health needs assessment assignment

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• Parenting, childcare and children's services
• Children's health and welfare
• Children's health
• Supporting public health: children, young people and families
• Public Health England

Population health needs assessment: a guide for 0 to 19 health visiting and school nursing services

Updated 19 May 2021

Applies to England

© Crown copyright 2021

This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: [email protected] .

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This publication is available at https://www.gov.uk/government/publications/commissioning-of-public-health-services-for-children/population-health-needs-assessment-a-guide-for-0-to-19-health-visiting-and-school-nursing-services

This guidance has been developed for health visitors, school nurses and their teams, though it may also be of use to other public health nurses. It aims to support them in their role assessing and prioritising local population health needs. Population health needs assessment is an element of the wider cycle to plan and deliver services at community and population level. It is the basis from which to continue planning, implementation, evaluation and dissemination phases to prioritise and deliver services to improve health and wellbeing outcomes.

Health visitors and school nurses have a substantial role in leading and coordinating delivery of public health interventions to address individual, community and population needs to improve health and wellbeing outcomes and reduce inequalities.

The focus is the population of children and young people that the health visitor and school nurse have responsibility for in a local community rather than assessment tools for individual children. A population may be a geographical area, school community, a specific group of children or young people, for example looked after children, young carers, or children who are asylum seekers or refugees.

It provides a framework for assessment, suggesting a range of practical steps to develop a profile of the health needs of the caseload or community that the health visitor and school nurse may be working with.

There are tools available to support health visitors and school nurses to deliver and evaluate, including the school nurse evaluation toolkit . The intention is to provide a simple approach to identifying and prioritising population health needs suggested through the commissioning for outcomes framework.

Improving health and wellbeing

A community-centred or place-based approach offers new opportunities to improve health and wellbeing outcomes, reduce health inequalities and develop local solutions that use all the assets and resources of an area. By integrating services, and building resilience in communities, individuals can take control of their health and wellbeing and have more influence on the factors that underpin good health.

This is illustrated through All Our Health , which demonstrates how improving outcomes is everyone’s business, working across settings such as community centres, green spaces and the workplace. Health visitors and school nurses are well placed to support families and communities to engage in this approach.

They have responsibility to lead, coordinate and provide services to the 0 to 19 years population. The High Impact Areas are those where the biggest difference can be made to children and young people’s health. This agenda is wide-ranging and public health challenges are increasing, health visitors and school nurses, with commissioners , make decisions about priorities and meeting local needs.

Health needs assessment is a way for health visitors and school nurses to gain a more in depth understanding of their communities and the needs that exist, enabling effective planning, prioritisation, development and delivery of services to improve outcomes for the population.

What is health needs assessment?

Health needs assessment is a systematic approach to understanding the needs of a population. The health needs assessment can be used as part of the commissioning process so that the most effective support for those in the greatest need can be planned and delivered. Responding to a health needs assessment provides an opportunity to improve outcomes where a population may be a group with a specific health need, school, cluster of schools, or a geographical community.

It is a holistic assessment considering social, economic, cultural and behavioural factors that influence health. In addition to readily available public health data, for example Child Health Profiles , a participatory approach should be adopted. It is important that the health visitor and school nurse recognise that there are different types of need, that some needs may be hidden and to make use of different perspectives.

Understanding the community, and the needs that exist, enables health visitors and school nurses to plan work to meet those needs, prioritise areas for service development, and determine any associated professional development required. Additionally, health needs assessment will enable teams and commissioners to work more closely together to ensure appropriate delivery. Health needs assessment should not be a one-off process but a continuous cycle to review the issues facing a population, leading to agreed priorities to improve health and reduce inequalities.

Planning for health needs assessment

Prior to starting the health needs assessment, it is important to have a clear understanding of the scope of the assessment. It is important to define the following:

• aims and objectives for the assessment – defining purpose and intended outcomes
• a target population to be assessed
• the data and information required
• a timeline for the health needs assessment – when, what, how and who. For example, for a health needs assessment of a school population, consider the school calendar for exam and revision periods
• potential challenges and how to manage them
• stakeholders who need to be involved, which may involve members of the health visiting team, school nurse team, key partners for example early years, schools, local authorities, voluntary, community and social enterprise ( VCSE ) sector
• resources required for example including IT equipment, room or space
• the strengths, limitations and opportunities of the health needs assessment

Other points to consider include:

• being clear on the intended outcome
• local or national priorities and issues of concern
• expectations of completing a population health needs assessment
• what is achievable within the resources available
• the boundaries and limitations of the health needs assessment

Stages of health needs assessment

There are 3 stages in health needs assessment:

• identifying need
• identifying assets
• determining priorities

Identifying health needs

The first stage of the health needs assessment involves gathering information and data. These sources will provide a breadth of perspectives on health and needs necessary for holistic assessment. The different sources of information help to define what influences the health needs as well as how many people are affected. When involving the children, young people and other key stakeholders, they will need to know why you are asking them to be involved, and to receive feedback on the results and outcome of the health needs assessment.

There is a wealth of quantitative data available to health visitors and school nurses about the health of the local population, which can be found in Child Health Profiles , that can be narrowed to the local area and compared to regional and national values.

Some example indicators are:

• children in poverty (under 16s)
• breast feeding
• immunisation uptake
• maternal mental health
• dental extractions
• family homelessness
• childhood obesity
• admission episodes for alcohol-specific conditions (under 18s)
• hospital admissions for asthma (under 19 years)

When the existing public health data is summarised in the health needs assessment report, consider the size and the severity of the issue, and how they relate to the High Impact Areas .

Every local authority publishes the latest statistics about the key issues affecting the health and wellbeing of their residents, including children and young people. The information, accessed through the local authority website, will include the Joint Strategic Needs Assessment (JSNA), ward profiles, the annual public health report or local authority school health profile.

Presentation in a spine chart format allows for easy comparison to England or regional benchmarks. This information can be accessed via the Public Health Outcomes Framework , the Overview of Child Health and Mortality Rankings web pages. Much of this information, which can be viewed by life course stage (for example school age children) or by theme (for example children and young people’s mental health and wellbeing). The findings should be summarised in a health needs assessment report.

Health visitor and school nurse knowledge and experience

Knowledge and experience of a locality are also an important data source. Health vistor and school nursing teams have rich knowledge and understanding about the communities that they work in and their experiences working with children and young people. This includes what is important to communities and issues affecting service provision and access.

Issues to consider include:

• any underlying local health and wellbeing issues
• current child health and school profiles
• any continually highlighted issues and the support evidence for them
• the top 5 health and wellbeing concerns and impact on local population
• whether these issues can be influenced
• the factors affecting health locally (positively or negatively)
• services that are currently being provided and how accessible they are
• how can children, young people and families be reached

Children, young people, carer and family views

It’s important to understand the experiences of the population themselves. Views and ideas about their health and influencing factors such as lifestyles and experiences of services may differ to those of professionals and other stakeholders and are a vital component of health needs assessment.

Consideration should be given to how to include the views of people who may be underserved and whose voices are often not heard. These groups may include looked after children, young carers, families from black and minority ethnic communities, families of asylum seekers, and lone parents. In addition, there are individuals or groups (for example early years, maternity voices, school council, year group, class of pupils, existing service users, and youth clubs and local authority youth councils) who may contribute to the heath needs assessment and should be identified.

There are a variety of methods for involvement. Plans should consider the time available and the skills needed by staff for some methods. The activity chosen will depend on the group, for example, the age of the children. Through these activities, it’s possible to work with stakeholders to explore local understanding of health issues, the issues that are important to the population, the impact and changeability of these issues, and the quality of services currently delivered. The results should also be summarised in the health needs assessment report.

Methods for population involvement

Informal discussion group (focus group).

• Optimum focus group size is 8 to 12 participants
• Outline questions should be devised in advance
• Facilitator introduces topics for discussion
• Findings should be audio recorded and transcribed, or notes taken (preferably by another facilitator)
• A variety of groups may be needed for a wide range of views

Individual interview (semi-structured)

• Findings may be audio recorded and transcribed, or notes taken

Questionnaire

• Questionnaire can be paper-based or online
• An existing questionnaire should be used or adapted where available, for example WHO Global School-based Student Health Survey and Health Behaviour of School aged Children
• If a new questionnaire or survey is developed, this should be piloted first

Talking wall

• Interactive group discussion with individuals recording their comments
• Flip chart displayed on wall with topic headings; individuals add post-it note with their comments
• Online recording methods are available (for example Mentimeter )
• Suggestion boxes, You’re Welcome criteria , NHS Friends and Family test , complaints or compliments and local service audits
• Mentimeter : a free interactive voting tool, which can display real-time responses including text comments

Other stakeholders

It’s important to gather further intelligence on population needs from other professionals working locally who have knowledge of the area. Pooling this knowledge can support the identification of health and social problems that affect the population group and provide information about uptake of services.

This may include teachers, school governors, education welfare officers, commissioners, early year’s practitioners, community leaders, youth groups, the police, community groups, social workers or elected members. Commissioners are a strategic stakeholder and will be a key partner once the health needs are prioritised and the action plan is being prepared for the target population, such as the school or community. Following the school nurse health needs assessment, the commissioners may consider making changes to the services commissioned locally. The same methods for involvement used with the population can be used to engage stakeholders. The findings should be summarised in the health needs assessment report.

Apart from ensuring that the health needs assessment captures information from different perspectives, engaging others in the process helps to strengthen networks and, during the process, solutions to some of the issues may be suggested by others. It is important to make a note of these.

Identifying assets

Identifying assets is an important part of the health needs assessment to ensure the views, perceptions and experiences of children, young people and local communities are captured. Other stakeholders will also have perspectives, for example residents’ or voluntary sector partners’ views on the strengths and assets in a locality. This will support the development of solutions to meet the needs of the population.

To identify what enablers of health exist, consider:

• the strengths and resources locally
• services available, for example, mental health services and sexual health services
• any early years opportunities
• any school-based opportunities
• the skills and expertise in the health visiting and school nursing service
• who else is available to support health needs, for example, community leaders
• local community groups, for example, youth groups, voluntary, community and social enterprises
• community facilities, for example, sports, leisure facilities and community pharmacies

Determining priorities

The different needs and findings should be determined and defined. This could include linking them to poor health indicators locally and to local policies . The identified needs can then be compared using an agreed process, where possible involving stakeholders, parents, children and young people, to determine 2 to 3 priorities.

The health visitor and school nurse should consider the following factors, whichever method is used to prioritise need:

• impact – the severity and size of the issue
• changeability – the realistic chance of achieving change
• acceptability – acceptable solutions available
• feasibility – resource implications of solutions are feasible

See Taxonomy of social need (Bradshaw 1972) .

Several simple methods can enable health visitors and school nurses to prioritise the most important health needs and are presented below.

If each method used produces a different order of priorities, it is important to give a rationale in the final health needs assessment report for the final priority list of needs. For example, this could include a list that supports a key local public health priority or national policy may be more successful in attracting funding from the local commissioner. Engaging commissioners in considerations will support the prioritisation of joint needs.

Forced ranking

In this simple method, each person or group of people rank every health need on a scale of importance. Overall ranking scores for each need are combined to identify the order of priority. This approach produces a priority list based on the experience of the individuals taking part.

Instructions for the process are as follows:

• if 5 health needs are identified, the most important need is allocated a ‘1’, the second most important is ranked ‘2’ and subsequently follows on to the least important need, which will be ‘5’
• when the ranking process has been repeated by each person or group, the ranking scores are added together to provide a total score for each health need. The lowest score has the highest priority and follows on until all needs have been ranked

An example:

This example indicates that mental health is the highest priority need as it has received the lowest score overall, followed by obesity and then alcohol.

Strategy grid

Prioritising needs using the strategy grid method places the focus on addressing needs within the resources available. Strategy grids provide a way of thinking about problems so that the greatest results can be achieved with limited resources.

Instructions for the process are as follows.

• Identify 2 criteria to prioritise need, which should be relevant to health visiting or school nursing. The example below uses impact and feasibility, but other examples may be ‘need and impact’, ‘importance and changeability’ or ‘impact and cost’
• Set up a grid with 4 boxes and allocate one criteria to each axis. Create arrows on the axes to indicate ‘high’ or ‘low’, as shown in the example below.
• Place needs in the appropriate box based on the criteria. The needs have been prioritised as:
• High impact and High feasibility – these are the highest priority needs and require resources and input to address and improve health outcomes
• Low impact and High feasibility – politically important, interventions for these needs can be redesigned to reduce investment and maintain outcomes
• High impact and Low feasibility – these needs often require long-term investment and creative solutions. Too many can be overwhelming. These needs may require breaking down into smaller component parts.
• Low impact and Low feasibility – these are low priority needs. Interventions provide minimal return on investment, so resources should be reallocated to high priority needs.

Priority grid

This is another grid method that scores health needs against a series of locally identified questions.

Enter the issues into the grid and allocate a mark based on the scoring mechanism identified. Scores are totalled to identify 2 to 3 priority needs to be addressed. The remaining needs can be tackled by others or managed later.

Download an example of a priority grid.

Nominal group technique

The nominal group technique supports the involvement of stakeholders by prioritising a wide number of needs in a short time. It encourages debate and quick decisions. It is a democratic process where stakeholders have an equal say regardless of seniority or background. This can be done with everyone together in a room at the same time, or the first 2 stages can be completed remotely.

The first task is to establish a group structure. This part of the process involves gathering a group of 8 to 10 people to participate including health visitors or school nurses, children or young people, or others. The group objective is to prioritise health needs.

Once the group is established, the health visitor or school nurse provides identified health needs and allows the participants to silently record their top 5 potential priorities and rationale for selection. A group meeting follows to share and record all potential priority needs.

The recorded list is then simplified by grouping similar needs or priorities together. The moderator reads out the priorities and participants feedback on how to group them together. Any suggestions that are unclear can be clarified. The moderator then facilitates a group discussion about the potential priorities, the importance of each and interventions.

Participants can then silently and anonymously rank each listed health need on a scale from 1 to 5, where 1 is the highest priority and 5 is the lowest. The moderator collects the results and calculates the total score for each health need. Those with no score are rejected. Of the remainder, the need with the lowest score is the highest priority need, and that with the highest score is the lowest priority need, with the rest on a sliding scale in between. If the list results in tied scores or the results need to be narrowed, the process can be repeated.

Presenting the results of the health needs assessment is an important stage in moving to action planning for change. The findings should be shared with all who participated in the process along with other stakeholders such as the wider health visiting, school nurse team, managers and commissioners. The report should be concise, accessible, informative and tailored to the intended audience.

