Approaches To Community Needs Assessment A Literature Review

JournalofAdvanced Nursing, 1995,22, 721-730
Approaches to community needs assessment:
a literature review
JenniferRuth BillingsBSc(Hons) RGNRHVDPNS
ResearchAssistant
and Sarah Cowley BA Phi3 PGDERGNRCNTRHV FWT HVT
Lecturer,Department of Nursing Studies, Kings CollegeLondon, London, England
Acceptedforpublication1December1994
BILLINGSJ.R.&COWLEYS. (1995) Journal of Advanced Nursing 22, 721-730
Approaches to community needs assessment: a literature review
In the light of the growing awareness of professionals in the community of the
need to undertake health needs assessments of the population, this literature
review sets out to explore, delineate and critically analyse the various
approaches to community needs assessment, to facilitate a greater
understanding of their strengths and weaknesses. The review commences by
highlighting its complex nature, and attempting to define what is meant by
'needs assessment' f~om the differing perspectives of three dominant
approaches, namely sociology, epidemiology and health economics. It
continues by putting forward an argument for the use of the community health
profile, being a multi-focal approach to needs assessment, combining
quantitative with qualitative data, and proceeds with a discussion of strengths
and weaknesses related to its compilation, in particular factors relating to
reliability and validity of data sources. The consumer perspective is also
reviewed, as are issues surrounding the ethics of data collection and problems
concerning aggregation of the numerous data sources into meaningful policy.
Throughout the review, issues are discussed with reference to the current
political context in the United Kingdom. Equally important is the community
nurse perspective, which is integrated into the arguments where appropriate.
INTRODUCTION
Needs assessment has always been a priority issue for
those concerned with community health, but it was the
publication of the Acheson report which led to a
resurgence of interest, proposing as it did that directors of
public health should be responsible for assessing the needs
of their local populations (Department of Health and
Social Security 1988}. Since this proposal, successive
Department of Health (England} papers (1989a, 1989b,
1990, 1991, 1993} have broadened the professional scope
Correspondence:JenniferB.Billings,DepartmentofNursing,King's
CollegeLondon,CornwallHouseAnnexe,WaterlooRoad,LondonSE1
8TX,England.
and application of needs assessment by reaffirming its
importance as a means of determining the provision and
extent of health care. As a result, this so-called 'needs-led'
style of planning signals a departure from previous
approaches, which were predominantly service-led
(Stalker 1993). Community needs assessment has been
defined simply as 'a description of those factors which
must be addressed in order to improve the health of the
population' (Harvey 1994).
Although needs assessment was initially seen as the
primary responsibility of potential purchasing and
commissioning authorities, and necessary to inform the
contracting process (Department of Health 1989c), com-
munity provider units are now recognizing the important
contribution they can make towards the identification of
©1995BlackwellScienceLtd 721

J.R. Billings and S. Cowley
local population needs, particularly through the work of
community nurses (Day 1992, Goodwin 1994). A recent
report concerning the progress of the Health Visitor
Marketing Project initiated by the National Health Service
Executive (NHSE 1994) also emphasizes that purchasers
recognize the central role potentially held by health visi-
tors in accumulating information about health needs in the
population, and require that this service be incorporated
into service specifications.
The ability to carry out a full assessment of the needs of
individuals, families and communities is, however, not a
new and fashionable marketing feature for community
nurses, but has always been a central feature of community
nursing practice, in recognition that an assessment of indi-
vidual client need is fundamental to ensuring suitable ser-
vice provision (Goodwin 1988). Indeed, the Council for
the Education and Training of Health Visitors specified in
1977 that the search for health needs and a stimulation of
their awareness were to be principle objectives within
health visiting practice. Considering the challenges of
today's practitioners, such as increasing social deprivation
and poverty (Blaxter 1990), inequalities in health
(Phillimore et al. 1994) and the growing morbidity and
mortality from heart disease and AIDS (Department of
Health 1991), these principles are as relevant today as they
were for community nurses in the 1970s (Twinn &
Cowley 1992).
APPROACHES TO 'NEEDS' DEFINITIONS
Assessment of health needs has been the subject of much
inquiry over the past two decades, escalating in recent
years due to the pressure of government legislation
(Buchan & Gray 1990). The complex, multi-dimensional
nature of needs assessment has been revealed, and those
health care managers and practitioners who have launched
into this field are realizing that the task is far from straight-
forward. Defining what is meant by 'needs' is a case in
hand. Orr (1985a) provides an initial interpretation that
reveals the multiple meanings attached to the concept,
defining need as 'social, relative and evaluative', social in
being defined according to standards of communal life,
relative in that its meaning will vary between people and
societies, and evaluative in that it is based upon value
judgements. The difficulties of operationalizing these
notions for assessment purposes becomes apparent.
In a broader perspective, sociologists, epidemiologists
and health economists have each defined needs from their
own standpoint. Generally, the sociological view is exem-
plified by Bradshaw (1972), whose taxonomy of formative
need, felt need, expressed need and comparative need
remains cogent in health care, distinguishing as it does the
important differences between needs as identified by pro-
fessionals (normative) and those 'felt' by the individual.
The influence of Bradshaw is also evident in community
nursing, where the concept of need is perceived as per-
sonal, subjective and variable (Orr 1985b, Twinn &Cowley
1992). This perspective does, however, raise issues
concerning the difficulty of forming clear and comparable
criteria for needs assessment.
Buchan & Gray (1990) argue that qualitative definitions
of need tend to be nebulous and of little help in determin-
ing appropriate levels of service requirement. In a study
of social welfare provision, for example, Thayer (1973)
concluded that the taxonomy of need was a useful way to
demarcate different approaches to assessment, but there
was little methodological evidence to suggest that the
concepts could be operationalized in a meaningful way.
