pregnancy, exposure to environmental toxins). On the basis of
these considerations, the question can be further refined to reflect more accurately both the target community and the information needed to formulate a possible solution. Ultimately, the end result should be a refined question that is both relevant (Will anyone care?) and researchable (Is there an answer?).
Data Collection There are a variety of approaches to data collection. The two methods that are the most useful and feasible for a community-based needs assessment are qualitative primary data collection and secondary data collection. In general, primary data collection involves original research that addresses a specific question, whereas secondary data is information collected by someone else for their own purposes. The tradeoffs involved in each approach are obvious, with primary data collection preferred but usually much more costly and time consuming. Secondary data is often not precisely applicable to the specific question to be addressed. Given that the costs associated with most approaches to primary data collection typically make it beyond the reach of individuals or small groups, this discussion focuses on how to find and best use secondary data and integrate it with less costly, but valuable, primary data collection techniques. As discussed at length in a later section on analysis of results, standards of comparison are essential to any needs assessment. This point is noted here because analysis cannot be completed if the comparison data have not been collected. The availability of such comparison data may shape what local information is to be collected; because the comparison data were used to answer someone else's question, the available data may be in very different forms. For example, if a comparison was to be made between local teen pregnancy rates and state and national standards, there must be some degree of sensitivity as to how data are reported at those levels. Healthy People 2000 standards (7) seek to reduce pregnancies "among girls aged 17 and younger," citing a target of 50 per 1,000 girls, whereas a Massachusetts report on adolescent pregnancy in the state presented birth rates for 15-19 year olds (8) and local data reported the actual number of births to women less than 20 years and less than 18 years old (8). None of these figures are comparable with each other as they stand, and although adjustments can be made to enable reasonable comparisons, it is the researcher's responsibility to plan and collect the information that will facilitate those comparisons.
Qualitative and quantitative data. Many different modes of inquiry can be used to gain an understanding
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of a particular issue or need. This is nowhere better understood than in the context of a midwife's practice. In assessing a client, a midwife considers multiple types of information and uses a variety of skills to elicit information from a client to better understand her needs and assess her health. A prenatal assessment consists of a blending of empirical, or quantitative information such as weight, fundal height, urinalysis, and other measurable, quantifiable data with qualitative information gleaned from answers to a series of open-ended questions, such as "What kind of support do you have from your partner/family/friends?" and "Tell me about your concerns with this pregnancy." An appropriate assessment of the client's well-being and health depends on the use of both methods of information gathering. Using these methods of inquiry is also valuable as a means of identifying, defining, and articulating a population need. Michael Quinn Patton (9) reinforces this idea, suggesting, "because qualitative and quantitative methods involve differing strengths and weaknesses, they constitute alternative, but not mutually exclusive, strategies for research." Quantitative data offer a summary of trends and patterns, and qualitative data usually provide information about fewer cases in more detail than statistical data. In general, the advantage of using quantitative data is that it can provide limited information about a large number of people, identify trends in the health status of given populations, and provide data that are appropriate for statistical and comparative analysis.