Reporting will vary depending on the audience but consideration should be given to:

• an executive summary giving the population health needs assessment background, summary of needs assessment methodology and summary of prioritised needs
• an introduction setting out the purpose of the health needs assessment, description of practice area or school nurse service and description of the community or population
• the method for data collection, prioritisation strategy and who was involved
• findings of needs review including data, views from health visiting and school nursing service, population and other stakeholders
• findings of the assets review and details of health resources available
• results of the prioritisation stage and the priority needs determined
• analysis to include making the case for addressing priorities, why these are important and the impact if they were addressed
• actions and next steps, including who will be involved in planning the interventions to address the priorities
• conclusion to restate your key points and link to evidence with a case for change
• acknowledgements: include stakeholders who had an input

The final stage of the health needs assessment process involves reflection. This is a vital part of the process if health needs assessment is to continue to be a relevant and effective tool in improving health and tackling health inequalities. Evaluation of the assessment process should consider:

• whether the objectives set at the start of the health needs assessment process were met
• was the range of stakeholders diverse and involved
• have the findings of the health needs assessment been shared
• what impact will the health needs assessment report have
• who is going to be involved in responding to the health needs assessment – for example in planning changes or a new intervention
• how will the local assets be incorporated into future work
• what opportunities were identified in this process
• were the barriers and limitations, identified at the start of the process, successfully overcome

The next stage is planning the interventions and changes that will be implemented as a result of the health needs assessment. This next stage is beyond the scope of this guidance, however, a useful guide for changing and improving services is the Plan, Do, Study, Act cycle.

Health visitors and school nurses are leaders of the Healthy Child Programme (0 to 19) and in improving health outcomes and reducing inequalities for children and young people. It is important to allocate resources according to need and where maximum impact can be achieved. This guidance provides health visitors and school nurses with the means to assess the priority health needs for their defined population. From this position, effective planning, development and delivery of services to improve outcomes for the population can be undertaken.

Acknowledgements

This guidance has been developed with our key partner, Liverpool John Moores University.

Gill Turner is Senior Lecturer and Programme Leader for Specialist Community Public Health Nursing at Liverpool John Moores University. Gill is a school nurse with an interest in healthy weight. She has written on contemporary school nursing issues.

Dr Sean Mackay is the Programme Lead for Primary Care and Advanced Practice at the School of Nursing and Allied Health at Liverpool John Moores University. He is a health visitor with a research interest in fatherhood and has written on evidence-based health promotion.

Tasneem Patel is Research Assistant at Liverpool John Moores University.

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Health Needs Assessment

• First Online: 27 April 2016

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• Patrick Tobi 3  

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Health needs assessment (HNA) is one of the approaches used to provide intelligence and inform decision-making on the planning and deploying of resources to address the health priorities of local populations. Need is an important concept in public health but is also a multifaceted one that represents different things to different people. From a public health perspective, need is seen as the ‘ability to benefit’, which means that there must be effective interventions available to meet the need. In present-day public health practice, assessing the health needs of local populations typically involves considering not just their physical and mental health and well-being, but the wider determinants or social factors, such as housing, employment and education that influence their health. This chapter describes the historic development of health needs assessment and its use in contemporary public health practice. The different ways in which need is perceived and their implications for the health service are discussed. A step-by-step guide through the HNA process is outlined and comparisons are made with other overlapping approaches to assessment. The practical challenges of carrying out HNAs are highlighted and case studies are used to illustrate real life experiences.

By the end of this chapter, you should be able to :

Discuss the concepts of need, want and demand.

Describe what is meant by a health needs assessment (HNA) and the different approaches that currently influence thinking and practice underpinning HNA.

Identify the key steps and practical challenges involved in conducting a HNA.

Compare HNA with other overlapping assessment approaches.

Understand, through case studies, how HNA is applied in practice.

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Tobi, P. (2016). Health Needs Assessment. In: Regmi, K., Gee, I. (eds) Public Health Intelligence. Springer, Cham. https://doi.org/10.1007/978-3-319-28326-5_9

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11.1 Health needs assessment

• Published: February 2015
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This chapter begins with a consideration of the technical processes used for conducting health needs assessment. The relationship between health needs assessment and health economics is then examined and the philosophy of utilitarianism and its influence on health economics is explored. Cost utility analysis and its links to studies of quality of life are described and the important relationships between equity and efficiency are considered. The chapter then proceeds to explore the political and philosophical issues attaching to health needs assessment. This leads to an elaboration of the concept of justice derived from the work of Sen. Using ideas about the importance of human capabilities an argument is developed about the relational approach to understanding justice. The relational as against the individualistic position is found to provide a novel and useful way of describing health need and of attempting to meet that need. It also provides a set of precepts about the ways that services might be configured.

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National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM)

Health Needs Assessment (HNA) Toolkit

Providing timely and appropriate support

Over 75,000 of the Afghans who were displaced when the Taliban took control of Kabul were resettled in the United States through  Operation Allies Welcome (OAW) Response. OAW was organized in 2021 as a coordinated effort across federal government offices, national non-profit organizations, state and local resettlement agencies, private businesses, and other stakeholders to resettle and support Afghan newcomers. As Afghans arrive in the United States, resettlement agencies, federal partners, healthcare systems, public health professionals, social service providers, and community-based organizations need to collaborate to provide timely and appropriate support. Conducting a health needs assessment is an important first step in designing and implementing public health interventions. 

What is a Health Needs Assessment?

A health needs assessment is a systematic process of collecting, analyzing, and using information to identify the health needs and priorities of a specific population or community. The goal is to identify gaps in health services, resources and health outcomes, and use the information to plan and implement programs and services to increase health equity and improve the overall health and well-being of the community. It typically involves gathering data on knowledge, attitudes, health behaviors, demographics, health status, access to care, and other factors, and using this information to identify health priorities and develop a plan to address them.

Purpose of Conducting a Health Needs Assessment

• Identify the health problems and priorities of a community, including any disparities and inequities in health outcomes.
• Assess the existing health system, including health infrastructure, resources, and capacity, to determine if it can meet the health needs of the community.
• Guide the allocation of resources and the design of health interventions that are tailored to the specific needs and context of the community.
• Evaluate the effectiveness of health interventions and track progress over time.

+ Surveys and Questionnaires

Surveys and questionnaires are standardized tools used to collect information about the health needs and behaviors of a community. They often include closed-ended questions that can be analyzed quantitatively.

+ Focus Group Discussions

Focus group discussions involve a small group of individuals who share their opinions and experiences on a specific health issue. This method allows for in-depth exploration of a particular topic and provides rich qualitative data.

+ Key Informant Interviews

Key informant interviews involve talking with individuals who have expert knowledge or experience with a particular health issue or community. These interviews provide valuable insights into local health needs and issues.

+ Medical and Health Records Review

Reviewing medical and health records can provide insight into the health status and needs of a particular community. This method can also help identify gaps in care and areas for improvement.

+ Direct Observation and Physical Examination

Direct observation and physical examination involve observing and assessing individuals or communities for signs of illness or disease. This method can provide valuable information about the health status of a community and identify health needs.

+ Community Mapping and Participatory Approaches

Community mapping and participatory approaches involve working with community members to identify local health needs and resources. This method can promote community engagement and ownership of health initiatives. It can also help identify barriers to accessing care and opportunities for community-based interventions.

Identify the community to be assessed.

Gather data on the community's health status, behaviors, and needs.

Analyze the data to identify priority health issues.

Involve the community in the assessment process.

Develop and Implement

Develop and implement a plan to address the identified health needs.

Evaluate the effectiveness of the plan and make necessary adjustments.

Best Practices for Conducting a Health Needs Assessment Among RIM Communities

This guide offers tips and reminders on what to remember or avoid when conducting an HNA among RIM communities. It emphasizes the importance of a community-driven approach and a thorough understanding a community's health needs to effectively address health disparities and promote health equity.

Download now >>

Health Needs Assessment Question Checklist

This checklist provides questions for service providers to use as a guide when conducting health needs assessments among RIM communities. Included are examples that showcase the varied ways that organizations can use HNAs to achieve their own program goals.

Promising Practice: Sexual and Reproductive Health Needs Assessments

Discover how Health Needs Assessments (HNAs) are addressing the unique healthcare challenges faced by Afghan women in the U.S. Learn about tailored interventions and impactful findings to enhance healthcare accessibility and cultural sensitivity. 

Learn More >>

Assessing Afghan Newcomer's Health Needs: A Home Visit Guide

This guidance document aims to assist Health Navigators, Community Health Workers, or other service providers in conducting an individualized health needs assessment with Afghan newcomers during a home visit to gauge Afghan clients' immediate healthcare needs and their understanding of navigating the U.S. healthcare system. 

Download Now >>

Individualized Health Needs Assessment for Afghan Newcomers

The Afghan Newcomers Individual Health Needs Assessment Form is a comprehensive tool designed to identify the unique health requirements of individuals migrating from Afghanistan to their new community. This fillable form aims to gather essential information to ensure that newcomers receive appropriate healthcare support and access to available resources.

In-Home Health And Safety Checklist

This checklist, which focuses mostly on safety concerns inside of the home, is based on a survey of providers’ experiences. It can be a useful reference during meetings or home visits with clients.  

Download Now >> 

Example 1:  IRC Atlanta

• Purpose : HNA used by IRC Atlanta for determining both gaps in knowledge around U.S. healthcare and gaps in health services needed by the client after the first 90 days in the U.S.
• Assessment Type : Questionnaire
• Implementation :   This HNA guiding document is used by IRC Atlanta’s bilingual community health workers (CHWs) during home health visits with Afghan clients. In these home health visits, the CHW visits the client(s) in their home at a time that is most convenient for the client(s). After conducting the HNA, the CHW will refer the client(s) to the necessary health services that are needed (e.g., dental care, mental health, specialty care, etc.)

Below are examples of HNAs that were created by two IRC offices, IRC Atlanta and IRC Salt Lake City. These two examples showcase the varied ways that organizations can use HNAs to achieve their program goals. 

Example 2:  IRC Salt Lake City

• Purpose : HNA used by IRC Salt Lake City for determining community needs around Afghan women’s health. 
• Assessment Type : Survey with facilitator scripts and notes
• Implementation : This sample includes a call script to introduce the HNA and recruit participants, notes to help guide facilitators in each section of the HNA, and different questions around women’s health topics, including health access, maternal health and family planning, preventative gynecological health, sexual and reproductive health rights, gender equity, etc. The HNA was created in collaboration with members of the Afghan community. 
• More information:   Download the Slides | Promising Practice

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• Open access
• Published: 17 January 2023

A scoping review of community health needs and assets assessment: concepts, rationale, tools and uses

• Hamid Ravaghi 1 ,
• Ann-Lise Guisset 2 ,
• Samar Elfeky 3 ,
• Naima Nasir 4 ,
• Sedigheh Khani 5 ,
• Elham Ahmadnezhad 6 &
• Zhaleh Abdi 7  

BMC Health Services Research volume  23 , Article number:  44 ( 2023 ) Cite this article

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Community health needs and assets assessment is a means of identifying and describing community health needs and resources, serving as a mechanism to gain the necessary information to make informed choices about community health. The current review of the literature was performed in order to shed more light on concepts, rationale, tools and uses of community health needs and assets assessment.

We conducted a scoping review of the literature published in English using PubMed, Embase, Scopus, Web of Science, PDQ evidence, NIH database, Cochrane library, CDC library, Trip, and Global Health Library databases until March 2021.

A total of 169 articles including both empirical papers and theoretical and conceptual work were ultimately retained for analysis. Relevant concepts were examined guided by a conceptual framework. The empirical papers were dominantly conducted in the  United States. Qualitative, quantitative and mixed-method approaches were used to collect data on community health needs and assets, with an increasing trend of using mixed-method approaches. Almost half of the included empirical studies used participatory approaches to incorporate community inputs into the process.

Our findings highlight the need for having holistic approaches to assess community’s health needs focusing on physical, mental and social wellbeing, along with considering the broader systems factors and structural challenges to individual and population health. Furthermore, the findings emphasize assessing community health assets as an integral component of the process, beginning foremost with community capabilities and knowledge. There has been a trend toward using mixed-methods approaches to conduct the assessment in recent years that led to the inclusion of the voices of all community members, particularly vulnerable and disadvantaged groups. A notable gap in the existing literature is the lack of long-term or longitudinal–assessment of the community health needs assessment impacts.

Peer Review reports

The population-based health approach aims to improve the population’s health, promote community resilience and reduce health inequities across the socioeconomic gradient via inter-sectoral partnerships among community groups, government, healthcare systems, and other stakeholders [ 1 ]. One key feature for adopting a population-based health approach is to ensure that it is grounded on a solid understanding of community health needs and assets by triangulating evidence from service providers and community members on services availability, accessibility, utilization and experience [ 2 , 3 ]. The process of identification of unmet health needs in a population is crucial for local authorities seeking to plan appropriate and effective programmes to meet these needs [ 3 , 4 ]. If these needs are ignored, then there is a risk of a top-down approach for providing health services, reflecting what a few people perceive to be the needs of the population rather than what they actually are [ 4 , 5 ].

In this context, community health needs assessment is a means of developing a comprehensive understanding of a community’s health and health needs as well as designing interventions to improve community health [ 6 ]. Though the process of community health needs assessment can be conducted in several ways, the primary purpose is to provide community leaders or healthcare providers with an overview of local policy, systems, and environmental change strategies currently in place and help to identify areas for improvement [ 7 ]. Community health needs assessment can provide them with a more nuanced understanding of the communities they serve, making them aware of pressing issues that require system-level changes and support their efforts for resource mobilization to initiate innovative programmes [ 8 , 9 ]. The process to gather evidence on community health needs can also serve as a springboard to strengthen community engagement [ 10 ].

In general, needs assessments are usually designed to evaluate gaps between current situations and desired outcomes, along with possible solutions to address the gaps. Recently, there has been a trend to move away from framing a community with a deficit perspective (need-based approach) to focus on community assets and resources, called community health needs and assets assessment [ 11 , 12 ]. In contrast to a need-based perspective which focuses on local deficits and resources outside the community, an asset-based perspective focuses on honing and leveraging existing strengths within the community to address community needs [ 12 , 13 , 14 ].

Studies have shown that community health needs assessment is used widely by different users and across different settings [ 15 , 16 ]. However, these studies varied widely in terms of purpose, process and methods of conducting community health needs assessment. Furthermore, the extent to which an asset-based approach is used is unclear, beyond the inclusion in guidance and recommendations. Thus, to support national or local decision-makers to make informed choices about the scope, tools, methods and use of community health needs and assets assessment, this scoping review of the literature aimed at: 1) Providing conceptual clarity on community health needs and assets assessment, 2) Determining for what purpose and with what methods community health needs and assets assessment are used globally, 3) Drawing the lessons learnt from previous experience with community health needs and assets assessment: what works in what context and under what conditions, 4) Documenting evidence of impact of community health needs and assets assessment, 5) Consolidating tools and methods used to collect evidence/data underpinning community health needs and assets assessment processes.

Search strategy

Ten databases, including PubMed, Embase, Scopus, Web of Science, PDQ evidence, NIH database, Cochrane library, CDC library, Trip, and Global Health Library were searched in February and March 2021. The search strategy was developed through discussion with experts in the field of population health, a research librarian, and a narrative review of the literature. Preliminary search terms were developed by the research team to reflect a number of core concepts including needs, population, needs assessment, assets assessment and participation. The search process was performed by a librarian with expertise in the use of literature databases (SK). The search terms were pilot-tested and agreed upon within the research team. The PubMed database search strategy presented in Additional file  1 .