In general terms, however, health is a broad concept
(Seedhouse 1986) and there would appear to be unlimited
scope for people to consider themselves unwell.
Traditional epidemiological approach
The traditional epidemiological approach to needs assess-
ment has been to use morbidity and mortality data to meas-
ure the total amount of ill health in the community, and
then use this information to set priorities for allocating
resources between different diseases (Knox 1976, Ashley
&McLachlan 1985). Need is thus defined in terms of lives
lost, life years lost, morbidity, or loss of social functioning.
Indicators of deprivation are used in a similar fashion,
based upon census data. Variables such as numbers of
single parents, elderly people living alone, families with
pre-school children and ethnicity are measured, combin-
ing social and material deprivation into a composite index.
This ultimately provides a means of scoring and ranking
areas according to their degree of relative disadvantages
or affluence (Jarman 1984, Townsend et al. 1988).
These approaches have the potential to provide valuable
information about the need for health, but by focusing
upon 'normative' or professionally defined need, there is
the assumption that, once categorized, population groups
are automatically in need of services, which may not be
the case (Orr 1985a). This lack of specificity regarding the
identification of the need for health care has also been
highlighted by Stevens &Gabby (1991), who argue that the
need for health care must be the focus of community needs
assessment if service provision is to be effective.
The health economists' contribution has been in contrast
to previous perspectives, defining need within the context
of cost-effectiveness and supply and demand. The main
thrust of the argument is to emphasize that areas of needs
are relative and can be 'traded off' against each other, given
limited resources (Culyer 1976, Donaldson & Mooney
1991). With the assumption that the objective of health
care policy is to maximize the contribution of health care
resources to the health of the community, defined in terms
of quality adjusted life years (QALYs), it is argued that
more resources within the health care budget should be
722 © 1995 Blackwell Science Ltd, fournal of Advanced Nursing, 22, 721-730

Community needs assessment
allocated to treatments with a low marginal cost per QALY
and less to those with a high marginal cost per QALY
gained. Bryan et al. (1991) give the example of expanding
a community chiropody service whilst contracting home
dialysis, as more QALYs would be produced without any
increase in expenditure.
Proponents of this approach state that it does not require
any assessment of total needs, and that the key concept is
getting the greatest benefit for each pound spent (Williams
1987). Although the economic viewpoint may rationalize
service provision in a 'cut and dried' fashion, it is not
difficult to imagine that the perspective has been strongly
criticized for its unethical stance, neglecting as it does con-
sumer views and issues relating to maintenance of quality
of life in illness (Harris 1987, Loomes & McKenzie 1989).
In addition to this, the economist viewpoint is difficult to
grasp when little textual simplification is offered, which
is particularly evident in Bryan et al.'s (1991) paper. For
this reason, those health care professionals unfamiliar with
the language may be overly critical or dismissive of the
approach.
Notwithstanding the ambiguities surrounding differing
interpretations of need, defining what is meant by 'com-
munity' and 'population' within this context also high-
lights inconsistencies and lack of clarity when undertaking
an assessment procedure. Briefly, with reference to com-
munity, Orr (1985b) states that the various meanings and
confusion surrounding the concept of community occur
because it is used in a descriptive, evaluative and emotive
manner, making precise definition arduous, a view shared
by Benson (1976). Regarding population, community
agencies are expected to set out the needs of the population
they serve (Department of Health). Stalker (1993) questions
whether the term refers to existing service users, potential
service users, or the totality of residents in a region.
THE COMMUNITY HEALTH PROFILE
Thus, attempting to identify community needs within a
population against this complex and multi-faceted back-
drop is an enormous task for professionals. However, an
approach that is gaining increasing interest and appli-
cation is the development of an area or community profile,
which incorporates the sociological and epidemiological
perspectives outlined. The concept is not new, and has
been adopted as part of determining social policy objec-
tives in a locality (Glampson et al. 1975, Hubley 1982),
and has been a requirement of health visitor training since
the 1970s (Hunt 1982). The approach is appealing in that
it combines quantitative data, such as demographic infor-
mation, epidemiological data and indicators of depri-
vation, with qualitative data, such as information from
health care professional caseloads and individual assess-
ments (Richards 1991).
Collaboration between and amongst professional groups
and agencies in the community is strongly advocated
(Twinn et al. 1990, Cernik & Wearne 1992) and is thought
to have considerable benefits. Peckham & Spanton (1994)
state that community nurses can build local networks and
alliances with groups and individuals, increasing their
understanding and awareness of local issues, and adapting
work priorities accordingly. Advocates of the profile stress
its value in providing a comprehensive and rounded
picture of population needs for health care, giving a
more accurate indication for health service provision, and
highlighting mis-matches between need and health care
delivery (Klein & Thomlinson 1987, Snee 1991, Cernik &
Wearne 1992).
The potential contribution that community nursing
information can make by the provision of explicit client-
related experiential material via individual assessment
and caseload data, is at present being fully exploited by
its proponents in the nursing press (Gooch 1989, Drennan
1990, Day 1992, Goodwin 1992). Although the extent of
profiling in practice has not been measured, studies are
now emerging that give an indication of actual outcomes
from caseload profiling, such as the construction of a
general practice health strategy (Colin-Thome 1993) and
health visiting strategy (Jackson 1989), the development
of a weighting system for district nursing caseloads
(Drennan 1990) and the identification of levels and types
of nursing needed (Hugman &McCready 1993). In a family
health needs study currently being undertaken by Cowley
&Billings (1994a), a comprehensive community profile has
been used to form the foundations of a semi-structured
interview schedule for ascertaining client need. This infor-
mation will subsequently be used to form a model for
identifying health visiting service specifications for
contracting.