Primary quantitative data. The most common form of primary quantitative data collection are surveys of public opinion. These can be very valuable, particularly if they are well-constructed, because they can provide insights into individual opinions, which can then be analyzed along a number of dimensions (eg, demographic characteristics). Unfortunately, a well-designed and implemented survey is also very costly and generally beyond the means of individuals; therefore, their strengths and weaknesses will only be briefly summarized here. For those interested in using surveys in their community, The Survey Kit (Sage Publications) is a valuable and relatively inexpensive tool (10). Surveys can be used to collect information from a large sample of the population and may be conducted via telephone interview, face-to-face interview, or self-administered questionnaire. For example, a group of midwives n~lay want to know if there is a need for their services among women in an adjoining community and may choose to use a combination of quantitative and qualitative methods to address the question. With some variations, survey methods could be used to collect
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qualitative data (often based on open-ended questions) or quantitative data (more likely relying on closed-ended questions). As in the case of a clinical assessment, the way a survey is constructed and the questions worded in a needs assessment will have a profound effect on the value of the data gathered. If a personal or telephone public opinion survey is used, the issue of who comprises the sample, as well as the size of the sample, is crucial to the validity of the results. If the goal of the survey is to generalize the findings to all women in the community, the sample selected must be representative of this population and must be of sufficient size for the variable studied (eg, 4 0 0 + , depending on sampling technique) for the data to be considered valid. Selecting a randomized sample is the best way to ensure that there is no bias in the selection of participants in the survey. It should be noted that the same considerations concerning survey sampling apply to studies that rely on a sample of hospital or provider records. For those who are unfamiliar with this method of research, it may be wise to hire a consultant for assistance in drawing the sample, developing the survey tool, and analyzing the results. Care should also be taken in the design of the survey tool to phrase questions in language that will be easily understood by the respondents and not to include biased questions that lead the respondent to certain desired answers (11). A mail survey may seem like a useful compromise because it is less costly; however, it is often a false savings. Mail surveys involve questions of sampling (results are determined by who chooses to send in a response; thus, it cannot be determined if those who returned a questionnaire have opinions comparable to the population of interest) and validity (it cannot be determined who actually completed the survey and under what circumstances). Additionally, if the respondent does not understand a question, it cannot be clarified for them. Mail surveys are typically shorter, involve few open-ended questions and must, as Bourque and Fielder (12) note, "stand alone," as no probes or follow-up questions are possible. Mail surveys require more care than may initially be understood and are most valuable when used as a complement to other forms of data collection.
Secondary quantitative data. Secondary data refer to data already collected, organized, and analyzed, which may or may not be published. Secondary data are often inexpensive to obtain and already available, resulting in a significant savings of time, personnel, and money. Secondary data may be the only available option to researchers who lack the resources to initiate a major community-wide study dedicated to their question. A
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good place to begin a needs assessment is with a review of secondary data pertaining to the topic of study as a means of exploring the scope and depth of the need the investigator is researching. Secondary data are available in many forms, and depending on the specific information necessary for the formulation of a needs assessment, much or all of the data needed may have already been collected. The major advantages of using secondary data are that such use is generally less expensive than conducting original surveys and studies, it may provide informarion on entire populations or at least much larger samples than data collected by an individual, and the data are available much more quickly, enabling the investigator to respond rapidly to requests for a profile of needs in a community. The major problems with secondary data are availability and applicability. The data might not be accessible (eg, in insurance company records) or typically, may not be organized in a way that directly addresses the target question. For example, statewide data on sexually transmitted diseases may be available but might not be organized at a community level; community data may exist but not be broken down by age or ethnicity; or the categories available do not necessarily coincide with the researcher's question (eg, a question about adolescent sexuality is addressed only by existing data about juniors in the local high school). Likewise, a question about the outcomes of planned home births in an area may lead to birth certificate data, which in most states combine planned and unplanned home births. There may also be questions of timeliness (How long ago were the data collected? What changes to the community have occurred in the meantime? How were the data collected?). Secondary data may be accessed through hard copy resources or more recently, through a variety of Internet and electronic sources. Ideally, a refined question should address a perceived need and not be a function of what data are available; however, reality often dictates compromises depending on what can be known with existing resources. There are several possible sources for data providing information about the characteristics of national and local populations. These data sources may include information about demographic trends, vital statistics, health history, service availability, service utilization, maternal and infant morbidity and mortality, and nutrition status. With any data source, it is important to bear in mind its particular strengths and weaknesses and how they affect the credibility of the needs assessment being developed (Table 2). Primary qualitative sources. Using data from a variety of sources and methods of inquiry can strengthen a
needs assessment. Methods for primary qualitative data collection include the use of key informant interviews, focus groups, and in-depth interviews with clients and the public. Depending on the investigator's skills, financial resources, and time frame for obtaining the data, one or more of these methods may be used to support the definition of need for the population to be served or studied. Qualitative methods rely on the researcher's ability to collect information about people's experiences, thoughts, opinions, and understanding of a given topic. This mode of inquiry usually involves the researcher's observations and interviewing of subjects involved in or related to the topic of study (perhaps a particular program or organization). One of the strengths of this type of inquiry is the support it provides a researcher seeking to learn about an issue in depth, in a way that exclusive use of quantitative methods often does not allow. The validity of qualitative data relies mainly on the researcher's skill as an interviewer, as opposed to the construction of the interview tool (as in collection of quantitative data). Through the use of the following techniques and information, a midwife may apply a w~riety of methods to obtain information to be effectively used in a needs assessment.