Inclusion and exclusion criteria

Studies that focus on community health needs and assets assessment in terms of concepts, rationale, uses and tools were considered in both high-income countries (HICs) and low-and middle-income counties (LIMCs). We included studies in the review if they met the following criteria: 1) Papers providing conceptual clarity and explaining rationale for community health needs and (assets) assessment (This can be articles describing community health needs assessment or community assets assessment or community health needs and assets assessments at the same time or separately). The terms capabilities/ strengths/ resources can be used in place of assets and were considered.); 2) Papers describing or evaluating experiences implementing community health needs (and assets) assessment in a single site or multiple sites; 3) Methodological papers describing tools/approaches for community health needs (and assets) assessment; 4) Review of the literature on community health needs (and assets) assessment.

Types of papers not include in the review were: 1) Studies without a clear description of the community health needs and (assets) assessment methods, 2) Studies assessed a single dimension (i.e. health outcomes only, or healthcare providers’ capabilities only such as patient surveys, health outcomes dashboard, health facility assessment), 3) Studies related to a single disease or programme, 4) Studies focused only on engaging individual patient in their own care, and 5) Studies were not in English.

Three reviewers participated in the selection of the relevant studies (HR, ZA, NN). The eligibility and relevance of the articles were determined by two reviewers independently using the above predefined criteria. In the event of disagreement, a consensus was found between all the reviewers about the status of the article.

Data extraction

Separate data extraction forms were developed for the extraction of the three main categories of papers: conceptual, empirical and review papers. Totally, 121 empirical papers (including 6 review papers) and 48 conceptual and methodological papers were reviewed. Following topics were extracted for empirical papers: 1) General characteristics including author(s), year of publication, country of implementation, study objective(s) and study method; 2) Community health needs and (assets) assessment framing including rational, definitions of community health needs and (assets) assessment/ needs/ assets/ community, initiator(s) or user(s) of the process; 3) Key steps of the process, collected data, data collection tools; 4) Community engagement and the level of engagement; 5) Use of community health needs and (assets) assessment findings, impact of community health needs and (assets) assessment; 6) Facilitators and barriers. Data extraction forms are presented in Additional file  2 .

Data extraction forms were pilot-tested prior to the implementation. Two authors (ZA, HR) independently performed a pilot data extraction of a random sample of ten original articles. After piloting, the authors assessed the extracted data in relation to the scoping review questions and revised them accordingly. The content of the form was finalized by discussion within the team. Regarding conceptual papers, two authors (NN and ZA) initially extracted data from three randomly selected papers and subsequently refined and amended the form having research team inputs.

Four reviewers extracted included studies independently. The data extracted were cross-checked by one of the authors and mutual consensus resolved discrepancies. Individual data extraction forms of empirical papers were then merged into a single, unifying document used for the interpretation and presentation of the results. Following typical scoping review methods, the methodological quality of the included articles was not assessed systematically, however, only peer-reviewed articles were included in our review process [ 17 ].

Synthesis of results

Following reading and extracting conceptual papers, a preliminary conceptual framework (Fig.  1 ) was developed and discussed and agreed upon by team members. The integrative synthesis of the evidence was employed. Specifically, it involved the narrative description of concepts and definitions, key steps of the community health needs assessment and barriers and facilitators of the implementing community health needs assessment.

Conceptual framework of the review

The study selection process is summarized in Fig.  2 . Just over 12,000 records were obtained from the ten databases searched. Articles with obviously irrelevant titles were excluded, as were news items, letters, editorials, book reviews, and articles appearing in newsletters or magazines rather than peer review journals. The remaining abstracts were retrieved, read and assessed. A total of 169 articles including both empirical papers and theoretical and conceptual work were ultimately retained for analysis. A list of all studies with a short description, including the year of publication, key focus, study period, and methods, is presented in Additional files  3 and 4 . The first part of the results section focuses on definitions and concepts of community health needs assessment using both conceptual and empirical papers. In the second part of the results section, we describe key steps of the community health needs assessment and tools and methods used to collect data through content analysis of 121 included empirical papers. We also report some important challenges and facilitators faced by included studies while performing community health needs assessment. Role of community participation in the process and the spectrum and types of the participation is discussed in the last part.

Information flow in scoping review

General characteristics of the included studies

The review showed that community health needs assessment is used widely by different users and across different settings in both HICs and LMICs. Among included empirical studies, 81 (out of 121) were conducted in the  United States (US). There were papers from Australia ( n  = 4), South Africa ( n  = 3), Kenya ( n  = 3), Uinted Kingdom (UK) ( n  = 2), Canada ( n  = 2), China ( n  = 2), Dominican Republic ( n  = 2), Republic of Ireland ( n  = 2), Iran ( n  = 2), India (2), Honduras ( n  = 1), Netherland ( n  = 1), Vietnam ( n  = 1), Sudan ( n  = 1), New Zealand ( n  = 1), Madagascar ( n  = 1), Malaysia ( n  = 1), Ecuador ( n  = 1), Indonesia ( n  = 1), Uganda ( n  = 1), Taiwan ( n  = 1), Kyrgyzstan ( n  = 1), Saudi Arabia ( n  = 1), Haiti ( n  = 1), Honduras ( n  = 1) and Korea ( n  = 1).

Definition of needs

The review showed “need” was a multi-faceted concept with no universal definition. There was a differentiation between “health need” and “healthcare need” in the reviewed literature. Healthcare needs can benefit from health care (health education, disease prevention, diagnosis, treatment, rehabilitation and terminal care). Healthcare providers usually consider needs in terms of healthcare services that they can supply. However, health needs incorporate the wider social and environmental determinants of health, such as deprivation, housing, diet, education and employment. This broader definition allows looking beyond the confines of the medical model based on health services, to the wider influences on health [ 3 ].

In this review, relatively few empirical studies focus narrowly on healthcare needs, without attention to other determinants of health that can affect health [ 18 , 19 , 20 , 21 , 22 , 23 ]. Most of the included empirical studies looked beyond “physical health needs” to consider wider “social determinants of health” or non-medical factors that can affect a person’s overall health and health outcomes as the conditions—shaped by political, social, and economic forces—in which people are born, grow, live, work, and age [ 24 ]. Notably, the need was recognised as a “dynamic concept” whose definition will vary with time according to context and resources available to address these needs [ 16 ].

Definition of community

In general, “community” has been defined as “people with a basis of common interests and network of personal interactions grouped either based on locality or on a specific shared concerns or both” [ 25 ]. Shared common interests are particularly important as they can be assessed and, hopefully, met at a community level [ 26 ]. Importantly, community is a dynamic concept as individuals can belong to several communities at various times. In our review, community was defined by included studies, particularly those initiated by local authorities or healthcare providers (e.g., hospitals), based on geographical indicators such as county designations or based on the location of the hospital’s/facility’s/authority’s existing or potential service users. Some included empirical studies considered community based on shared interests or characteristics such as race/ethnicity, sexual orientation, or occupation. Medically underserved populations including rural areas [ 27 , 28 , 29 , 30 ], impoverished urban sectors [ 31 ], the homeless [ 32 , 33 , 34 , 35 ], persons in poverty or of low socioeconomic status, vulnerable children and families [ 18 , 28 , 36 , 37 , 38 ], the elderly [ 8 , 39 , 40 , 41 , 42 ], women and girls [ 43 , 44 , 45 , 46 , 47 ], LGBT (Lesbian, gay, bisexual, and transgender) individuals [ 48 , 49 , 50 , 51 ], displaced populations, immigrants and racial, ethnic and religious minority groups [ 12 , 19 , 36 , 42 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 ] and persons with severe and chronic health problems [ 79 ] were considered as a “community” by a number of included studies.

While defining community, a number of its characteristics were determined by included studies including: history, existing groups, physical aspects (i.e. geographic location, community size, its topography and etc.), infrastructure (i.e. health and social care facilities, public transportation, roads, bridges, electricity, mobile telephone services and etc.), demographics (i.e. age, gender, race and ethnicity, marital status, education, number of people in household, first language and etc.), economic conditions, deprivation and/or inequalities, government/politics, community leaders (formal and informal), community culture (formal and informal), existing institutions, crime and community safety, lifestyle and leisure, general health problems and epidemiology.

In our review, community health needs and assets assessment were performed by different organizations as the first step in community health promotion planning, including local health authorities (district/local), community entities [i.e. non-governmental organizations (NGOs), civil society organizations (CSOs), faith-based organizations (FBOs), community-based organizations (CBOs)] and hospitals (public/private). Included studies mostly conducted health needs assessment at the local level (e.g. cities, counties, or other municipalities). The broader understanding of health and its determinants suggests that many public and private entities have a stake in or can affect the community’s health. To engage stakeholders in the process, a number of included empirical studies ( n  = 56, 49%) sought representatives from the community that were best positioned to speak about community health based on their specific knowledge or line of work. These stakeholders were individuals from community and entities who may explicitly be concerned with health or not, which varied by the community context and culture. To have a comprehensive overview of a community needs, it was asserted that defining communities needs to be dynamic and socially constructed to take into account all voices and members, especially those not ordinarily included [ 80 ]. Community should be defined in a manner that does not exclude medically underserved, low-income, or minority populations. Integrating community voices is especially important in designing plans and programmes aimed at reducing health disparities in the community [ 58 , 81 , 82 ].

Definition of assets

Overall, there were limited definitions for “community assets” in the reviewed literature. Assets were described as resources, places, businesses, organizations, and people that can be mobilized to improve the community [ 11 , 83 ]. This includes members of the community themselves and their capabilities. Assets can therefore be described as the collective resources which individuals and communities have at their disposal, which protect against adverse health outcomes and promote health status [ 83 , 84 ].

Of 115 included empirical studies, 30 studies addressed community assets while performing community health needs assessment. A wide range of assets, from tangible resources to intangible ones, were considered that can be classified into seven broad categories as follows:

Community demographic characteristics: Literacy rates [ 13 ], youth population [ 58 , 68 ], and elderly population [ 68 ];

Natural capitals: Geographical location and natural resources [ 21 , 81 , 85 ];

Economic and financial capitals: Community business [ 12 , 81 ] community members’ income [ 21 ], and housing land ownership [ 13 ];

Community infrastructure: Level of technology/mobile phone coverage [ 13 , 21 ], transportation [ 86 ], parks and sidewalks [ 12 ], sport and recreational facilities [ 31 , 87 , 88 ], public libraries and community centres [ 88 ];

Community social and educational facilities: Non-profit and non-governmental organizations [ 59 , 87 ], media [ 89 ], educational institutions [ 12 , 31 , 81 , 90 ], faith communities [ 58 , 81 , 90 ], and community associations [ 31 ];

Community health and social facilities: Health and social facilities and providers [ 72 , 81 , 85 , 86 , 89 ], traditional medicine providers [ 72 ], and ongoing health programmes [ 13 , 87 ];

Community’s social and cultural values and resources: Tribal and community culture [ 58 , 68 , 74 , 91 ], cultural diversity [ 81 ], spirituality and religion [ 58 , 74 ], strong family bonds and values [ 59 , 74 ], strong community connections, teamwork and willingness to volunteer [ 21 , 81 , 86 , 91 ], mutual support, social support and networks [ 45 , 58 , 81 , 85 ], unity, community cohesion and collectivity [ 21 , 59 , 74 ], community capacity [ 58 ], community-led activities [ 86 , 91 ], and community values and traditions [ 68 , 74 , 86 ], resiliency [ 58 ], unifying power of communities [ 13 ], community administration units e.g. women’s committees [ 13 ], an existing group of dedicated healthcare providers [ 39 ], a group of concerned citizens [ 39 ], community safety [ 12 ], the knowledge base of the community members themselves [ 39 ] and members’ desire to be healthy [ 58 ].

Various qualitative methods such as individual interviews (one-on-one structured conversations) or focus groups (guided, structured, small group discussions) with community members, or key informants’ interviews (formal and informal conversations with leaders and stakeholder groups) or a combination of these methods were reported as the main methods to collect information on community’s assets among reviewed studies. Of these, focus group was the widely used method in community assets assessment [ 8 , 21 , 31 , 45 , 58 , 59 , 67 , 81 , 82 , 85 , 87 , 90 , 92 , 93 ].

Definition of community health needs (and assets) assessment

The terms “Community Needs Assessment (CNA)”, “Community Health Needs Assessment (CHNA)”, and “Community Health Needs and Assets Assessment (CHNAA)” were used interchangeably in the literature referring to the process of identifying health needs (and assets) of a given community. Since this review focuses on both community needs and assets, we will use the CHNAA term for the description of the process in this paper.

None of the papers reviewed provided a specific definition for CHNAA. In general, reviewed papers defined CHNAA as: A collaborative, community-engaged, systematic, ongoing, continuous, proactive, comprehensive, cyclical, regular, modifying method or process [ 28 , 33 , 69 , 92 , 94 , 95 , 96 , 97 , 98 ]; For the identification, collection, assembly, analysis, distribution, and dissemination of information on key health needs, social needs, concerns, problems, gaps, issues, factors, capabilities, strengths, assets, resources; About communities (or individuals) [ 21 , 23 , 28 , 31 , 33 , 37 , 41 , 45 , 54 , 79 , 89 , 94 , 95 , 96 , 97 , 99 , 100 , 101 , 102 ]; To achieve agreed priorities, create a shared vision, plan actions, garner resources, engage stakeholders, work collaboratively, establish relationships, implement culturally appropriate, multi-sectoral/multilevel intervention strategies, empower residents and enhance community capacity and participation in decision-making process [ 12 , 13 , 20 , 27 , 28 , 37 , 45 , 70 , 79 , 89 , 91 , 92 , 94 , 95 , 97 , 98 , 99 , 101 , 102 , 103 , 104 ]; Towards improving health and wellbeing, building and transforming health of the communities, increasing community benefits, reducing inequalities; Through which primary/secondary healthcare can respond to local and national priorities [ 20 , 23 , 28 , 40 , 51 , 59 , 69 , 97 , 103 , 105 , 106 ].

The included studies listed a number of reasons as the rationale for conducting CHNAA. Legislative requirements were most cited as the main rational for conducting CHNAA, particularly among studies conducted in the UK and US. Since the late 1980s, the concept of health needs assessment has gained increasing prominence within the National Health Service (NHS) in the UK. This has been prompted by a series of policy initiatives requiring health facilities to assess needs of their populations and to use these assessments to set priorities to improve the health of their local population [ 107 , 108 ]. In the US, several national, federal, state, and local funding sources require entities to conduct CHNAA to demonstrate a significant need for their services and programmes to be funded. The most important one is Patient Protection and Affordable Care Act (ACA-2010), requiring non-profit hospitals as tax-exempt entities to perform CHNAAs to maintain non-profit status regularly [ 92 ]. Other reasons were mentioned by included studies as the rationales for conducting CHNAA were: lack of information of health needs of a specific community, to facilitate health research and related interventions in a community, to inform the design of contextually relevant programmes and policies, to develop community health improvement plans or health promotion interventions, to develop or update strategic plans, and to receive resources and funds.