Community profiling, however, as with other
approaches to community assessment, should not be
viewed as a panacea for all ills. There are numerous issues
associated with its compilation, some of which will be
addressed. Although the above examples highlight the
potential of the profile approach to needs assessment, the
impact does not appear to be widespread. In reality,
the time and resources needed to complete a profile would
be beyond the scope of most hard-pressed practitioners
(Twinn et al. 1990). From a research perspective, profiling
is plagued with difficulties concerning the identification
of an appropriate research design for data collection and
analysis. In general, data are collected in an ad hoc
manner, using what appears to be readily available infor-
mation, and there is little description of how broad census
data are aggregated with individual perspectives, which
renders the derivation of findings, conclusions and ulti-
mately action difficult to comprehend in some studies.
Cowley & Billings (1994a) are, however, using a case
study approach to profiling (Yin 1989), which allows
for the development of a case description through a
© 1995 Blackwell Science Ltd, Journal of Advanced Nursing, 22, 721-730 723

pattern-matching of themes identified within the various
data sources. This strategy allows for the complexity of
community profile information to be described in terms of
needs identification, and permits potentially meaningful
aggregation of data across its differing methodological
types. The dilemmas of data aggregation are further
explored when discussing the consumer perspective.
VALIDITY OF DATA SOURCES
A further issue to consider is the validity of data sources
for a community profile, as it would appear that the range
of information obtained is rarely questioned for reliability
or validity determinants. To illustrate this point, the use
of 1991 census material to determine a range of population
characteristics and circumstances is heavily recommended
as a valuable source of data (Hubley 1982, Orr 1985a), but
it has been identified that census variables such as age and
ethnicity are not in themselves causes, nor necessarily
indicators of need (Stalker 1993). Robinson (1985) and Orr
(1985b) argue that such classifications may lend them-
selves to professional stereotyping regarding needs assess-
ment, rather than recognizing individual variation within
the categories.
Census data also continue to request information regard-
ing the 'head of the house' upon which to base social class
position. This is still largely completed as the male partner
in a 'couple' household for most situations, despite
differing economic activity between partners (Office of
Population Censuses and Surveys 1992). McDowall (1983)
highlights the shortcomings of this approach, particularly
in relation to women. Firstly, most women now work, and
not classifying them individually by their own occupation
may conceal health hazards; and secondly, the earnings of
working women may influence and improve the standard
of living within the household. Difficulties with the unem-
ployed, the elderly and children also occur, in that occu-
pational class does not fully encapsulate the circumstances
under which they live (Whitehead 1987). Thus the needs
of large sections of the population may be hidden or over-
estimated using this classification.
Several alternatives have been put forward, such as
Arber's (1987) household class, based upon the occupation
of the spouse who is economically dominant, or the child-
centred social index (Osborn & Morris 1979), which was
intended to be more in tune with the home environment
of the child than occupational class alone. Their use has
not as yet been widely replicated and evaluated.
A further difficulty regarding census data is the useful-
ness to potential 'profilers' regarding the geographical dis-
tribution of its results. The present availability of small
area population statistics (electoral ward and enumeration
district) has facilitated planners in identifying need, but it
does not assist the GP-attached practitioner whose popu-
lation may span a wide geographical area with three or
four families per ward (Young & Haynes 1993, Cowley &
Billings 1994b). This argument highlights the difficulties
associated with 'goodness of fit' of the various data
sources, which is a recurrent obstacle regarding meaning-
ful profile compilation. However, the case study approach
as previously described may overcome this problem to
some extent.
Further to this, the apparent under-representation of
single people aged 16 to 44 in comparison with the 1981
census has also caused speculation regarding the
reliability of data in this group, particularly concerning
potential poll tax evasion (Office of Population Censuses
and Surveys 1992). This has obvious implications concern-
ing the accuracy of identifying needs. Also, census data
become very rapidly out-of-date, assuming that they were
accurate in the first place, a feature that hounds all
'snapshot' population information (Stalker 1993).
Social inequality and deprivation
Moving now to measures of social inequality and depri-
vation -- as stated most have been welcomed as an import-
ant adjunct to estimating the health of a population
(Whitehead 1987, Stalker 1993), but there are singular
problems attached to their measurement. For example,
Jarman's (1984) score has been criticized for its bias
towards using determination variables associated with the
elderly (Thunhurst 1985). Foy et al. (1987) and Chase &
Davies (1991) have pointed out that the aggregated data
may hide large variations between smaller groups; the
deprivation within a housing estate, for example, that is
situated in an area of relative affluence may be masked.
However, enumeration data from the census may now
largely overcome this problem, by giving specific house
number information. Whitehead (1987) remarks that some
indices combine direct indicators of deprivation, such as
overcrowding and unemployment, with indirect measures
of numbers of people 'at risk' of deprivation (i.e. single-
parent families or ethnic minorities), where, as previously
mentioned, not all people are deprived in these groups.
Townsend et al. (1988) have highlighted contradictions
between scores when indices are monopolized by highly
skewed variables such as ethnicity; for example, the
Department of the Environment's (1983) and Jarman's
(1984) indices discovered that the most deprived local
authority areas were in London, with none in the north of
England. Townsend et al's (1988) own observations record
the converse to be more the case. However, this problem
may be overcome by choosing only indicators of material
deprivation such as the proportion of households with no
car, and unemployment (Townsend et el. 1985), by
employing more sophisticated statistical techniques
(Wagstaff et aL 1991), or by using 'grass root' surveys to
check and extend the statistical results (Thunhurst 1985).