Key informant interviews and in-depth interviews with clients and the public. Key informant interviews involve solicitation of information from carefully selected experts or other individuals knowledgeable about the issue or need being studied. Questions may be phrased to elicit open-ended, "yes/no", or multiple-choice responses. AIthough this type of data source can enhance understanding of an issue or problem, it is also important to bear in mind that key informants may have their own biases and prejudices that might emerge during the interview. A comparison of data collected from several key informant interviews can enhance the quality and depth of the data collected. By using a similar format, a midwife interested in providing a specific service may conduct interviews with current clients or members of the community to assess the need or desire for the service. Focus groups. Focus groups are a method of collecting qualitative data from a carefully chosen population who are led by an individual skilled in facilitating group discussions (13). As Krueger (13) notes, "The focus group is a special type of group in terms of purpose, size, composition and procedures. A focus group is typically composed of seven to 10 participants who are selected because they have certain characteristics in common that relate to the topic of the focus group." The goal is to elicit the views and
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opinions of each member of the group in an e{fort to emerge from the meeting with a deeper understanding of the issue of interest. One of the unique and most intriguing aspects of conducting research using this method is the p h e n o m e n o n of the group yielding a richer and more complex set of data than the sum of its parts. The effect of asking questions in a group setting as opposed to questioning several people individually can result in responses building on each other; however, it is also important to acknowledge that this group dynamic may result in "group think" and thereby stifle individual ideas or opinions. A midwife may choose to conduct a focus group as a means of collecting qualitative data to support a needs assessment. For example, a midwife who wants to begin a new practice may attempt to assess the need for a midwifery practice in several communities by assembling focus groups in the target areas. The group setting may be used to introduce questions about the group's attitudes, knowledge, and experiences with midwives. This essential information would be more difficult to obtain through quantitative methods of inquiry. The members of the group may offer information that supplements equally important data about women's access and use of available health care providers. Utilization data may show that although most women in the community have adequate access to providers, utilization rates are low. A focus group may help to illuminate the reasons for such a discrepancy. The midwife may ascertain that several women are not comfortable with the available providers and would prefer to seek care from a midwife, a provider who speaks their language, a provider whose specialty is specifically women's health, or a female provider. Although the quantitative data may show an adequate number of accessible providers, a need for a new midwifery practice may be supported by the qualitative data obtained from a focus group in which the participants were able to articulate in depth their needs for the type of provider with whom they would be most comfortable and most likely to see regularly for care. ANALYSIS OF RESULTS
There are three terms that are essential to understanding analysis of data from a needs assessment: comparison, comparison, and comparison. The research process usually involves one of three basic designs, and all involve some form of comparison: I. Experimental design (comparison of subjects randomly assigned to an experimental or a control group) 2. Time series (comparison of the same population over time)