Key steps to conduct CHNAA

The number and nature of CHNAA process steps varied among reviewed studies. However, broadly CHNAAs involved six main steps as follow:

Formulation of a leadership team

Forming a leadership team, which was called by different names such as the steering committee/ the research advisory committee (RAC)/ the collaborative task force/ or the community advisory board (CAB), was known as the preliminary step of a CHNAA process. The steering committee was usually composed of local representatives from local agencies and organizations (e.g. non-profit organizations, community service agencies, media outlets, county and municipal governments, colleges and universities, faith-based organizations, and healthcare providers), community members, community stakeholders and leaders, academic partners, health and social officials, and representatives from the investigator body to help guide the development of the CHNAA project.

Leadership team responsibilities were reported as providing inputs on the research purpose, selecting and verifying study methodology and design, providing inputs and feedback on initial survey/topic content and selecting final survey/ topic guide questions, reviewing survey/topic guide length, and ensuring culturally relevant and resonant wording, comprehension and face validity, and monitoring the progress of the data collection. Feedback and recommendations from the steering committee were incorporated throughout the CHNAA process as well. Steering committees usually met on a regular basis.

Identification of needs, assets and prioritisation

To collect information on community health, needs and assets, both primary and secondary data were utilized by included studies. Secondary data included information on community socio-demographic and indicators on health status, access, utilization and satisfaction with health and social services at different levels (e.g. community, sub-national and national) to develop a picture of the overall community health. Primary data were collected through quantitative and qualitative methods and mixed-methods approaches.

Quantitative studies 

Some empirical studies used individual/household surveys as the only source to identify community needs and concerns ( n  = 28, 24.%). Surveys were a popular method of gathering opinions, preferences and perceptions of needs. Needs assessment surveys typically have written, closed-ended questions filled through the interview (face to face/telephone) or self-completion (paper or online) by community members. Generally, two main kinds of surveys were used by included studies: a) community health assessment survey, and b) community concerns survey. A number of included studies used health assessment surveys as the key data sources of the CHNAA process ( n  = 22, 19%) or along with other types of data, mainly qualitative data ( n  = 21, 18.%). Health assessment surveys typically collected information on demographics, socio-economic variables, respondents’ health status, choice of healthcare providers, and healthcare access issues among community members. Survey questionnaires were mostly developed with inputs from the literature review (similar health assessment surveys conducted at the local or national level), community members and project team discussions. Additional file  5 shows the most important data and indicators collected by included studies through conducting community health  assessment surveys.

Another form of surveys, used alone or in combination with qualitative methods ( n  = 15, 13.5%), was the community concerns survey in which people (community members and/or key informants) are asked to help identify what they see as the most important issues facing their community leading to an inventory of their health priorities [ 12 , 20 , 23 , 27 , 29 , 55 , 69 , 74 , 101 , 103 , 109 , 110 , 111 , 112 , 113 ]. A straightforward way to estimate the needs of a community was to simply ask residents their opinion on what particular services are most needed in the community. The focus of this methodology was to create an agenda based on the perceived needs and concerns of community residents. The concerns surveys were based on either focus group discussion with community members and experts or literature review by the researchers or both. Generally, while filling community concerns survey, individuals were asked to rate the importance of each issue in their community on a scale (e.g. 0 = not important, 5 = extremely important) [ 23 , 27 , 29 , 55 , 74 , 110 ]. Participants could also add and rate concerns or service needs that were not listed. Finally, each health problem identified by the community was weighted based on the frequency it was selected on the survey.

General coverage of the surveys was the population aged 18 or over currently residing in the community for a minimum period of time (at least a few months) and able to provide consent for participation. Most surveys were written, closed-ended questions filled through face to face or telephone interviews or self-completion by community members. In addition to the paper-form survey, some studies used email and social media platforms to allow residents to anonymously complete online surveys [ 29 , 51 , 57 , 96 , 103 , 110 , 114 ]. A few studies reported that residents received monetary or nonmonetary incentives for their participation upon survey completion [ 19 , 71 , 74 , 77 , 110 ]. Sampling techniques commonly used are those that promote participation in CHNAAs such as convenience sampling [ 20 , 35 , 40 , 51 , 52 , 57 , 64 , 65 , 71 , 74 , 75 , 77 , 86 , 96 , 101 , 103 , 104 , 110 , 114 , 115 ]. Only a few studies used random sampling or demonstrated the representativeness of their samples. Their response rates varied between 8 to 95.5%. Most surveys recruited local surveyors and provided them with research training to ensure consistent survey administration to attract community participation. Some studies that assessed health needs among immigrant communities or minority groups recruited bilingual surveyors or/and provided participants with two versions of the instruments, one in the native language to maximize community engagement [ 12 , 27 , 52 , 65 , 71 , 86 , 103 ]. Surveys that took a participatory approach to the design, content, terminology, and language level, were reported more understandable and culturally relevant to the community members [ 52 , 65 , 75 ].

Health needs assessment surveys (both concerns surveys and health assessment surveys) reported limitations to data collection based on the assessment timing, data availability, and sample response. As said earlier, using a convenience sampling and non-representative samples, small sample size and inter-rater reliability between surveyors were among some important methodological limitations reported by these studies, which limited the generalisability of the study findings to the entire community population [ 35 , 57 , 65 , 71 , 74 , 75 , 77 , 96 , 106 , 116 ]. Convenience sampling method and using community events as sampling sites led to sampling bias in some studies (e.g., an over-representation of some specific groups of the population such as women and low –income or high-income groups) [ 57 , 63 , 65 , 66 , 71 , 74 , 75 , 78 , 103 , 114 , 115 ].

Qualitative studies

Among included studies, about 34% ( n  = 39) used qualitative methods as the main source of data collection on community needs and assets. Some of these studies justified the use of qualitative approach by explaining how the overreliance on quantitative, population-level data resulted in CHNAAs failing to identify health needs and interests of all community members, particularly those of vulnerable population and underrepresented marginalized segments of the community. In addition, these studies concluded that integrating qualitative methods into the CHNAA process has the potential to involve community members in a more participatory fashion, perhaps improving future collaborations between communities and service providers. Such collaborations can help to design focused initiatives, making them more meaningful and culturally appropriate [ 12 , 59 , 91 , 102 ].

Key informant interviews, individual interviews with community members, focus groups with community members and community forums were among the qualitative data collection techniques used individually or in combination with each other by these studies to collect data on community needs and assets. They asserted that qualitative techniques specifically targeted to underrepresented segments of the population proved to be effective mechanisms to explore the participants’ perceptions on issues surrounding community health needs and assets. The most used technique to elicit community members’ opinions were focus group discussions and key informant interviews.

Small sample size and single-site setting were mentioned as the most cited limitations of  the qualitative CHNAAs that limit these studies generalisability. Because the studied communities were unique communities with unique assets, constraints, and health needs, the CHNAA findings cannot be generalised to other communities [ 32 , 39 , 62 , 70 , 72 , 73 , 91 , 117 , 118 ]. Another limitation mentioned by some studies was that the demographic composition of the focus group participants, specifically with regards to race, gender, socio-economic status and age group, did not fully reflect the population of studied community as a whole [ 13 , 61 , 62 , 72 , 97 , 119 ]. Some studies reported that they could not include all influencing key informants in the community to facilitate broader understandings of health needs [ 13 , 120 ].

Mixed- methods studies

A variety of data collection methods were used in a number of included studies to ensure that a comprehensive picture of community health needs and resources was obtained ( n  = 48, 42%). Some of these studies were two-phase explanatory mixed-methods studies, with the quantitative phase preceding the qualitative phase ( n  = 14, 12%). They conducted targeted focus groups or community listening sessions or interview with community members/key informants following needs assessment survey to supplement the findings from the survey and provide further information about health status, needs of daily living, barrier to health and access to community resources [ 8 , 21 , 41 , 53 , 55 , 66 , 67 , 93 , 94 , 95 , 99 , 113 , 114 , 121 ]. In addition to these studies, some studies used triangulation mixed-method design to obtain complementary qualitative and quantitative data on community health needs and issues ( n  = 13, 11%). These studies confirmed that using multiple data sources ensured researchers obtain a complete picture of the community health needs. Applying qualitative methods in the form of focus groups and semi-structured interviews enabled exploration of problems and needs within their social context and provided a wider perspective on issues raised. However, to conduct such studies CHNAA teams had to have members who have qualitative and quantitative expertise. There were some limitations specific to the mixed-method studies, including lack of rigor in integrating qualitative and quantitative findings, relying heavily on quantitative data for health need determination, and absence of the voices of the communities most in need [ 69 , 91 ].

Data analysis and interpretation

Qualitative data from focus group discussions and key informant interviews were mainly audio-recorded and transcribed verbatim by the research team and all identifying information was removed. Different analytical approaches, mostly content analysis and thematic analysis, were used to identify main themes related to assets, needs and gaps in the service system and priority populations.

Quantitative data from surveys were analysed using statistical software. Descriptive statistics were used to describe the sample in terms of socioeconomic background and present the prevalence of chronic diseases, risk factors, and health behaviours. Statistical analytical tests were also used to compare results between different groups of community members. Results also were compared by those at the state/ national level or from a similar community. Those diseases or risk factors that had a high prevalence among community members are regarded as priorities that to be addressed further.

Formulation of recommendations across various levels (individual, institution, community, policy levels)

Following analysis of the quantitative and qualitative data, the studies included in the review provided a thorough list of health needs and assets of the community. Included studies mainly used CHNAA outputs: 1) as a resource to provide baseline data of community’s health; 2) as a resource to prioritize and plan services; 3) as a resource for writing grant applications; 4) as a resource to guide a comprehensive health promotion strategy.

Not all included CHNAAs proposed interventions to address identified needs and issues. Some of the included studies ( n  = 45, 39%) just provided a snapshot of the most important issues faced by the studied community. They demonstrated several areas where CHNAAs provide more information to researchers, community organizations, and policy-makers. On the other hand, not all identified issues and needs were addressed by those studies performed CHNAA in order to implement interventions or strategies. In practice, specific populations or a number of specific health conditions or health risks, or overarching issues such as health inequality and disparities were prioritized by these studies.

In most cases, decisions on implementation were carried out by the CHNAA steering committees or the research teams. Only a number of studies used a clear and explicit set of criteria for deciding the importance of each issue [ 22 , 27 , 43 , 67 , 94 , 118 , 122 ]. A wide range of criteria were used by included studies such as: impact, urgency, community concern, achievability within the set time [ 94 ], seriousness, urgency, solvability, and financial burden of the problems [ 27 ], perception of survey participants on importance of the identified issues and feasibility of intervention, prevalence, fatality, social and cultural stigma [ 22 ], possible interventions, organizational capacity, and community assets and resources [ 13 ], importance and possibility of the effecting change [ 43 ], prevalence, impact on the duration of sickness, impact on mortality, and the availability of treatment [ 122 ], impact of the problem on the overall wellness, quality of life, and resources of their community [ 118 ], factors of health issue, size, seriousness, and effectiveness of available interventions [ 101 ], importance and feasibility [ 67 ].

Different techniques for ranking priorities were applied by included studies such as: 1) Multi-voting technique (decide on priorities by agreeing or disagreeing in group discussions and continuing process/rounds until a final list is developed), 2) Strategy lists (determine if the health needs are of “high or low importance” by placing emphasis on problems whose solutions have maximum impact, with the possibility of limited resource), 3) Nominal group technique (rate health problems from 1 to 10 through group discussion), and 4) Prioritization matrix (weigh and rank multiple criteria for prioritization with numeric values to determine health needs with high importance).

Overall, health priority types were categorized into four main categories by included studies:

Medical conditions (e.g. obesity, diabetes, heart diseases, asthma, mental health disorders, substance abuse, vision/ dental problems, HIV/AIDS and sexually transmitted diseases, injuries and health consultations).

Health behaviours (e.g. physical activity, eating habits/ nutrition, tobacco consumption, teen pregnancy and violence/gangs).

Community conditions (e.g. poverty and unemployment, environmental and infrastructural conditions, such as air quality/pollution, transportation, access to clean water and sanitation, community collaboration, and access to healthy food, exercise facilities and occupational concerns).

Health systems priorities (e.g. access to care, including primary care and higher levels of care, specialty care, mental/ behavioural health care and dental care, quality and acceptability of health services, lack of cultural competence in health systems, flexible hours and waiting time).

However, guided by a community-based participatory research (CBPR) approach, a number of studies involved community members and stakeholders in priority identification or ranking [ 12 , 21 , 22 , 23 , 27 , 29 , 31 , 36 , 41 , 43 , 49 , 53 , 55 , 56 , 58 , 59 , 60 , 62 , 63 , 68 , 70 , 74 , 86 , 87 , 88 , 90 , 92 , 99 , 100 , 103 , 104 , 110 , 114 , 117 , 118 , 119 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 ], in potential strategy selection [ 13 , 19 , 67 , 82 , 89 , 130 ], and in carrying out strategies [ 8 , 37 , 69 , 81 , 93 , 105 , 113 ]. They asserted that by involving the perspectives of the relevant stakeholders, a comprehensive overview of the issues and possible effective solutions was created.

Planning of programmes and interventions, implementation and evaluation

The results of CHNAA were used in various ways by included studies. In some studies, particularly researcher-led studies with limited support or involvement of the local authorities, CHNAA just led to the identification of new, locally relevant issues and priorities without any further actions ( n  = 45, 39%). The results of these CHNAAs provided more information to researchers, community organizations, and local policy-makers. Their results also may guide further research agenda in the community [ 18 , 21 , 23 , 29 , 35 , 39 , 40 , 42 , 44 , 48 , 49 , 50 , 52 , 54 , 55 , 62 , 64 , 65 , 66 , 69 , 70 , 71 , 72 , 73 , 76 , 77 , 78 , 85 , 96 , 106 , 122 , 123 , 131 , 132 , 133 , 134 , 135 ]. Some of these studies tried to present their results to the local authorities through various channels in the hope that it would modify existing programmes or implement new ones to meet the needs of the community residents. In addition to identification of relevant issues and priorities, included studies listed at least one outcome associated with the reported CHNAA activity as follows:

Development or modification of health and social policy and programmes: The knowledge provided by CHNAAs helped develop better tailored, and thereby potentially more effective interventions by a number of studies. Further, the information gathered from the CHNAA process was used as the baseline against which to measure future targets for assessment efforts and progress in areas were targeted ( n  = 36).

Formation of new partnership: In some cases, a new partnership among entities involved in CHNAA was formed to address health issues. One of the partnerships reported successful was the community–academic partnership in which communities used the research capacity of academic institutions to conduct the CHNAAs ( n  = 20). Another type of the partnership reported by some studies was the collaboration among healthcare organizations serving the same geographic area to conduct CHNAA jointly. Conducting a joint CHNAA may avoid duplication of planning efforts and obviate the creation of multiple community health needs assessments for the same population ( n  = 5).

Development of new recommendations: Several suggestions were proposed to be considered while designing health improvement interventions in the future by some of the included studies ( n  = 18).

Setting or altering strategic direction: Strategic agency direction was established or altered in some cases, which might indicate that the CHNAA was used to redirect resources better to meet the needs of the community ( n  = 4).

Raising awareness about health issues: One of the most important insights brought by CHNAA findings was the recognition of the health priorities and contributing factors by the community members, leaders and researchers, leading to an increased awareness of community issues among them ( n  = 8).