Acquiring epidemiological evidence has largely
724 © 1995 Blackwell Science Ltd, Journal of Advanced Nursing, 22, 721-730

depended upon morbidity and mortality data. Stevens &
Gabby (1991) argue that an epidemiologically sound
assessment of needs is a vital inclusion to any profile and
the ultimate development of the health service, focusing
as it does on prevalence rates of death and disease.
Although death rates are obviously a necessary concept
for assessing disease, Patrick (1986) observes that these
statistics have lost their importance in assessing a popu-
lation's health. He adds that this is particularly so when
death rates are low, as by implication the majority of the
population remain alive in varying states of health. Wilson
(1981) adds that the increase in chronic conditions and
the development of medical treatments to prolong life,
such as renal dialysis and insulin therapy, have contrib-
uted to the decreasing value of this data.
Thus information relating to the prevalence of disease
would appear to have greater potential application to
needs assessment (Mays 1987). Stalker (1993), however,
urges for morbidity rates to be translated with caution,
supporting critics of census and deprivation data by
stating that incidence must not be confused with actual
need. Inconsistencies in measurement also abound, par-
ticularly in relation to mental health. McCollam (1992)
discovered that incidences of mental health problems are
obtained in a variety of different ways, and that differing
methods used in one area produced competing perspec-
tives of mental health prevalence. On the other hand,
Bebbington & Davies (1980) acknowledge the difficulties
in reaching consensus regarding criteria for measurement,
and suggest that attempts to develop national indicators
would meet with limited success. A potentially valuable
source of morbidity information is from GP practice data
bases, but accuracy and availability of this information
can be limited to the ability of hard-pressed practice staff
to process and enter the data, and can vary between
practices rendering comparison difficult (Cowley &
Billings 1994b).
However, a lateral perspective that criticizes the some-
what ironic emphasis upon disease as a way of determin-
ing health is offered by Rijke (1993). He states that most
medical research has been undertaken in academic settings
or hospitals where a select group of the population with
certain abnormalities and diseases are investigated. Rijke
goes on to argue that focusing upon disease groups to esti-
mate population needs is not profitable, as very little is
known in medical science about the natural history of
diseases in the general public (Lorber 1980, Nelson &
Ellenberg 1982). Rijke (1993) asserts that there is an
assumption that the occurrence of a disease is determined
by a causal factor(s), and that the elimination of the disease
is achieved by medical intervention or lifestyle changes.
He argues that reducing certain factors does not necessarily
lead to better health when applied to larger population
groups, especially in relation to cardiovascular disease
(Coronary Drug Project Research Group 1980) and urges
for a scientific approach to research which studies health
rather than disease.
To support his view, Rijke (1993) outlines research that
has focused upon how people remain healthy. This points
to factors such as autonomy, vitality and social support as
being essential to the reduced frequency of physical com-
plaints and illness, and maintenance of a sense of well-
being (Rijke 1985, Antonovsky 1987, Rohe & Kahn 1987).
Not only has this perspective profound implications for
the nature of current health education and promotion pro-
grammes, which work from a perspective of disease avoid-
ance rather than health persistence, but it offers another
dimension to the assessment of community and individual
needs and service provision. Services such as health visit-
ing that are able to provide the necessary skills to assess
these qualities, and potentially augment their deficiencies
through facilitating empowerment and networking
(Drennan 1988), should, by intimation, be enhanced rather
than eroded.
CONSUMER PERSPECTIVE
Having now debated some of the issues concerning the
accumulation of health data for community profile compi-
lation, the review will now focus upon obtaining the con-
sumer perspective. The profile has been accused of being
restricted in providing a picture of health needs, limited
as it is at present to the collection and collation of existing
information from a service perspective (Peckham &
Spanton 1994). Consultation, however, appears to be an
aspect of planning that is attracting considerable interest,
offering a unique opportunity for the community to make
their needs known and, theoretically, ensure that they are
adequately addressed within plans (Clode 1992). It appears
to be one means of bridging the gap between the 'micro'
and 'macro' levels of health estimation (Stalker 1993).
Criticism has been directed against health care pro-
fessionals for setting the health agenda without consulting
the public (Forrester 1991).
Amongst the population (Richardson et al. 1992) and
health care professionals (Higgens 1992), there appears to
be increasing importance attached to the notion of consul-
ration about health needs. The current wave of con-
sumerism in health and social circles has, however, not
occurred due to the sudden development of socially con-
scious managers. Phillips et el. (1994) state that the govern-
ment's policy of controlling public expenditure and
encouraging a mixed economy of care has introduced a
strong element of enterprise culture into public service
organizations. Central policy thus demands greater choice
and independence for service users, evidenced by their
publications (Department of Health 1990, National Health
Service Management Executive 1992).
Reviewing the various approaches to consultation,
Bowling (1992) highlights numerous ways in which this
© 1995 Blackwell Science Ltd, Journal of Advanced Nursing, 22,721-730 725

can be achieved, namely consumer feedback via forums
and public meetings, and consumer representation on
user-groups. Local interview, postal or telephone surveys
of views and satisfaction surveys have also been used
(Roberts & Magowan 1994). Bowling (1992) adds that
observation techniques can also be applied in care settings
where clients find difficulty in expressing views. The use
of focus groups has also been advocated as a valuable
method of exploring perceptions of need (Morgan 1993),
and indeed has been enlightening when used in this con-
text, indicating consumer awareness of their contributive
strengths and limitations in the needs assessment process
(Cowley et al. 1994).
Methodological difficulties
Consultation is, however, not without its methodological
difficulties. Focus groups, for example, are generally
characterized by small numbers, which raises questions
regarding the ultimate reliability of the results, as evi-
denced by Cowley et al.'s (1994) paper. To overcome this
problem, some studies have used a combination of tech-
niques to obtain a more comprehensive picture of con-
sumer need (Judge &Solomon 1992). Also, the constraints
of satisfaction surveys have long been recognized, relating
particularly to the validity of current methods of oper-
ationalizing the concept of client satisfaction (Avis 1994).