3. Cross-sectional (comparison between similar groups at one point in time) Most needs assessments involve some form of time series or cross-sectional analysis~ as well as comparison to external standards (eg, Healthy People 2000); experiments are uncommon in field settings and are, thus, of limited value here. In any comparison, it is critical to ensure that the data being compared are sufficient and actually comparable, as demonstrated by the case of different "adolescent" age groups cited earlier. Equally important in many community studies is the problem of population size. For example, there may appear to be an alarming finding that the infant mortality rate in a community has jumped from 6.0 to 8.0 per thousand births (a 33% increase) in the past year, but in a community with 500 annual births, that represents a change of one infant death. If there were a substantial fall in the number of births, it may represent no change at all in the actual number of infant deaths. If a rare event (eg, an infant death or disability) in a small population is being studied, it is sometimes preferable to combine years for purposes of comparison (eg, compare average infant mortality rates for 3-year periods rather than single years) to reduce the effects of random variation on the data. A second overriding concem in the analysis stage of a needs assessment is to ensure that correlation is not confused with causation (14). Finding a relationship between two events (opening of a midwifery s e ~ c e and a fall in community infant mortality) is a necessary, but not sufficient, condition to determine that one caused another, although such a finding may seem entirely plausible. Time Series
The simple question, "Are we doing better than before?" is at the heart of time series analysis. Have infant mortality, breast cancer, teen births, and sexually transmitted diseases in the community increased or decreased during the past 5 years? There are several important questions to ask in looking at data over time: • Has the form of measurement changed in the time studied? (eg, the national standard certificate of a live birth was revised in 1989 with a change in key categories) • Has the population studied changed over that time? (eg, a long-term increase in the incidence of low birth weight in a city may be less the result of changes in care and more a function of an increasing number of at-risk mothers in the community) • Is there a long enough period to determine a trend? If teen births increase for three consecutive years, is there a trend? Perhaps, but more information is needed to discern a trend. Unfortunately, the longer
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the data period used, the more likely the two concerns cited earlier will become more prominent. Cross-Sectional Analysis
Many needs assessments involve some form of crosssectional analysis, comparing comparable groups with each other. This may involve comparisons with other similar communities, or breakdowns of a general population into smaller parts in an attempt to isolate a problem. The validity of the conclusions drawn from this approach will depend on the extent to which the groups compared are truly comparable. Are the two towns used in the comparison really alike? Are adolescents in one part of a large city similar to those in another?
External Standards
"In determining that individuals or groups have a need, it is important to evaluate existing conditions against some societally established standards. If the community is at or above those standards there is no need; if it is below those standards, there is need" (7). The most notable effort to establish standards for health outcomes has been the Healthy People 2000 project (7), which includes 14 targets to be achieved in maternal and child health by the year 2000. These targets serve as goals and they provide an outside, credible standard to present to the community. Many state health departments are also measuring state performance on a number of indicators, with a movement toward reaching consensus on a set of standard indicators in maternal and child health (15).
PRESENTATION OF RESULTS
Results are presented as part of the decision-making process and are instrumental in the subsequent steps of setting priorities, goals, and objectives (16). Before presentation of results, the following questions should be considered: • Who is the audience for the needs assessment? • What is their interest in the data? Is this a presentation or a confrontation? • What is their level of methodologic sophistication? (eg, will they expect a discussion of statistical significance or will the discussion bore them?) • What kind of comparisons are most effective, relevant, and convincing for this audience? • How should the information be presented? • If it is a community report, what materials should be prepared for the media?