Engaging and motivating policy-makers and stakeholders: A few studies reported that CHNAAs provided health organizations with the opportunity to identify and interact with key policy-makers, community leaders, and key stakeholders about health priorities and concerns, which might foster a sense of collective ownership and trust in the results and increase the likelihood that the CHNAA will be used ( n  = 5).

Having an impact on obtaining resources and resource allocation: The CHNAAs provided the community partners with locally relevant information regarding the current status of health and perceived community needs to inform resource allocation and applications for new grants for the initiation of new programmes ( n  = 14)

Contribution to the development of CHNAA process: Some studies reported that the specific methods used in their CHNAA processes could contribute to more relevant and effective community health need assessment process ( n  = 10).

Dissemination of findings

Disseminating of the findings and knowledge gained to all partners involved was a foremost step of CHNAAs. The most cited product of the CHNAA process in the included studies was the community needs assessment report. This report includes information about the health of the community as well as the community’s capacity to improve the lives of residents. The report provides the basis for discussion and future actions. In addition to the final report, other channels to disseminate CHNAAs findings were reported as: publishing CHNAA main results in local newspapers, communicating research results with community members and stakeholders in public forums or meetings, presentation results to the steering committee and various stakeholders, posting the report on the local authorities websites, individual meetings with community leaders and stakeholders, posters, and presentation of findings in academic conferences.

Community participation

Among included studies, around 50 studies (44%) reported using participatory approaches and techniques to encourage community members' participation in CHNAA process. Unlike traditional approaches to health needs assessment, participatory approaches aimed to incorporate community inputs at all stages of the research process to enhance capacity building and overcome barriers to research raised by matters of trust, communication, cultural differences, power and representation. A variety of participatory approaches (e.g. community based participatory research (CBPR), participatory rural appraisal, participatory action research (PAR), rapid participatory appraisal (RPA), tribal participatory research, community-based collaborative action research (CBCAR), precede-proceed model, concept mapping and photovoice) were used by these studies to ensure that communities participate in CHNAA, from defining the community to identifying needs and assets and developing new interventions.

Pennel and colleagues classified the depth of the community participation in CHNAA activities into four main categories [ 136 ]. In this classification, depth of the community participation was assessed by the types of activities in which participants were involved throughout the assessment and planning process as follows:

No participation: No attempt to engage community stakeholders or members;

Consultation-only: Engagement of health-related stakeholders, broader community stakeholders, and/or community members to identify health needs through surveys, interviews, and/or focus groups; verified or validated health needs/priorities with local experts;

Moderate participation: Involvement of community stakeholders/ or community members in priority identification; involvement of community stakeholders in strategy selection;

Extensive participation: Involvement of community stakeholders/or community members to develop and carry out strategies.

The above classification was used to assess the depth of the community participation by included studies. Based on the content analysis, community participation in CHNAA process varied considerably across the included empirical studies, from minimal to in-depth participation (Table 1 ). Around 65% of the included studies were involved in consultation-only to identify health needs through one-way communication using tools such as surveys, interviews, and focus group to identify community needs and resources. Around 22% of the included studies solicited moderate participation from the community by involving community in verifying needs and final priority selection and only about 10% of the included studies reported a broad and deep community participation including community involvement in designing and implementing strategies to improve community health.

Three categories of challenges were cited by the reviewed studies while performing CHNAA projects.

Methodological challenges: These are mainly associated with quantitative and qualitative data collection methods, which were discussed earlier. Other methodological challenges cited were: difficulties in aggregating and making sense of data collected from various sources (triangulation), non-generalisability of site-specific data and limitations of the use of existing epidemiological data alone, which does not provide a comprehensive view of health needs, yet is often the most available source of information. Traditional approaches to data collection were challenging where language and literacy barriers existed [ 12 , 52 , 65 , 71 ]. Another major challenge reported by studies used community-based participatory research approaches was the challenge of involving the community in decisions related to research design and data collection methods while maintaining an appropriate level of methodological validity and reliability [ 56 , 81 , 121 ]. In addition, participation was not without challenges. Including the perspectives of stakeholders and residents can lead to differing accounts of what services are seen as essential, and each party may push their own agenda based on their personal or professional interests. Further, linguistic and cultural barriers may be a major factor among minority groups hindering participation in such endeavors [ 81 , 137 ].

Logistical challenges: The major logistical challenges reported were the need for a considerable amount of time (often inadequate), and resources required to conduct a comprehensive assessment [ 80 , 138 ]. Good quality local data on the needs and utilization of health services are usually difficult to obtain [ 9 ]. Financial costs are considerable and the depth of information obtained will ultimately depend upon the methods employed [ 139 , 140 ]. In addition, health professionals, managers and others involved in health services planning and delivery may not have the requisite skills to conduct CHNAAs. This goes beyond technical skills and places an emphasis on soft skills and flexibility including good listening skills, the ability to establish trusting relationships, empathy, working with diverse groups and reflexivity [ 140 , 141 ]. Moreover, limited health information infrastructure and systems in developing countries settings may have hindered the availability of good quality information to conduct CHNAAs [ 13 , 28 , 30 , 142 ].

Ethical challenges: Concerns were raised about the ethical issues associated with community consultation about felt needs followed by priority setting process that leaves many needs unaddressed and the bulk of expectations dashed. Labelling, stigma and stereo- typing are other problems raised by needs assessment [ 143 ]. Needs assessment results may not be utilised, leaving unmet expectations and may require extensive financial and political support to lead to changes in health service planning and delivery [ 9 ]. Comprehensive health needs assessment is likely to produce different, potentially conflicting needs, exposing hidden conflicts and tensions in communities without any mechanisms to address these issues [ 5 ]. Further, local participation may only allow those who are able to voice their needs to do so, leaving behind the silent or hidden voices [ 81 ]. Involvement of the community in the needs assessment process also impacts upon possible outcomes of the project especially since it is likely that expectations of changes to programmes and service delivery may have arisen from local participation [ 144 ].

Facilitators and enablers

CHNAA projects need to be organized in such a way that they have clear objectives, and are adequately resourced by experienced staff. In addition, factors such as clear objectives, decisive leadership, teamwork, communication, sound study design, adequate resourcing, skilled staff, sufficient time and ownership by stakeholders are among those factors that contribute to the successful implementation of CHNAAs [ 15 , 145 ]. Most studies cited community participation as a major facilitator of the CHNAA process and outcomes. Participation was shown to foster bidirectional learning and communications, where both health authorities and the community learnt about needs and priorities. Different benefits for community engagement were mentioned by reviewed literature including, improved participants’ recruitment, enhanced capacity among stakeholders, productive conflict resolution, increased quality of outputs and outcomes, increased sustainability of project goals beyond funding and timelines and development of linguistically and culturally appropriate measures. In addition, incorporating community voices has the potential to inform the development of sound measures to tackle health disparities in the basis of race, social class and ethnicity [ 12 , 27 , 30 , 91 , 103 , 110 , 126 , 146 ].

The main objective of our scoping review was to provide an overview of why and how community health needs and assets assessments (CHNAAs) have been used globally. Substantial variation was found among the studies reviewed concerning definitions, process, participants, methods, goals, and products, yet there were many common characteristics.

Some CHNAAs focused narrowly on health care in assessing needs, with scant attention to other community issues that can affect health. However, most of the included studies looked beyond health needs and considered social and environmental conditions influencing community health. We argue all CHNAAs should approach community health needs assessment holistically, focusing on both individual physical and mental wellbeing as well as casting a social determinants of health lens on the population health.

The review showed that community health needs assessment is used widely by different users and across different settings in both HICs and LMICs. However, in countries such as the US it has become institutionalized and has accordingly been developed, as service providers, particularly hospitals, are mandated to perform CHNAA to compliance with legislative mandates. However, though federal and state laws impose requirements on hospitals to conduct CHNAAs, the methods for needs assessments are generally left to the discretion of each hospital [ 147 ]. As a result, assessment methods vary widely. US-based CHNAAs either develop their own CHNAA processes or utilize a process developed at the state or national level to guide their efforts. A number of toolkits have been provided by different organizations across US to help healthcare providers to conduct CHNAA projects [ 6 , 148 , 149 ]. This highlights the need for consensus guidance across many countries and settings while maintaining the responsiveness to contextual needs, assets and priorities.

Both qualitative and quantitative approaches were employed to collect data on community health needs and assets. Overall, there has been a growing use of mixed-methods approaches to conduct CHNAA in recent years, owing to the recognition in the literature that using qualitative and quantitative approaches simultaneously can provide complementary insights determining community health needs and assets [ 69 , 91 , 104 ]. Although quantitative approaches yield concrete evidence of community needs and assets, qualitative approaches provide a context for how these issues can be addressed using available resources [ 91 , 102 ]. Using qualitative methods in conjunction with more traditional quantitative approaches is especially appropriate for studying complex public health issues and promotes the alignment of implementation plans with the local needs of community members [ 59 , 69 , 91 ]. The growing use of mixed-methods approaches has practical implications for research training and capacity building within entities performing CHNAAs. Organizations who wish to conduct CHNAAs will need to ensure that the competencies and expertise required for mixed-methods studies are available.

Although only a small number of studies provided definitions of assets, there is a growing interest in the literature in asset-based assessment, which examines and mobilizes community assets, instead of focusing on only the needs of communities [ 11 , 84 ]. Unlike need-based or deficit approaches, asset-based approaches document resources and focus on strengths to enhance and preserve rather than deficits to be remedied. Related to principles of empowerment, it postulates that solutions to community problems already exist within a community’s assets. By recognizing existing capacity, communities can become empowered to take ownership of their health and improve as a population [ 11 , 31 , 125 ]. An asset-based approach was recognized as essential for enhancing trust and community coalitions [ 83 ]. Further, it is more participatory in nature through involving community stakeholders throughout the needs assessment process [ 82 , 83 ]. In particular, it highlights community resilience, resources, and opportunities for positive growth rather than focusing solely on health problems or other concerns [ 14 , 84 , 88 ]. In developing countries, assets identified from within the community are crucial for later use in the implementation of health programmes. The shift from a traditional needs-based perspective to an asset-based perspective to health needs assessment can help to address resource constraints in these countries [ 13 , 30 , 150 ].

There was a growing interest in the use of participatory approaches and in their value in identifying and addressing community health needs over recent years among included studies. About half of the reviewed studies applied CBPR or other community-engaged approaches to perform CHNAA. There are several opportunities to fully engage patients, families, and communities in healthcare delivery redesign to ensure that they are provided in a way that address the community members’ needs and preferences. The CHNAA process is one mechanism for this engagement—and a good precursor to deeper engagement and collaboration [ 91 , 97 , 123 ]. Integrating community voices into CHNAA process may be crucially important for confronting health disparities at the community level, which stemming from socio-historical processes, including racial and ethnic discrimination and economic inequality [ 33 , 74 , 86 , 91 ]. To eliminate health disparities, it is critical first to understand social, cultural, and economic determinants of health. CHNAAs, particularly when they include the voices of community residents, can provide an opportunity to understand local processes contributing to health disparities. This knowledge can then be used to inform health and equity initiatives [ 91 , 110 , 126 ]. The development process and implementation of a CHNAA project is an important example of evidence-based public health practice. It is a way to address health and health care disparities experienced by medically underserved populations [ 86 , 92 , 126 ]. Those studies used a participatory approach reported that by having community participation, concerns and issues of the most marginalized and vulnerable populations were voiced. The inclusion of these voices allowed for a broader and deeper understanding of the concerns of those who are typically marginalized and that may be missed in traditional health needs assessment methodologies [ 33 , 56 , 58 , 74 , 86 , 110 , 137 , 146 ]. Hence, defining communities while performing CHNAA needs to be dynamic and socially constructed to take into account all voices and members especially those not ordinarily included. This deeper understanding is critical to move public health practice and research upstream to address structural and social determinants of health necessary for population-level reductions in health inequities [ 80 , 91 ].

Although there is widespread theoretical recognition of the importance of in-depth community participation in CHNAA, this has not been fully embraced in practice based on our review. Included studies reported community involvement in various stages of CHNAA with varying depth reflecting a continuum from no participation to extensive participation, in which most studies were located at the middle of the participation continuum. The literature review suggests while certain community stakeholders were engaged in the CHNAA process, most studies did not involve a broad range of stakeholders through adopting a full participation approach. One reason for this could be that for most studies conducted in the US, CHNAA was performed to comply with ACA requirements, which requires hospitals to incorporate inputs of the population served as part of the CHNAA process. Since community inputs as well as the process as a whole is not well-defined by these regulations [ 20 ], it seems that the majority of included US-based studies tried to meet legislative requirements by incorporating a minimum level of community and stakeholders’ participation in CHNAA process. In addition, the concept of community engagement in health services planning and implementation has evolved over recent years, from one-way consultative processes to bi-directional collaboration and shared leadership. Although undertaking an in-depth participatory approach through extensive participation of community stakeholders in CHNAAs may pose certain challenges for healthcare providers including requiring additional time and other resources to collaborate with community residents, we argue the benefits to this approach are important to improve health, as reported by some included studies [ 80 , 118 , 151 ].

A notable gap in the existing literature is the lack of long-term or longitudinal–assessment of CHNAA. The review showed that additional research into CHNAA implementation and outcomes is needed. Currently, there are limited data describing the impact of CHNAAs on health outcomes. However, there is ample evidence on different short-term impacts associated with CHNAA implementation, including, the development of health and social interventions, forming the new partnership, raising awareness on health issues, engaging policy-makers, and facilitating obtaining resources. In other words, it is unclear how CHNAA projects are linked directly to health outcomes. Furthermore, the mechanisms between the conduct and use of CHNAA remain largely unknown in the literature [ 152 , 153 ]. Clearly, not all CHNAA projects result in changes to policies or programmes, and conversely, many programme and policy decisions are made in the absence of CHNAA data [ 154 , 155 ]. Still, further research to understand these mechanisms and the long term impact of CHNAA is needed to support evidence of its use and value in addressing individual and population health needs.

This scoping review aimed to provide clarity and supplement the evidence on the key concepts, rationale, methods, tools and outcomes of community health needs and assets assessments (CHNAAs). Importantly, it highlights the need for holistic approaches to needs assessments to focus on physical, mental and social wellbeing, along with considering wider systems factors and structural challenges to individual and population health. Furthermore, the findings emphasize the inclusion of community assets in community health assessments, beginning foremost with community capabilities and knowledge. It is encouraging to see the use of pragmatic approaches including both qualitative and quantitative methods in CHNAA process in the literature. This will help to ensure that a robust and in-depth exploration of needs and assets is available to guide decision making. Although we recognize the challenges with providing consensus on definitions, processes and tools for CHNAA, we argue that more clarity is needed on the key considerations, steps and outcomes for this process across various settings. This study attempts to provide some theoretical insights and empirical information concerning the process, which hopefully will provide useful guidance to community organizations, policy- makers, health service providers and researchers seeking to develop and implement community health needs and assets assessment.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

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Acknowledgements

We acknowledge contribution of the research assistants helped with data extraction.