A factor common to all approaches to consultation con-
cerns reliability of sample selection. Rodgers (1994) and
Bowling (1992) suggest that, where researchers do not
strive to gain equity of response, there will be a tendency
for the more articulate, less burdened consumer's voice to
be heard loudest. Consultation therefore has the potential
to reinforce inequalities in service provision, rather than
address them.
However, obtaining the views of 'quieter' sections of
the population has its constraints. In a community project
based in Stirling, the needs of a sample of elderly people
were obtained with the aid of a schedule (Hudson 1992).
Prior to the assessment, a 10-point questionnaire was
completed by the referrer, indicating the degree to which
the elderly person was perceived to be 'in need'. Hudson
(1992) documents the difficulties experienced by elderly
people, who found expression of need arduous and con-
sistently linked need to availability of resources. This
was in contrast to the referrer's perceptions, which gener-
ally identified multiple needs among the sample regard-
less of available service provision. Further complications
were revealed in this study regarding the tension between
the carer's needs and those of the elderly person.
Decisions regarding whose needs would drive the care
plans thus became difficult. The study highlights some
important issues surrounding the complexities of needs
assessment, but it is lacking in detail regarding sample
numbers, questionnaire and schedule details, rendering
the research difficult to appraise for methodological
rigour.
Once data from the consumer have been compiled by a
chosen method, consideration must be given to their syn-
thesis with broader health information into local policy, a
difficulty highlighted earlier. In an analysis of community
plans, Richards (1991) noted that while most emphasized
the importance of aggregation of data, few practical pro-
posals for achieving it were made. This becomes increasing
significant when considering the depth of information
obtained by community nurses through individual needs
assessment. Incorporating such information into meaning-
ful policy statements can be onerous. For example, unless
the total population within an area can be targeted, bias
may be an inevitable consequence and 'felt' need never
fully identified (Stalker 1993).
Conversely, rendering the needs of individuals into
meaningful components for policy determination may
necessitate a radical aggregation of felt need, so a true pic-
ture may never be explicated. However, focusing upon
small groups within a locality, such as corers or families
of physically challenged children, may converge areas of
need in a more meaningful way (Richards 1991, Morris &
Lindlow 1993).
This latter argument highlights a concern regarding the
ethical consequences of needs assessment. To elaborate, a
consideration of the ethical issues involved in obtaining
information about a community, both from statutory and
informal sources, appears to be largely absent from the
literature (Cowley 1993). This 'invasion of privacy'
becomes of increasing significance if a large percentage of
the population from which data are being obtained will
not benefit from any service provision (Orr 1985b).
Coupled with this, the often perceived unequal relation-
ship between professionals and recipients of care (Becker
1967, Dunnell & Dobbs 1983, Orr 1983) may mean that
clients are placed in uncompromizing situations concern-
ing the revelation of personal details for the purposes of a
profile. This is particularly evident when viewing the very
personal components of the individual assessments, evi-
denced by questions relating to intimate physical and
sexual components (Bell 1993). A balance must therefore
be achieved between a desire to locate and provide for
unexpressed needs and the right of citizens to maintain
their privacy (Pinker 1982).
Notwithstanding methodological and ethical issues,
further contradictions to this approach to needs assess-
ment are evident. For example, the financial costs are con-
siderable (Richardson et aI. 1992), and the depth of
information obtained will ultimately depend upon the
methods employed. As there is no 'minimum standard' to
be achieved, cost-restrictions may limit areas to obtaining
superficial consumer data only, whilst still fulfilling
government recommendations. Rodgers (1994) argues that
the Citizen's Charter (HMSO 1993) is a case in hand; with

its 'vague promises and relaxed standards' it may leave
the organization with a comfortable feeling that the issues
are being addressed.
The fact that public consultation may be nothing more
than 'tokenism' in some areas has been suggested by
Wistow et al. (1992). In their analysis of 22 English com-
munity care plans, it was discovered that, where consul-
tation had been employed, methods differed considerably
across regions. Importantly, the extent to which the results
of the exercises had influenced the completed strategy
documents and service specifications was far from clear,
nor were there distinct evaluative accounts ofhow satisfac-
tory the process had been. Respondents in Cowley et al.'s
(1994) study were not uniformly convinced that their
views were respected, either at an individual level, or as
part of a service planning exercise. Indeed, Richardson
et al.'s (1992) findings support this 'powerlessness' per-
spective and highlight the consumer's dilemma, by indi-
cating that most respondents in their survey felt they were
unable to influence decisions in health care, despite wel-
coming the opportunity. Studies are now emerging that
document participant's frustration at the lack of feedback
and positive action following consultation (Southampton
and South West Hants Health Commission 1993).
Paradox
It is within this context that the true paradox of community
needs assessment occurs. Critics of the community care
reforms have argued that without a substantial increase in
resources, assessment of needs, however it is undertaken,
becomes an almost meaningless exercise, since the ser-
vices and support required by the population will not be
available (Cornwell 1992, Jack 1992). The more compre-
hensive the assessment, the more inevitable the possibility
that a plethora of social needs will be revealed that
providers are unable to act upon, resulting in universal
disillusionment (art 1985b, Twinn et al. 1990).
Cheetham (1991), whilst urging local authorities to use
the results of assessment as a means of exposing uninet
need and 'social ills', acknowledges the political risks
involved if the shortfall between planned services, needs
identified and resources available were laid bare. Phillips
et al. (1994) add that for care agencies to fully encompass
the notion of consumerism is to make demands that both
the public and professionals are unable to meet. It is there-
fore not surprising that superficial data collection and
interpretation may become the preferred option.