486
Although data may be presented in a variety of methods, the use of graphic presentations in tables, graphs, or charts can be particularly effective. These can be created by hand or (preferably) through the use of a computer program (eg, PowerPoint: Microsoft Corporation; Redman, WA). Time series data can be especially powerful in a graph that illustrates either a clear trend or involves a presentation of "before and after" data that shows substantial change associated with a key event (eg, the rate of infant mortality was rising before the establishment of a new birth center, and since its opening it has dropped). As noted earlier here in the analysis section, showing the correlation between two events does not prove causality, but a "before and after" time series is a powerful means by which to focus a discussion. The purpose of the needs assessment will determine its written style and depth; most begin with a brief executive summary of the important findings, an organization of results into major sections, an explanation of the methodology used to collect the data, results presented in graph format (preferably with the actual data available in the text or in an appendix), and carefully referenced sources. The format should be appropriate to the expected audie n c e - b e they neighborhood groups, granting agencies, legislators or your own organization. The information should be organized so that the audience will be able to visualize the most important comparisons of data, both in table and chart format. A valuable reference for presentation of information in altemative formats is Wallgren et al's Graphing Statistics and Data (17). RECOMMENDATIONS
A needs assessment is both a process of data collection about a community and a written and often public report of the findings. In general, the final product is akin to a "SOAP" (subjective, objective, assessment, plan) note, combining subjective and objective findings into an overall assessment. An assessment of the needs of the community should be derived from the findings and support the development of a plan that, while drawing on general knowledge through the literature review, is specifically attuned to the local community's needs. Just as a written history of patient contact is crucial to patient care, so the written needs assessment is central to addressing a community's health needs. Midwives should use needs assessments to assist their decision-making and identify populations that may be underserved in their practice or the community as a whole. Needs assessments can be particularly valuable in justifying service provision to vulnerable populations, as many of these services are publicly funded and require needs assessments to justify fund-
Journal of Nurse-Midwifery • Vol. 42, No. 6, November/December 1997
ing proposals. Also, m a n y of these groups are relatively small and need very specialized services including outreach, translation, and other innovative a p p r o a c h e s that midwives are especially suited to incorporate into health care provision. A needs assessment m a y identify m a n y services that are in place but can also describe existing barriers to certain groups. For example, a needs assessment can describe local provider service hours and locations and also reveal a lack of transportation to those locations at those times. The assessment can then provide justification for a proposal to add or c h a n g e locations, e x p a n d service hours, or add a transportation van. Three major problems should be considered in conducting a needs assessment (1). The first is that current m e t h o d s are useful only for deriving estimates, and decision makers often prefer greater precision. Such expectations are unrealistic because studies of h u m a n behavior can seldom be precise and estimates are of considerable value in identifying service gaps and providing targets. The second is the problem of data availability; typically, a lack of resources m e a n s the ideal data are not available or are not specific to the particular planning issue in question, therefore, existing data sources should be used creatively and their limitations expressed. The third problem is that of creating expectations. As a needs assessment is conducted, it may create a desire for a service or make public what had been a latent p e r c e p t i o n of need in the community. It is, therefore, important to prevent unrealistic expectations as interviews are designed and to analyze the data in light of a possible bias toward the p r o p o s e d p r o g r a m (1). A needs assessment is both a research process and a written document that carefully and often publicly documents a problem. The literature review about other programs and strategies also may identify possible solutions to the problem. Needs assessment sources should be traceable and accurate, and the literature search should include all relevant prior knowledge about the target group, with some type of comparison made to put the information in a larger context. As midwives begin providing more primary care services to existing caseloads and consider opening or expanding their practices to include underserved populations, a needs assessment is a vital step in determining both the necessity and the demand for services, as well as a way of presenting a potential program to local officials, grant makers, or insurers. In a managed care environment, midwives will need to justify systematically not just the quality of their care
but also the demand for their services. For midwives, needs assessments will become an increasingly valuable tool in systematically building the case for expanded and more effective practices.
Preparation of this article was supported in part by grant #MCJ259501 from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services.