This work was funded by department of UHC Life course/Integrated Health Services (IHS), World Health Organization (WHO) headquarter (HQ). ZA received the research grant. The authors HR, AS, and SE from WHO commissioned the study, contributed to the direction of the work, and commented on the drafts.

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Samar Elfeky

Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK

Naima Nasir

National library and Archives of Iran, Tehran, Iran

Sedigheh Khani

National Institute of Health Research (NIHR), Tehran University of Medical Sciences, Tehran (TUMS), Tehran, Iran

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Contributions

AG, HR and SE conceived the study and participated in its design. SK conducted the literature search and prepared the search results for analysis. NN developed the study framework, the data abstraction forms and the manuscript outline. The literature was analysed by ZA, EA and NN under the supervision of HR and AG. ZA drafted the final version of the manuscript and HR, NN, AG and SE reviewed it. All authors read and approved the final manuscript.

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Correspondence to Zhaleh Abdi .

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Health indicators collected by community health assessment surveys.

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Ravaghi, H., Guisset, AL., Elfeky, S. et al. A scoping review of community health needs and assets assessment: concepts, rationale, tools and uses. BMC Health Serv Res 23 , 44 (2023). https://doi.org/10.1186/s12913-022-08983-3

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Seven Steps for Conducting a Successful Needs Assessment

When launching a public health program, one of the first things to do is conduct a needs assessment. A needs assessment helps you determine what needs to be accomplished to reach your project goals . This assessment of needs then informs a project’s overall plan and approaches by helping you identify targeted strategies and prioritize resources.

Needs assessments serve as incredibly powerful tools for decision making, resource allocation, and ultimately reaching programmatic goals. They can be utilized across a range of settings (e.g., community, school, hospital, state) to shed light on a variety of topics, such as what programmatic actions should be taken to improve breastfeeding rates in a hospital or increase kindergarten readiness across a state. It's important to conduct needs assessment at the onset of the project, so that programs are appropriately tailored to the individuals and communities you serve.

Not sure where to begin? To help you get started, we've compiled the seven tips below. Following them will ensure that your needs assessment planning, analysis, and subsequent actions are efficient and effective.

Step one: Clearly define your needs assessment objectives

When defining your objectives, ask yourself: Why are you conducting the needs assessment and what do you plan to do with the findings? For example, if you are working on a program seeking to increase breastfeeding initiation among first-time mothers in a community, your needs assessment objectives may include:

• Understand breastfeeding knowledge and intentions of first-time mothers in your community
• Understand perceived assets and barriers to breastfeeding among first-time mothers in your community
• Assess assets and barriers related to the provision of breastfeeding support in local hospitals and after discharge
• Determine necessary training and supports to increase breastfeeding among first-time mothers in your community

Concretely identifying a few, key objectives at the onset will help you identify your needs assessment activities—including who to collect data from and what questions to ask. The objectives in the breastfeeding example show that the needs assessment should collect data from first-time mothers as well as from health care providers and, possibly, lactation consultants and social service providers in the community. The objectives also suggest that survey and/or focus group questions should target topics including, but not limited to, knowledge, intentions, assets, and barriers related to breastfeeding.

Step two: Be realistic about your resources and capacity

Consider how much time, money and staff capacity you can devote to the needs assessment. For example, do you need to assess the current state of your program and implement changes within three months, or do you have an entire year to examine your program’s landscape? Also, how many staff are working on the project and what percentage of their time are they devoting to the project? The availability of resources will greatly impact the needs assessment activities you are able to conduct.  If a needs assessment must be conducted quickly and/or with few staff resources, a simple online survey to key stakeholders serves as a powerful (and often free!) tool to collect data critical to informing programmatic efforts. Teams can also tap into secondary publicly available data, such as the National Survey of Children’s Health or the CDC WONDER databases. 

Step three: Identify target audiences and data sources

Given your objectives and resources, consider the target audiences and data sources that will help you assess your needs. Is it most effective to administer a survey to a wide range of community members, to hold several focus groups with hospital administrators, examine existing reports, or directly observe project participants? Sometimes you’ll need to conduct several, complementary needs assessment activities to collect data for a range of stakeholders.

Consider, also, the competing priorities of your target audience and how to encourage them to participate in your needs assessment. If sending surveys, include an introductory sentence that shows your appreciation and why the survey responses matter, and be prepared to send multiple reminders to increase response rates. If conducting focus groups, be gracious and consider providing snacks, water, or other incentives to participants to thank them for their time and contributions. Helpful new tools can also increase participation. Photovoice is a tool that helps people use videos and photos to share their environment and experiences with others, which can then inform the needs assessment. This tool can be especially powerful for engaging communities that may have been less likely to participate due to language barriers, poverty, or other social determinants.

Step four: Think small and big when summarizing results

You’ve collected the necessary data to achieve your needs assessment objectives. Now, it’s time to dig into that data. Try to summarize and reflect on data for each of your needs assessment objectives individually. Depending on the nature of your data, you may want to develop graphs, tables, and other visuals to display data as well as a narrative describing results.

Then, take a step back, and think about cross-cutting themes that may apply to multiple needs assessment activities, which may help inform priorities for action. For example, in the breastfeeding program example, was there a salient theme, perhaps a barrier to breastfeeding initiation, that emerged when collecting insights from first-time mothers, health care providers, and other social service providers? If so, highlight this finding and ensure recommendations address this cross-cutting theme.

Step five: Get feedback

While developing the needs assessment deliverable, whether it is a formal report, peer-reviewed manuscript or presentation, discuss results with a diverse and inclusive audience—including community members, colleagues, funders, project partners and other target audiences—who may interpret your needs assessment results differently and identify unique recommendations. From an equity standpoint, it is especially important to engage community members as equal partners in understanding and translating results from the needs assessment. This ensures that the people most affected by the program will have power in determining its design.

Step six: Disseminate

You’ve done the work, now share your findings internally and externally. This helps ensure that all project stakeholders are on the same page regarding project priorities and resource allocation. Present your findings at community events, professional conferences and other relevant venues. Your efforts may inform and inspire other public health programs working on similar initiatives, and feedback from others can help you move your work to the next level.

Step seven: Take action

At the conclusion of the needs assessment process, review your original objectives with the final results and recommendations. Doing so will highlight what steps are needed to achieve your goals—whether that’s addressing gaps in knowledge or building capacity among project participants. Then, most importantly, take action and use those findings to develop your project approaches. To ensure that your needs assessment learnings come to fruition, consider developing a workplan that outlines key approaches and strategies, and identifies a team lead and deadline for each

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Community Health Needs Assessment

The National Center for Rural Health Works has provided a community health needs assessment (CHNA) for many years. With the pass of “The Patient Protection and Affordable Care Act” in 2010, al 501©(3) hospitals must conduct a CHNA process to meet the US Dept. Treasury and IRS rules.

The CHNA toolkit was created to provide state and community organizations the ability to complete a community health needs assessment. State and community organizations that should be contacted to complete a CHNA are state offices of rural health, rural health associations, economic development organizations, and hospital associations. Organizations utilizing our community health needs assessment toolkits should have the ability to complete a study for your community.

How long is a community health needs assessment process?

A community health needs assessment will take about 6 months. However, using our CHNA toolkit and our economic impact and data analysis tools, the process should run smoothly and be useful in creating a robust community-based health system.

What is the process of a community health needs assessment?

Shown below is a diagram, of the steps and timeline for your community health needs assessment. While the diagram shows that only three meetings are necessary, the NCRHW recommends that your center have a fourth meeting, to finalize your community health needs assessment.

Click on each of the steps you will find the necessary documents to complete each step

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Aiken, J.A., & Griner, S.B. (2021). Health associations for male survivors of unwanted and non-consensual sex. Journal of Interpersonal Violence. doi.org/10.1177/08862605211042806

Griner, S.B., Vamos, C.A., Phillips, A.C., Puccio, J.A., Thompson, E.L., & Daley, E.M. (2021). Assessing college students’ interest in university-based oral health information and services. Journal of American College Health, 12, 1-5. tandfonline.com/doi/full/10.1080/07448481.2021.1876706

Thompson, E.L., Garg, A., Collier Esser, K., Caddy, D., Matthes, S., Rohr, D., & Spence, E.E. (2021). Development and validation of a child physical and sexual abuse prevention scale. American Journal of Health Behavior, 45 (5), 947-955.

Thompson, E.L., Fulda, K.G., Grace, J., Galvin, A.M., & Spence, E.E. (2021). The implementation of an interpersonal violence screening program in primary care settings: Lessons learned. Health Promotion Practice, [Epub ahead of print]. doi: 10.1177/1524839921989273

Thompson, E.L., Zhou, Z., Garg, A., Rohr, D., Ajoku, B., & Spence, E.E. (2021). Evaluation of a school-based child physical and sexual abuse prevention program. Health Education and Behavior, [Epub ahead of print]. doi: 10.1177/1090198120988252.

Vamos, C.A., Puccio, J., Griner, S.B., Logan, R., Piepenbrink, R., Richardson, M., Lovett, S., Mahony, H., & Daley, E. (2022). Health literacy needs and preferences for a technology-based intervention to improve college students’ sexual and reproductive health. Journal of American College Health . doi.org/10.1080/07448481.2022.2040517

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2022 Community Health Needs Assessments and Implementation Strategies

Every 3 years, Kaiser Permanente conducts Community Health Needs Assessments, which guide and inform Kaiser Permanente’s investments and business decisions. They are a critical tool for identifying and measuring community needs and assets, which lets us better tailor our engagement with communities and use our organizational resources to further community health at every opportunity.

The Community Health Needs Assessments and development of Implementation Strategies are driven by a commitment to improving health equity and are intended to be transparent, rigorous, and collaborative. The CHNA use local data, information from the Community Health Data Platform , and input from the community to help us understand our communities’ needs and the best way to respond to them. The CHNA also provide information and data on how social drivers of health — including financial opportunity, income and employment, housing, food, and transportation — affect communities.

Kaiser Permanente developed the accompanying Implementation Strategy reports, which demonstrate how Kaiser Permanente will respond to the health needs identified by the CHNA.

We welcome feedback on these assessments. For more information or to provide feedback on any of the CHNA reports, please email  [email protected] .

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Health Needs Assessment

When you think about the word health, you may probably be thinking about healthy meals, healthy living, and any other way to make you stay healthy , especially in times like these. A lot of people would find it difficult to stay healthy or at least to remain healthy. There are those who are fortunate to find ways, while there are others who may not be as fortunate. The same goes as there are others who are able to afford the lifestyle, while others, not so much. It goes without saying, finding a good way to keep your health as a number one priority should also be for everyone especially those in communities that are not as privileged as others.

Of course, you may not immediately be able to tell which community or family or anyone in public may need all the help they would need. This is why making a health needs assessment can help you . It helps you by giving a complete list of the things that you can do to make your health needs assessment successful. For more ideas on what you can do with a health needs assessment, you should take a look at these 10+ examples of health needs assessment now.

10+ Health Needs Assessment Examples

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9. Health Needs Assessment Questionnaire

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11. Standard Health Needs Assessment

What Is a Health Needs Assessment?

A health needs assessment is a method used by nongovernment organizations in order to check, review, assess, analyze and evaluate a community’s health needs, the public’s health needs, or even a specific family’s health needs. This assessment consists of a series of questions in the form of a checklist . The assessment is given to the community or the head of the community in order to know how bad or how severe the problem is with regard to the overall health of the people living.

In order to be able to get the right type of information about a community, a family, or the general public, organizations use the health needs assessment to aid them through that. Basically, the general purpose of a health needs assessment is to give the estimated number of people whose illnesses or diseases may not be addressed due to the fact that it is not as well known or there are no correct medications for them. For that to stop, the health needs assessment comes to play.

How Do You Write a Health Needs Assessment?

There are a lot of ways to write a health needs assessment. This of course would depend on the target or the aim of your health needs assessment. If you are aiming for a community health needs assessment, a family health needs, or even a public one, they are all the same except for some other specific things. 

1. Gather Your Information for the Assessment

Information for the assessment means that you must at least know what you are planning to do, what you are going to be doing, and how you are going to do that. Since you are going to be doing a health needs assessment in a community, at least find out more about the place first. This does not necessarily mean that you should not be thinking about the risks, but you should at least have some idea as to how to approach this situation.

2. Make the Assessment Something Specific

Match your assessment to something specific as possible. That way, it would be easier for you to conclude the entire assessment and the entire result of the assessment later. It is also going to be easier for you to gather the right materials to help out with the health needs of the community. However, if you think that a general assessment is a better and safer way to conduct it, you may do so as well as long as you are able to hit the target reason for using the needs assessment.

3. Aim the Assessment for Something Good

When making your assessments, always aim for the good parts. Of course, there are certain circumstances that may make you think that the needs assessment has to be aimed in a different way; however, as much as possible, aim it at the goal you have made in order for the assessment to be complete. 

4. Analyze the Total Answers to the Assessment

The total percentage of their answers is what you are going to be basing on your future needs assessment. The percentage helps you find the right health needs assessment answers. It also helps you figure out which type of needs assessment they should have and what type of help they should also be getting.

What is a health needs assessment?

A health needs assessment is a kind of documented checklist that ensures the people who may be a target for this to have the correct and right health needs that they can get.

Who benefits from the results of the assessment?

The people who took the time to fill out the assessment would benefit from the results. The results help those organizations know what can be done in order to make it better for those affected.

How can the health needs assessment work for a community?

The health needs assessment helps by assessing the needs of the people in a community.

It goes without saying making a health needs assessment is necessary. It helps you find the general issue that could be used as a way to help you find the correct needs for that issue. It helps you understand the correct needs of a community, of a family, or of the general public.

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The Southeastern PA Regional Community Health Needs Assessment (rCHNA) fulfills federal requirements through the Patient Protection and Affordable Care Act for non-profit hospitals to complete a Community Health Needs Assessment and implementation plan to inform their community benefit and community building activities. Coordinated by the Health Care Improvement Foundation and in collaboration with the Department of Public Health and other partners, the rCHNA assesses population health and social needs indicators for geographic communities, and engages community residents and stakeholders to gain their perspective on community assets, needs, and proposed solutions.

To access the 2019 Regional Community Health Needs Assessment report, please click here .

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A needs assessment of people living with diabetes and diabetic retinopathy

Claudette e. hall.

Department of Work and Social Psychology, Faculty of Psychology and Neuroscience, University Maastricht, P.O. Box 616, 6200 MD Maastricht, The Netherlands

Anthony B. Hall

Newcastle Eye Hospital Research Foundation, 182 Christo Road, Waratah, NSW 2289 Australia

Joyse Mallya

Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Tanzania

Paul Courtright

KCCO International, Division of Ophthalmology, H53 OMB, Groote Schuur Hospital, University of Cape Town, Observatory, 7925 South Africa

Associated Data

The dataset supporting the conclusions of this article are included within the article.

The Kilimanjaro Diabetic Programme was initiated in response to the needs of people living with diabetes (PWLD) to identify barriers to uptake of screening for diabetic retinopathy, to improve management of diabetes, and establish an affordable, sustainable eye screening and treatment programme for diabetic retinopathy. Intervention Mapping was used as the framework for the needs assessment.