FURTHER CONSIDERATIONS IN NEEDS
ASSESSMENT
Thus, whilst the consumer perspective is becoming a
necessary focus of needs assessment within a locality,
investigation into its components has revealed consider-
able methodological and political restraints. Indeed, the
whole issue of community needs assessment, arguably a
fundamental component of 'care in the community',
appears to necessitate substantial and disproportionate
resource allocation on the part of community agencies.
Little guidance for undertaking this task within policy
documents and the literature is apparent and, although
policy appears to have largely pinned its hopes upon
greater collaboration between community agencies and
consumers, health care professionals are becoming
increasingly unsure about their own organization's ability
to realize this potential (Higgens 1992). Indeed, Stalker
(1993) points out that the changes required on the part of
community agencies to undertake this task, in terms of
activity and skills, are often under-estimated and only
fully realized once assessment is underway. For example,
training staff is essential to facilitate their transition from
'assessor' to 'assessed' (Hudson 1992), and in helping them
to cope with the cultural shift of power to the consumer
(Higgens 1992), a change that cannot occur overnight.
Also, as the ultimate approach to needs assessment may
depend upon the prevailing philosophy of a locality, vari-
ations between districts may render cross-comparison
impossible. It could be argued that effective nationwide
implementation of 'care in the community' may thus be
problematic to audit. Selecting the most suitable approach
is only the first step, and Cheetham (1991) emphasizes the
importance of consideration in this initial stage, as future
community plans may hinge upon comprehensive and
sound community needs assessments. But, as Stevens &
Gabby (1991) point out, producing facts and figures to pro-
vide a comprehensive picture, coupled with staff training
and development, are lengthy procedures, in contrast to
the headlong rush to agree contracts. They continue by
declaring the fear that needs assessment is being put to
one side, and that the logical sequence of needs identifi-
cation, service specification and contracts may be reversed.
CONCLUSION
In conclusion, this literature review has attempted to
debate definable, methodological, ethical and contextual
factors surrounding community needs assessment, high-
lighting the multi-dimensional difficulties surrounding its
compilation. The issues raised have been projected within
the current political climate, and have recognized its
strongly influential nature concerning community needs
assessment. This arena served to highlight the inherent
paradoxes and dilemmas within the needs assessment pro-
cedure. It has also attempted to highlight the potentially
vital position of community nurses regarding data sources,
which has yet to be fully recognized and taken advan-
tage of.
In general, it must be stated that needs assessment
literature tended to be characterized more by assumptions,
© 1995 Blackwell Science Ltd,Journal of Advanced Nursing, 22, 721-730 727

predictions and for the most part, speculative rhetoric,
rather than sound evaluative research, due possibly to its
emergent nature. However, the difficulties associated with
community needs assessment, coupled with its continued
high political profile, dictate to a large extent the protrac-
ted but welcome appearance of needs assessment deliber-
ation within health-related literature, necessary to increase
awareness among professionals in the community
involved in these processes.
References
Antonovsky A. (1987) The salutogenic perspective -- towards a
new view of health and disease. Advances 4(3), 47-55.
Arber S. (1987) Gender and class inequalities in health: under-
standing the differentials. In Inequalities in Health within
Europe (Fox A.J. ed.), Gowar, Aldershot.
Ashley J. & McLachlan G. (1985) Mortal or Morbid? A Diagnosis
of the Morbidity Factor. Nuffield Provincial Hospitals Trust,
London.
Avis M. (1994) Satisfying solutions: a review of issues in measur-
ing patient satisfaction. Paper presented at the RCN Annual
Research Conference, Hull, April. [Available from Royal College
of Nursing, London.].
Becker H. (1967) Whose side are we on? Social Problems 14, 241.
Bebbington A.C. & Davies B. (1980) Territorial needs indicators:
a new approach. Journal of Social Policy 9(2), 145-168.
Bell I. (1993) Less impertinence, more partnership. Health Visitor
66(10), 370-372.
Benson J. (1976) The concept of community. In Talking About
Welfare (Timms N. & Watson D. eds), Routledge & Kegan
Paul, London.
Blaxter M. (1990) Health and Lifestyles. Routledge, London.
Bowling A. (1992) "Local Voices' in Purchasing Health Care:An
Exploratory Exercise in Public Consultation on Priority Setting.
Needs Assessment Unit, St Bartholomew's Hospital Medical
College, London.
Bradshaw J. (1972) The concept of social need. New Society 30,
640-643.
Bryan S., Parkin D. & Donaldson C. (1991) Chiropody and the
QALY: a case study in assigning categories of disability and
stress to patients. Health Policy 18, 169-185.
Buchan H. & Gray J.A. (1990) Needs assessment made simple.
Health Service Journal, 100, 240-1.
Cernik K. & Wearne M. (1992) Using community health profiles
to improve service provision. Health Visitor 65(10) 343-345.
Chase H.D. &Davies P.R.T. (1991) Calculation of the underprivi-
leged area score for a practice in inner London. British Journal
of General Practice February pp. 63-66.
Cheetham J. (1991}Community care: bridging the gap. Community
Care, 870, 24-25.
Clode D. (1992) Best laid plans. Community Care, 39th April.
Colin-Thome D. (1993) The public health nurse: a new model for
health visiting? Primary Care Management 3(5) 4-6.
Coronary Drug Project Research Group (1980) Influence of adher-
ence to treatment and response of cholesterol in the coronary
drug project. New England Journal of Medicine, 303, 1038-41.
Cornwell N. (1992) Assessment and accountability in community
care. Critical Social Policy 36 (4052) 42-52.