REFERENCES
1. Kettner PM, MoroneyRM, Martin LL. Designingand managing programs: an effectivenessbased approach. NewburyPark (CA):Sage Publications, 1990. 2. Peoples-Sheps M, Farel A, Rogers M. Assessment of health status problems: self-instructional manual. Washington (DC): Maternal and Child Health Bureau, 1996. 3. Institute of Medicine. The future of public health. Washington (DC): Academic Press, 1988. 4. Collins-FuleaC, editor. An administrative manual for midwifery services. 2nd ed. Washington (DC): American College of Nurse-Midwives, 1996. 5. Keppel KG, Freedman MA. What is assessment? J Public Health Manage Prac 1995;1:1-17. 6. Fink A. Evaluation fundamentals: guiding health programs, research, and policy. Newbury Park (CA): Sage Publications, 1993. 7. Department of Health and Human Services (US). Healthy people 2000. Washington (DC): U.S. Department of Health and Human Services, 1991. 8. Massachusetts Department of Public Health. Adolescent births: a statistical profile, Massachusetts, 1994. Boston: Department of Public Health, 1996. 9. Patton MQ. Qualitative evaluation and research methods. 2nd ed. NewburyPark (CA): Sage Publications, 1990. 10. FinkA. The surveykit. Thousand Oaks (CA):Sage Publications, 1995. 11. Work Group on Systems Development. Needs assessment for improved systems of care. Arlington (VA):National Center for Education in Maternal and Child Health, 1994. 12. BourqueLB, Fiedler EP. How to conduct self-administered and mail surveys. Thousand Oaks (CA): Sage Publications, 1995. 13. Krueger RA. Focus groups: a practical guide for applied research. 2nd ed. Thousand Oaks (CA): Sage Publications, 1994. 14. BlalockHM. Theory construction. EnglewoodCliffs (NJ): Prentice-Hall, 1969. 15. Klerman L, Rosenbach M. Needs indicators in MCH planning. Washington (DC): National Maternal and Child Health Clearinghouse, 1984. 16. TimmreckT. Planning, program development and evaluation. Boston: Jones and Bartlett, 1995. 17. Wallgren A, Wallgren B, Persson R, Jorner U, Haaland J. Graphing statistics and data. Thousand Oaks (CA):Sage Publications, 1996.
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ADDITIONAL SUGGESTED READING Aikins Murphy P. Interpreting research for clinical practice. J Nurse Midwifery 1988;33:249-51. Aikins Murphy P. Clinical epidemiology: applying science to the art of nurse-midwifery. J Nurse Midwifery 1992;37:219-21. Cheadle A, Wagner E, Koepsell T, Kristal A, Patrick D. Environmental indicators: a tool for evaluating community-based health-promotion programs. Am J Prev Med 1992;8:345-50. Farel A. Needs assessment in MCH Programs. In: Wallace H, Nelson RP, Sw~eney PJ, editors. Maternal and child health practices. 4th ed. Oakland (CA): Third Party Press, 1994. Fine A. Indicators for accountability: an overview of recent developments. Washington (DC): Data Analysis and Information Resource Management Branch, Maternal and Child Health Bureau, HRSA, 1996. Helms W, Isaacs M. Review of needs assessment approaches. Technical assistano~ memorandum. Washington (DC): Alpha Center, 1991. Ireys H. Blueprint for needs assessment: contributing to a system of care for children with special needs and their families. Baltimore: Johns Hopkins University Children's and Adolescent Health Policy Center, 1995. Kahn, C. Picking a research problem: the critical decision. N Engl J Med 1994;330:1530-33.
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Paine L, Greener D. Nurse-midwives speak out on research: results of the 1987-88 needs assessment survey, part 2. J Nurse Midwifery 1989;34:66-70. Peoples-Sheps M, Farel A, Ahluwalia I. Needs assessment: resource handbook. University of North Carolina at Chapel Hill, Chapel Hill (NC): Department of Health and Human Services (US), Maternal and Child Health Bureau, 1996. Peoples-Sheps M, Farel A, Rogers M. Health services needs assessment: self-instructional manual. University of North Carolina at Chapel Hill, Chapel Hill (NC): Maternal and Child Health Bureau, 1996. Strobino D. Child health needs assessment: a review of data sources to measure child health status. Baltimore: Johns Hopkins University Children's and Adolescent Health Policy Center, 1995. Varkevisser C, Pathmanathan l, Brownlee A. Designing and conducting health systems research projects. Health systems research training series, vol 2. Ottawa (Canada): IDRC, Marketing and Distribution Unit, 1991. Wigton A, Grason H. Child health systems primary care assessment. Baltimore: Johns Hopkins University Children's and Adolescent Health Policy Center, 1995. Work Group on Systems Development. Needs assessment for improved systems of care. Arlington (VA): National Center for Education in Maternal and Child Health, 1994
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