A mixed methods approach was used. Five psychometric measures, Diabetes Knowledge Questionnaire, Diabetes Health Beliefs, Self-Efficacy scale, Problem Areas in Diabetes scale, and Hopkins Scale Checklist-25 and a structured interview relating to self-efficacy, addressing disclosure of living with diabetes and life-style changes were used to triangulate the quantitative findings. These were administered to 26 PWLD presenting to rural district hospitals.

The interviewees demonstrated low levels of perceived stigma regarding disclosure of living with diabetes and high levels of self-efficacy in raising community awareness of diabetes, seeking on going treatment from Western medicine over traditional healers and in seeking care on sick days. Self-efficacy was high for adjusting diet, although comprehensive dietary knowledge was poor. Negative emotions expressed at diagnosis, changes in life style and altered quality of life were reflected in high levels of anxiety and depression.

Conclusions

Low levels of stigma surrounding living with diabetes were linked to a desire to raise community awareness of diabetes, help others live with diabetes and to secure social support to access hospital services. Confusion over what constituted a healthy diet showed the importance of comprehensive, accessible diabetes education, essential to ensuring good glycaemic control, and preventing diabetic complications, including diabetic retinopathy. Low levels of self-efficacy along with high levels of anxiety and depression may have a negative impact on the uptake of screening for Diabetic Retinopathy. The findings of this needs assessment led to the planning and delivery of a comprehensive health intervention programme for PLWD in Kilimanjaro Region. The programme has provided them with support, resources, education, and screening for diabetic retinopathy at the regional hospital and at district level with mobile digital retinal cameras, an electronic diabetic database and computerised follow up to ensure continuity of care.

Diabetes has reached epidemic proportions with an estimated 285 million people living with diabetes globally in 2010 and 366 million in 2011 [ 1 ]. Global figures for those living with the disease must be viewed with caution due to difficulties in areas where social, economic and political factors make regular diabetes services difficult [ 1 , 2 ]. It is estimated that in 2010 approximately 12.1 million people in Sub-Saharan Africa (SSA) were living with diabetes.

Diabetes in Africa is perceived to be more common amongst affluent urban dwellers than among poorer members of communities living in rural areas [ 3 ]. This urban versus rural pattern appears to be shifting in Africa, with an increase in diabetes among countries that are of low and middle income, and amongst the poorer of these nations. In 2010 in Tanzania the prevalence of diabetes was estimated at 5.8 % in urban and 1.7 % in rural areas and in the next two decades there is a projected 50 % increase in the prevalence of diabetes [ 3 ].

The relationship between diabetes and blindness due to diabetic retinopathy (DR) is well established. Global estimates for the prevalence of blindness are 0.55 %, of which blindness due to DR ranges from 1 to 4.8 % of this total [ 4 ]. In Sub-Saharan Africa it is estimated that 21–25 % of people with type 2 diabetes have diabetic retinopathy (DR) at diagnosis [ 5 ].

Screening people living with diabetes (PLWD) for DR meets the World Health Organisation criteria for screening and blindness prevention [ 6 ]. Screening for DR is effective if individuals are identified and DR treated early, before loss of visual acuity occurs. The longer the duration of diabetes the greater the risk to the individual of micro-vascular complications including DR, neuropathy and nephropathy [ 7 ].

When the study was conceived there were no up to date data available on the incidence and prevalence of diabetes and of DR for the Kilimanjaro Region [ 8 ]. When the diabetic clinic was first established at Kilimanjaro Christian Medical Centre (KCMC) hospital in 1996 a study of 474 patients found a prevalence of 14.5 % among this group [ 8 ].

There are no current data on uptake of diabetic services, how effectively health care workers communicate health information to PLWD; and in particular what information PLWD receive about eye health. Neither were there documented experiences or guidance concerning the establishment of DR screening services in developing countries.

A study conducted at KCMC Hospital in 2006 showed that a number of issues need to be addressed if blindness due to DR is to be prevented in the Kilimanjaro Region. The study found that in spite of specialist eye services at KCMC Hospital to support the diabetic clinic, most patients presented late for treatment of DR. As part of this study, a nurse counsellor attended the twice weekly adult diabetic clinic to give PLWD information about DR, encouraged them to ask questions and gave them a free referral to the eye clinic that could be used at their convenience. The study demonstrated that free referral for DR screening from the KCMC Diabetic Clinic to the nearby (less than 100 meters) KCMC eye clinic only managed to increase uptake to by 36 %. In this diabetic population 93, 71 % had not had a dilated eye examination in the past year. The authors suggested that knowledge, by itself, does not result in a change in health behaviour [ 9 ].

We aimed to develop a health promotion programme that would be informed and supported by the local community, draw upon local resources and be evidence based. Using intervention mapping [ 10 ] as the framework for the Kilimanjaro Diabetic Programme (KDP) [ 11 , 12 ] we began by conducting a needs assessment (NA) [ 10 ]. A needs assessment is the first of 6 steps in planning health promotion programmes using an intervention mapping approach [ 10 ]. Bartholomew describes how this uses the PRECEDE model as a conceptual framework. The model examines a number of determinants including environmental and behavioural factors which have an effect on the health problems and ultimately the quality of life of the population at risk. The aim of this study was to provide an overview of the needs of a self-selecting group of people known to be living with diabetes in the Kilimanjaro Region.

Behavioural factors

A comprehensive ecological approach is valuable in gaining an understanding of the eye health behaviour of PLWD and in identifying barriers to the uptake of eye screening services, in order to establish an affordable, sustainable eye screening and treatment programme for DR [ 10 ]. This paper describes the first part of this process. The following concepts form the theoretical basis for this study.

Until the early 1990s knowledge, attitudes and belief models were the focus of diabetes education [ 13 ]. Subsequently it was recognised that PLWD required education from the perspective of self-management with an emphasis on self-empowerment and self-efficacy. This allows PLWD to manage their self-care in order to live a healthy life and prevent potential micro-vascular and macro-vascular complications, such as, DR [ 14 ].

Bandura [ 15 ] describes ‘perceived self-efficacy’ as beliefs in an individual’s capabilities to plan, organize and conduct behaviour to achieve set goals according to self-set standards. It is not enough just to know what to do. The individual must have an effective and organised set of sub-skills; cognitive, social, emotional and behavioural, that can be engaged appropriately under different and sometimes difficult and challenging situations [ 15 ]. If an individual has a strong perceived self-efficacy they will set high goals, be firmly committed to achieving these goals and be able to persist with considerable effort in the face of difficulties in achieving their goals. The converse is true [ 16 , 17 ].

Diabetes knowledge

What is the role of education in self-management of diabetes? Certainly individuals require knowledge and skills in all aspects of their treatment and how to prevent complications in order to be effective in self-care. However, whilst knowledge and skills are important they do not of themselves ensure competent self-care or behaviour change [ 10 ]. Education and skills training of PLWD is an essential starting point to tailor diabetes education. So too is assessment of knowledge, to address knowledge gaps and provide appropriate and adequate training. This is a challenge for health intervention programme planners.

Anxiety and depression

Living with a chronic disease, such as diabetes is known to lead to psychosocial distress and depression [ 18 – 21 ]. The work done by Lee et al. [ 22 ] reports that researchers in Eastern Africa in general and specifically in Tanzania have found that in primary care, mental health tends to be undiagnosed. In East Africa symptoms of depression are usually dismissed as being psychological or due to social problems. In Tanzania depression is thought to be due to psychosocial problems [ 23 ]. It is clear from the work of these researchers that more needs to be done to develop appropriate cultural scales that reflect both indigenous classifications and expressions of illness [ 24 ].

Social stigma

Social stigma is complex and relevant to our NA of PLWD. Stigma has played a historical role from the earliest of times when bells were rung to warn of the approach of lepers [ 25 ]. Social stigma is experienced as prejudice and negative stereotyping for a number of reasons, including for example, physical illness, disfiguration or deformity, personality traits perceived as deviating from social or cultural norms as in mental illness, drug or alcohol addiction, sexual orientation, and tribal taboos, i.e. ethnicity, race and religion [ 26 , 27 ]. People who are stigmatised by their community are ostracised, devalued and kept at a distance [ 25 ]. Diabetes is an invisible illness, so PLWD may choose either to conceal their illness and appear ‘normal’ to others or reveal it and face possible stigmatization by those who are well. Diabetes may be regarded as a self-imposed illness, due to a lack of self-control and laziness. We wanted to investigate the concept that there is stigma towards those with diabetes in our NA of Tanzanian PLWD.

Assessment tools

There are a number of tools that have been developed to study these issues. Some have been developed for use in PLWD and we therefore chose and adapted these rather than more general quality of life or vision questionnaires. The following five psychometric measures were used to evaluate the needs of the group of PLWD in the study; Self-efficacy scale [ 28 ], Diabetes Health Belief [ 29 ], Diabetes Knowledge Questionnaire [ 30 ], Problem Areas In Diabetes [ 31 ] and Hopkins Scale Checklist-25 [ 22 , 32 ].

Self - Efficacy (SE) Measuring SE activities for PLWD involves questions on carrying out tasks that focus on treating their disease and preventing complications. From these tasks three distinct classes of activities can be identified on a type two diabetes SE scale: [ 28 ]

• Performing activities that relate to the treatment of diabetes: taking medication, oral or injection; maintaining a healthy diet and physical exercise.
• Self-observation: monitoring and control of blood glucose, body weight, condition of feet and general health.
• Other self-regulation activities: recognition and correction of hypoglycaemia and hyperglycaemia, variety in diet, preparing to travel away from home, self-regulation in recognition of weight gain and appropriate response to illness and stressors.

The SE scale for people living with type two diabetes was developed to measures both situation specific tasks and whether people consider themselves capable of completing them [ 28 ].

Diabetes Health Beliefs (DHB), Health beliefs have been shown to have a direct and indirect effect on metabolic control. Use of this 25 item DHB measure focuses on self-management and measures health outcomes [ 33 ].

The Diabetes Knowledge Questionnaire (DKQ) was developed for individuals who are not first language English speakers, with a low level of literacy, to test the outcome of diabetes self-management education [ 30 ].

Problem Areas in Diabetes (PAID) is a 20 item psychometric measure of the emotional distress of living with a chronic disease and the burden of self-management from the perspective of the individual living with diabetes [ 31 ].

The Hopkins Scale Checklist - 25 (HSC-25) has been used since the 1950s in a variety of settings to measure levels of anxiety and depression among individuals in a wide range of populations and of diverse cultural origins. This psychometric measure has more recently been adapted for use among Kiswahili speakers within the primary care setting in Tanzania [ 22 , 32 ].

Eye Health Questionnaire (EHQ )

The EHQ included questions relating to past eye health behaviour, whether individuals knew they needed to have annual eye screening and what barriers prevented them from attending for DR screening (see Table  1 ).

Table 1

Summary of Eye Health Questionnaire

The research question forming this needs assessment was, ‘What are the needs of people living with diabetes and diabetic retinopathy in Kilimanjaro Region?’

The setting for this study was in 5 rural district hospitals in Kilimanjaro Region, Tanzania. Kilimanjaro Region has a population of 1,376,702 (Population census, 2002) [ 34 ]. Most roads in the area are gravel and access to health care is made either by foot, bicycle or public transport. In the rainy season some of these roads are difficult to access.

A mixed methods approach was used with one qualitative standardised questionnaire and five quantitative psychometric measures to triangulate the findings. In addition to this an eye health questionnaire (EHQ) was asked of all participants and screening for DR was offered to all who took part in the study. All PLWD who attended the health facilities where the NA were conducted were also offered screening for DR.

PLWD were invited to attend DR screening at the district hospitals with invitations being given through Faith Based Organizations, community groups and health services. The first people to arrive on each DR screening day were asked to take part in the NA interviews. Subjects completed all 7 questionnaires on the same day. These data were gathered using convenience sampling of 27 self-selecting known diabetics. All the PLWD who came to the NA day were offered screening for DR. The data from one person was discarded as it was incomplete. People under the age of 18 years and people who were considered to be too ill to take part in the study (e.g. with a high random blood sugar) were excluded from the study. People were read information about the purpose of the study gave written consent to take part in the study. Ethical approval was granted by the Ethics Committee of Kilimanjaro Christian Medical College, Tumaini University.

Socio-demographic information included age, gender, number of children, level of education, and occupation [ 35 ]. Visual acuity was calculated with reference to the International Classification of Diseases (ICD-10th revision) [ 36 ].

Qualitative measures

A series of 21 item structured interviews were conducted, in Kiswahili, with each of the 26 participants of the NA by an experienced community health care worker (see Table  2 ). The interview sessions were discussed on conclusion by the interviewer (JM) and researchers (CH and AH). Each interview was taped and then transcribed and translated into English. The interviews were thematically coded using Atlas-ti 6, to establish the expressed needs of each PLWD. The data were coded into nine themes identified during the coding and re-coding process and measured in terms of self-efficacy, i.e. seeking initial diagnosis; expression of emotion at diagnosis; dialoguing with others about having diabetes (stigma); social support and raising public awareness; seeking on going treatment, engaging in dialogue about treatment; coping with sick days; seeking alternative therapy (herbalists), burden of disease and associated changes in life-style (understanding healthy living—diet and exercise). There was discussion between researchers (CH and AH) during the coding, re-coding and analysis of the structured interviews.

Table 2

Qualitative interview questions

Quantitative measures

The five psychometric measures that were selected to evaluate the needs of the group of PLWD in the study were administered by the interviewers in Swahili

Self - Efficacy (SE) The 20 items on 5 subscales were scored on a five point Likert scale ranging from ‘For sure not’ (1) to ‘Yes for sure’ (5). The original self-efficacy instrument for type 2 diabetes had only 4 subscales. —In the Kiswahili version the item ‘I think that I am able to keep to my diet whenever I am away from home,’ was considered to be a repetition of the item, ‘I think that I am able to keep to my diet when I will be away for a holiday or family visit’. As there are high levels of hypertension among PLWD in Kilimanjaro Region the item, ‘I think that I am able to keep my blood pressure under control’ was added as a fifth subscale. High means scores indicate high levels of SE and low mean scores indicate low levels of SE (see Table  3 ).

Table 3

Results of Self Efficacy scale

Diabetes Health Beliefs (DHB) [ 29 , 33 ] The 25 item DHB measure focuses on self-management and measures health outcomes with 5 themes, as follows;

• One item of perceived control of diabetes.
• Total Barriers (to diet and medication are combined) with higher scores indicating higher perceived barriers.
• Social support for diet, with higher scores indicating higher perceived social support.
• Impact of job on therapy, with higher scores indicating higher perceived impact of job on diabetes therapy.

Table 4

Results of Diabetic Health Beliefs

A five point Likert scale was used ranging from ‘Strongly disagree’ (1) to ‘Strongly Agree’ (5).

The Diabetes Knowledge Questionnaire We used this 24 item DKQ [ 30 ] to broadly assess diabetes knowledge of diabetes to establish a baseline for future education needs of PLWD. There were eleven items 2, 5, 6, 8, 11, 14, 15, 16, 18, 19, 20, items rated as true. The remainder of the items, items 1, 3, 4, 7, 9, 10, 12, 23, 17, were rated as false (scoring = yes, no, or I don’t know) (see Table  5 ).