Council For the Education and Training of Health Visitors (1977)
An Investigation into the Principles of Health Visiting p.9.
Council for the Education and Training of Health Visitors,
London.
Cowley S. (1993) Skill mix: value for whom? Health Visitor 66(5)
166-8, 171.
Cowley S. & Billings J.R. (1994a) Family health needs project
report. Unpublished report, Primary Health Care Development
Fund, Kings College London, London [Available from
Department of Nursing, King's College London.].
Cowley S. &Billings J.R. (1994b) A community profile of Hastings:
Phase 1 of the family health needs project. Unpublished report,
Primary Health Care Development Fund, Kings College
London, London.
Cowley S., Bergen A., Young K. & Kavanagh A. (1994) The chal-
lenging nature of needs assessment in primary health care.
Paper presented at the Fourth International Primary Health Care
Conference, London. [Available from Department of Nursing,
King's College, London.]
Culyer A. J. (1976) Need and the National Health Service. Martin
Robertson, London.
Day L. (1992) Promoting the health visiting profession. Health
Visitor 65(8), 270-272.
Department of Environment (1983) Urban Deprivation:
Information Note no. 2 From the Inner Cities Directorate.
HMSO, London.
Department of Health (1989a) Working For Patients. HMSO,
London.
Department of Health (1989b) Caringfor People: Community Care
in the Next Decade and Beyond. HMSO, London.
Department of Health (1989c) The Role of the District Health
Authority. HMSO, London.
Department of Health (1990) Caring for People: Implementation
Document -- Assessment and Case Management. HMSO,
London.
Department of Health (1991) The Health of the Nation. HMSO,
London.
Department of Health (1993) Implementing Community Care:
Population Needs Assessment, Good Practice Guide. HMSO,
London.
Department of Health and Social Security (1988) Public Health in
England: The Report of the Committee of Enquiry Into the
Future Development of the Public Health Function. HMSO,
London.
Donaldson C. &Mooney G. (1991) Needs assessment, priority set-
ting and contracts for health care: an economic view. British
Medical Journal 303, 1529-1530.
Drennan V. (1988) Health Visitors and Groups: Politics and
Practice Heinemann Nursing, Oxford.
Drennan V. (1990) Gathering information from the field. Nursing
Times 86(39), 46-48.
Dunnell K. &Dobbs J. (1983) Nurses Working in the Community.
HMSO, London.
Forrester P.H. (1991) Assessing health information needs. In
Promoting Choice: Consumer Health Information in the 1990s.
Consumer Health Information Consortium, Loughborough
University, Loughborough.
Foy C., Hutchinson A. & Smythe J. (1987) Providing census data
for general practice. Journal of the Royal College of General
Practice 37, 451-454.

Glampson A., Scott T. & Thomas D.N. (1975) A Guide to the
Assessment of Community Needs and Resources. National
Institute of Social Work, London.
Gooch S. (1989) The health visitor's influence: imperatives for
change. Nursing Standard 25 October, 4-5.
Goodwin S. (1988) Whither health visiting? Keynote speech to the
Health Visitors' Association Annual Study Conference. Health
Visitors' Association, London.
Goodwin S. (1992) Community nursing and the new public
health. Health Visitor 65(3), 78-80.
Goodwin S. (1994) Purchasing effective care for parents and young
children. Health Visitor 67(4), 127-129.
Harris J. (1987) QALYifying the value of life. Journal of Medical
Ethics 13, 117-123.
Harvey J. (1994) Assessment of Population Health Needs. Paper
presented at the RCN Public Health Conference, London, July.
RCN, London.
Higgens R. (1992) Consumerism and participation. Senior Nurse
12(5), 3-4.
HMSO (1993) Citizen's Charter (ref. CM 2290). HMSO, London.
Hubley J. (1982) Making the community profile. Journal of the
Institute of Health Education 20(1), 4-9.
Hudson H. (1992) Needs-led assessment: nice idea, shame about
the reality? Health and Social Care 1, 115-118.
Hugman J. & McCready S. (1993) Profiles make perfect practice.
Nursing Times 89(27), 46-9.
Hunt M. (1982) Caseload profiles -- an alternative to the neigh-
bourhood study. Health Visitor 55(11), 606-607.
Jack R. (1992) Case management and social services: welfare or
trade fare? Journal of the British Society of Gerontology 2 4.
Jackson C. (1989) Wherefore to Oxfordshire? An interview with
health visitors. Health Visitor 82(5), 159-160.
Jarman B. (1984) Underpriviledged areas: validation and distri-
bution of scores. British Medical Journal 289, 1587-1592.
Judge K. & Solomon M. (1992) Public opinion and the National
Health Service: patterns and perspectives in consumer satisfac-
tion. Paper presented to the Annual Conference of the Society
for Social Medicine, University of Nottingham.
Klein L. & Thomlinson P. (1987) Patchwork. Nursing Times
83(26), 39-40.
Knox E.G. (1976) Epidemiology in Health Care Planning. Oxford
University Press, Oxford.
Loomes G. &McKenzie L. (1989) The use of QALYS in health care
decision-making. Social Science and Medicine 28, 299-308.
Lorbar J. (1980) Is your brain really necessary? Science 210,
1232-1234.
Mays N. (1987) Measuring morbidity for resource allocation.
British Medical Journal 295, 703-706.
McCollam A. (1992) Community Care Planning for Mental
Health in Scotland. Scottish Association for Mental Health,
Edinburgh.
McDowell M. (1983) Measuring women's occupational mortality.
Population Trends 34, 25-29.
Morgan D. (1993) Successful Focus Groups. Sage, Newbury Park,
California.
Morris J. & Lindlow V. (1993) User Participation in Community
Care Services. Community Care Support Force, Leeds.
National Health Service Management Executive (1991) Assessing
Health Care Needs: A DHA Project Discussion Document.
NHSME, London.
National Health Service Management Executive (1992) Guidance
on the Extension of Hospital and Community Health Services
Elements of the GPFund-Holding Scheme from April 1993. EL
(92) 48. NHSME, London.
Nelson K.B. & Ellenberg J.H. (1982) Children who 'outgrew'
cerebral palsy. Pediatrics 69, 529-536.
Office of Population Censuses and Surveys (1992) Census
Newsletter: Coverage Check from the 1991 Census Validation
Survey. HMSO, London.
Orr J. (1983) Is health visiting meeting today's needs? Health
Visitor 58(6), 200-203.
Orr J. (1985a) Health visiting and the community. In Health
Visiting (Luker K. & Orr J. eds), Blackwell Scientific, Oxford,
pp. 32-66.
Orr J. (1985b) Individual and family needs. In Health Visiting
(Luker K. &Orr J. eds), Blackwell Scientific, Oxford, pp. 67-120.
Osborn A.F. & Morris A.C. (1979) The rationale for a composite
index of social class and its evaluation. British Journal of
Sociology 30(1), 39-60.
Patrick D.L. (1986) Measurement of health and quality of life. In
Sociology as Applied to Medicine, (Patrick D.L. & Scambler G.
eds), Bailliere Tindall, Eastbourne, pp. 223-237.
Peckham S. & Spanton J. (1994) Community development
approaches to health needs assessment. Health Visitor 67(4),
124-125.
Phillimore P., Beattie A. & Townsend P. (1994) Widening
inequality of health in northern England, 1981-91. British
Medical Journal 308, 1125-1128.
Phillips C., Palfrey C. & Thomas P. (1994) Evaluating Health and
Social Care. Macmillan, Basingstoke.
Pinker R. (1982) An alternative view: appendix B. In Social
Workers: Their Bole and Tasks. National Institute for Social
Work; Bedford Press, London, pp. xv-xviii.
Richards J. (1991) Consumer-oriented planning. In Community
Care Plans -- the First Steps. Social Services Inspectorate;
Department of Health, London.
Richardson A., Charney M. & Hanmer-Lloyd S. (1992) Public opi-
nion and purchasing. British Medical Journal 304, 680-682.
Rijke R. (1985) Cancer and the development of will Journal of
Theoretical Medicine 6, 133-142.
Rijke R. (1993) Health in medical science: from determinism
towards autonomy. In Towards a New Science of Health
(Lafaille R. & Fulder S. eds), Routledge, London, pp. 74-83.
Roberts H. & Magowan R. (1994) Local sensitivities. Health
Service Journal 104(8393), 30-31.
Robinson J. (1985) Health visiting and health. In Political Issues
in Nursing (White R. ed.) John Wiley & Sons, London,
pp. 67-86.
Rodgers J. (1994) Power to the people. Health Service Journal 104
(5395), 28-29.
Rohe J.W. &Kahn K.L (1987) Human ageing: usual and successful.
Science 237, 143-149.
Seedhouse D. (1986) Health: The Foundation for Achievement.
John Wiley & Sons, Chichester.
Snee K. (1991) Neighbourhood needs. Community Outlook 1,(2),
38-39.
Southampton and South West Hants Health Commission (1993)
Consumer and Public Health Commissioning: Learning from
Experience, Southampton and South West Hants Health
Commission, Southampton.
© 1995 Blackwell Science Ltd, Journal of Advanced Nursing, 22, 721-730 729

Stalker K. (1993) The best laid plans.., gang aft agley? Assessing
population needs in Scotland. Health and Social Care 2, 1-9.
Stevens A. & Gabby J. (1991) Needs assessment needs assessment.
Health Trends 23(1), 20-23.
Thayer R. (1973) Measuring need in the social services. Social
and Economic Administration, 7 May, 91-105.
Thunhurst C. (1985) The analysis of small area statistics and plan-
ning for health. The Statistician 34, 93-106.
Townsend P., Simpson D. & Tibbs N. (1985) Inequalities in health
in the city of Bristol: a preliminary view of statistical evidence.
International Journal of Health Service 15(4), 637-663.
Townsend P., Phillimore P. & Beattie A. (1988) Health and
Deprivation: Inequality in the North. Routledge, London.
Twinn S. & Cowley S. (1992) The Principles of Health Visiting: A
Re-Examination Health Visitors' Association in conjunction
with United Kingdom Standing Conference. HVA, London.
Twinn S., Dauncey J. & Carnell J. (1990) The Process of Health
Profiling. Health Visitors' Association, London.
Wagstaff S., Paci P. & van Doorslaer E. (1991) On the measurement
of inequalities in health. Social Science and Medicine (5),
545-557.
Whitehead M. (1987) The Health Divide. Penguin, London.
Williams A. (1987) Health economics: the cheerful face of the
dismal science? In Health and Economics, (Williams A. ed.)
Macmillan, London.
Wilson R. (1981) Do health indicators indicate health? American
Journal of Public Health 71(5), 461-463.
Wistow G., Leedham I. & Hardy B. (1992) A Preliminary Analysis
of a Sample of Community Care Plans. Department of Health,
London.
Yin R.K. (1989) Case Study Research: Design and Methods. Sage,
Newbury Park, California.
Young K. & Haynes R. (1993) Assessing population needs in pri-
mary health care: the problem of GP attachment. Journal oJ
Interprofessional Care 7(1), 15-27.
730 © 1995 Blackwell Science Ltd, Iournal of Advanced Nursing, 22, 721-730

Approaches To Community Needs Assessment A Literature Review

More Related Content

Approaches To Community Needs Assessment A Literature Review