Table 5

Results of Diabetes Knowledge Questionnaire

Problem Areas in Diabetes (PAID) [ 31 ] The 20 item PAID was measured with a five point Likert scale ranging from ‘Not a problem at all’ (1) to ‘A serious problem’ (5). High scores indicate that individuals are experiencing emotional distress in relation to living with diabetes. This instrument was altered by excluding Item no. 20, ‘Feeling burned out by the constant effort needed to manage diabetes.’ because it was not being well understood. This reduced the scale to 19 items (see Table  6 ).

Table 6

Results of Problem Areas in Diabetes

The Hopkins Scale Checklist - 25 (HSC-25) [ 32 ], was used as a psychosocial screening measure with 10 items for symptoms of anxiety and 15 items for symptoms of depression. Scoring on each item of the two subscales was on a 4 point Likert scale ranging for ‘Not at all’ (1) to ‘Extremely’ (4). The cut-off point for the HSCL-25 was 1.75. A score above this indicates significant risk of anxiety and depression (see Table  7 ).

Table 7

Results of Hopkins Scale Checklist-25 (HCL-25)

Eye Health Questionnaire (EHQ ) The EHQ included questions relating to past eye health behaviour, whether individuals knew they needed to have annual eye screening and what barriers prevented them from attending for DR screening (see Table  1 ).

The psychometric data were double entered and analysed in Excel. The qualitative structured interviews were thematically coded using Atlas-ti.

Demographic data

Among the 26 participants, age ranged from 48 to 104 years, although in this community knowledge of dates of birth are unreliable. Average number of children reported per family was 3 children. Occupation groups included: professionals (4), technicians (1), service workers (1), agricultural workers (4) and elementary workers (e.g. cleaners, labourers etc.) (3). Some occupations were not recorded because people were either self-employed as subsistence farmers, retired or unemployed (13) [ 37 ]. Only 3 members of the group had any secondary education, 10 members of the group had some primary education (standard 4–8), the rest did not give any indication of having received any education. The mean duration of diabetes was 8 years.

Of the themes from the structured interviews with PLWD, 5 of the 9 themes demonstrated high to moderate levels of self-efficacy, as described in SCT: [ 15 – 17 ] these included seeking initial diagnosis; dialoguing with others about having diabetes (stigma); social support and raising public awareness; coping with sick days; seeking alternative therapy (herbalists), and seeking on going treatment. The remaining 4 themes demonstrated lower levels of self-efficacy: expression of emotion at diagnosis; engaging in dialogue about treatment; burden of disease and associated changes in life-style in terms of understanding healthy living related to diet & exercise

High to moderate levels of self - efficacy —When seeking the initial diagnosis more than half of the group initiated the consultation that resulted in their diagnosis of diabetes, exercising control over their actions, and demonstrating a high level of self-efficacy The remainder of the group followed the advice of family, friends or health care workers to seek a diagnosis for their symptoms.

Ref 27: 3 ‘I felt thirsty at night and drank a lot of water. Some people advised me to go and check for diabetes. Then I went to Kibongoto and they told me I had diabetes, about fifteen years ago’.

Self-efficacy was high for the majority of the group who were open about talking to family, friends and members of the community about diabetes for a number of reasons: for transport, for care, when socialising (to explain why they did not take sugar in their diet), telling others to raise awareness of diabetes.

Ref 29:32 ‘It is good to tell others because you might need their assistance and they ought to know where you are up to.’

Ref: 36: 19 ‘I am free (to talk to others about diabetes) and I am trying my best to tell people that they should check early. In case they have diabetes they can be advised on how to live.’

Ref 31: 31 ‘Í go to hospital to check whether the amount of sugar has gone up or lowered.’

Ref 27: 11 ‘I go to check and get advice whether to increase or reduce the amount of tablets I take.

Ref 34:29 ‘I can’t say that traditional healer can check me because they have nothing that they can use to tell me what the level of sugar in my body is. Their medicines too are not proven to be curing diabetes, so you just take it without knowing anything. So I can’t say that it helps treat diabetes.’

Ref 43: 38 ‘They have nothing…liars. They will make you grieved over your relatives and neighbours.’

The majority of people (24/27) were positive about seeking regular ongoing treatment demonstrating moderately high levels of self-efficacy. Only three people in the group admitted that they only went for a diabetic check-up when they felt ill. During treatment the relationship with health care-workers was described positively as a good or very good relationship. Health care workers were further described as kind, respectful and helpful and some were thankful for the care they received. (This was contrary to the findings in the PAID questionnaire, item 19 . I am not satisfied with my relationship with my doctor/my nurse who are treating my diabetes (m  =  4.7).

Specific barriers to on-going treatment were mentioned by six people, including: Not being able to get medication, having to buy one’s own medication at the private dispensary, the expense of diabetic care/management and one person commented on long waiting times at KCMC Hospital. Modes of transport to access on-going treatment included: bus (15) walking (9), bike, motorbike, taxi (1 each) with some people using more than one mode of transport. The time taken to reach the diabetic clinic from home varied from 5 to 10 min (2), ½ h (8), 1 h (2), 1½ h (3) to 2 h (3). The time taken to access regular treatment was not recorded for 8 participants.

Lower levels of self - efficacy were noted by a number of participants. The majority of people expressed negative emotions at the diagnosis of diabetes, ranging from anger, shock, sadness and sorrow to worry. One person was relieved with the diagnosis of diabetes, as prior to this diagnosis he thought that he was HIV positive and was going to die. Another person on learning that she had diabetes felt free from the anxiety of not knowing why she felt ill.

Ref: 30: 07 ‘…I have had many problems…One day…I was very thirsty and the muscles were extremely tight. I would get very tired while I was walking. I started losing weight everyday despite the excellent food cooked. I went to a doctor….I didn’t know the issues with diabetes. The doctor checked but did not tell me whether I had diabetes. I told my fellows that I was an HIV positive person. I was taken to a UN camp where I was checked out. The result came back to be HIV negative. I thought that maybe they were lying to me and that I would kill myself if they told me the truth. I stayed like that. All the time I was tired and weak. I was in Kibongoto. I could not even get up and my colleagues help me out. The day I found out that I had diabetes I urinated a lot and drank five litres of water. I came to find out that I had diabetes in 2003.

Ref 27: 34 ‘I feel free. Now that I know my disease, I simply feel free.’

Ref 45:13 ‘When I get there I provide money for consultancy and stay on queue until the time to be called comes. Then the doctor comes. Then the doctor would check and if there is a need for medicine they would provide.’

Ref 34: 26 ‘I ask the doctor how the level of my sugar in my body is so that I can tell the people at home my progress.’

Ref 45:24…’I don’t feel happy because I’m restricted to eat. I’m told not eat any red meat except for chicken and fish. I’m not very happy. I am allowed to eat all kinds of vegetables.’

Ref: 43: 9 ‘If you don’t continue with treatment properly, diabetes can affect you really badly due to the reasons I said earlier…’

Ref: 27:25…’changes to eating sweet things. So it was hard to eat what I was told to eat by the doctors.’

Coping with changes in life-style demonstrated the most striking area of low self-efficacy in this group: When asked, ‘Once you had diabetes, what changes did you make regarding your lifestyle about being diabetic?’ Change in diet appears to have been the most difficult and challenging aspect of life-style change facing this group. ‘We are told the food types…It is very hard to follow.’ The concept of life-style change and being able to eat a healthy diet in this area of self-management appeared not to have been comprehensively taught or understood by most of the group, ref 40:7.

Of the group 18 people specifically mentioned having to change their diet. Of these 11 people said that listening to what the doctor said about changing diet was important and 8 people mentioned that they had to eat what they had been instructed to eat (by the doctor).Reduction of carbohydrate intake was specifically mentioned (14) although only one person mentioned foods such as bread, rice and ugali (maize meal). Some culturally difficult issues were specifically mentioned: having to drink sugarless tea (6 people), increasing the intake of fruit and/or vegetable (18 people), the need to reduce the quantity of food eaten at each meal (3 people), and cook vegetables with less oil (2 people). Only two people mentioned the principle of eating a healthy diet.

Ref 27:10 ‘We are told the food types but it is hard to follow exactly what these types are. It is very hard to follow.’

Ref 42: 9 ‘If I don’t follow the instructions on food types, it can affect me severely. I don’t eat high sugar content food.’

Ref 40:7 ‘There are no specific food types for a diabetic patient but it is the quantity that matters. When you are eating you need to make sure that there are fruits, vegetables, protein and carbohydrates in order to have a complete meal.’

Ref 39:25 ‘There are many things that I have stopped after getting diabetes. For instance alcohol consumption, meat and high cholesterol content food…We are told to eat more vegetables and should not be added too much oil.’

Ref 34:22 ‘I was told to eat non carbohydrate foods.’

Ref 44:22 ‘I stopped eating a variety of food types. So I became thin due to that.… A little bit of bananas and barbeque meat.’

Self-efficacy (Table  3 )

The mean scores on the five subscales reflect high levels of self-efficacy in each area of self-care with the exception of Item 10 (nutrition/treatment m  = 4.2) ‘I think that I’m able to keep to my diet most of the time’ ( m  = 3.3). This indicates low self-efficacy for this aspect of self-care. This is supported by findings in the structured interview.

Diabetic health beliefs (Table  4 )

This psychometric measure is divided into five subscales. In the first subscale the majority of participants believed their diabetes was well controlled ( m  =  4.2). Diet appears to be a burden to this group of PLWD. In the theme “Barriers (to diet and medication)” item 2, I would have to change too many habits to follow my diet (diabetic foods) ( m  = 3.9) is the highest perceived barrier to achieving this health behaviour. In the theme “Impact of Job on Therapy”, item 10 , If I changed “jobs” it would be easier to follow my diet (diabetic foods) ( m  = 1.9) is the highest perceived barrier to achieving this health behaviour. Benefits of Therapy (diabetic foods, diabetic medication and weight control, mean scores for all 11 items of = 4.1 or more) and Social Support (for diet, m  ≥ 2.4) are both perceived as being beneficial in maintaining health.

Diabetic knowledge questions (Table  5 )

There were clear gaps in knowledge. Knowledge overall was poor ( m  = 15.92, 61.25 %); only 15 % were correct on knowledge on impact of exercise on need for medication (item 10) and only 19 % were correct about sign of hypoglycaemia (item 21).

PAID (Table  6 )

On the PAID scale the mean was 4.2, SD 9.72 (range = 55–95), suggesting a high level of emotional distress overall amongst this group. Item 3, I feel anxious when I think about living with my diabetes (m = 4.7) is supported by the findings on the anxiety subscale of the HSCL-25 below and item 19 I am not satisfied with my relationship with my doctor/my nurse who are treating my diabetes (m  =  4.7) is an interesting contrast to the responses in the standard interview on the relation between PLWD and health care workers.

Hopkins Scale Checklist-25 (Table  7 )

On the anxiety subscale 6 out of the 10 items were above the 1.75 cut off suggesting high levels of anxiety among the group. Item 2. Feeling fearful ( m  = 2.3) would appear to reflect the state of anxiety on this subscale. This is in support of item 3 on the PAID scale above, I feel anxious when I think about living with my diabetes ( m  = 4.7)

On the depression scale 11 out of the 15 items were above the 1.75 cut off point, suggesting high levels of depression among the group, as are reflected by item 20. Thoughts of ending your life ( m  = 2.8) and item 25 Feelings of worthlessness ( m  = 3).

Eye Health Questionnaire (EHQ)

All PLWD who responded to the request take part in the study were offered DR screening. A total of 79 people were screened for DR over the course of the NA, of these PLWD 29 were male and 50 were female. There was no difference in visual acuity between those included in the NA and the extra PLWD who were screened for DR. Visual acuity was recorded for 71/79 of all of those screened, and coded according to presenting distance visual acuity (see Table  8 ). Outcome of visual acuity assessment is shown in Table  9 , and outcome DR findings are shown in Table  10 . There were signs of DR in 9 of those whose were screened; dot blot haemorrhages, cotton wool spots, exudates. In one case there was also cataract in the other eye. Each person who was screened for DR was asked to complete the EHQ, the results are shown in Table  1 . Reasons given for not previously being screened for DR included: cost—2 (2.5 %), ill health—2 (2.5 %), access to the clinic—3 (3.8 %), unaware of the need—23 (29.1 %), other reasons—19 (20 %). No reasons given—30 (38 %).

Table 8

Coding of presenting distance visual acuity (ICD revised changes to definition of blindness)

Table 9

Outcome of visual acuity coding for DR screening

Table 10

Summary of findings from DR screening

In much of Sub Saharan Africa services for detecting and treating DR are often rudimentary and largely confined to urban centres. Many barriers to the care of diabetic retinopathy in the region have been identified. In addition to the obvious shortage of ophthalmologists and their lack of training in DR, low numbers of other ancillary ophthalmic staff such as optometrists and poor training in retinal examination to detect DR compound the problem. Furthermore there are inadequate referral systems from primary to secondary care and from diabetic clinics to ophthalmic services. The latter are poorly resourced in terms of imaging equipment and treatment infrastructure such as lasers [ 38 , 39 ].

However the needs of PLWD and how these might interact with the health services have not been studied.

Health services

In the structured interview, PLWD spoke positively about their relationship with the health care workers caring for them, yet the PAID scale revealed a different picture. In answer to item 19 it was clear that there was dissatisfaction with relationship with those treating PLWD ( m  = 4.2). People were reluctant to openly criticise those who provided them with regular care or to talk about the limited resources that were clearly evident to all who visit the hospitals and clinics and are reported by the health care workers themselves. Given the lack of training in DM and chronic staff shortages in SSA [ 38 ] it is not surprising that PLWD revealed a level of dissatisfaction with health care workers.

Education, knowledge

Burgess in his discussion on the emerging epidemic of diabetes in SSA calls for the education and empowerment of patients as an important part of disease management [ 39 ].

The assessment of diabetes knowledge with the DKQ [ 30 ] and the structured interview and the EHQ revealed gaps in knowledge and diabetes self-management, self-care and dietary advice among the group that needed to be addressed as part of a health intervention programme. The EHQ revealed that knowledge of need for eye screening and eye health services did not result in an uptake of eye health services. Knowledge does not lead to a change in health behaviour [ 10 ]. More has to be done to ensure that PLWD are screened annually for DR than making them aware that diabetes damages the eye. SCT suggests knowing what to do must be supported by the cognitive, social, emotional and behavioural skills to adopt, maintain and persist with health behaviours in the face of difficulties and obstacles [ 17 ]. The gap between knowledge and behaviour helps explain why one of the main challenges faced by new screening services has been uptake of referrals to the eye department after a positive screening test [ 11 ].

Uptake of screening for DR

Previous research conducted on the uptake of eye health service in Kilimanjaro show many barriers exist [ 40 ]. These include socio-cultural challenges; elderly people may have to ask relatives for social and financial support when they need eye treatment and surgery. For some this is difficult when limited, seasonal resources are required for food, clothing and school fees. Ill health is defined locally as pain, so in many instances a loss of visual acuity does not meet this definition [ 40 ].

Our previous experience with DR screening in Kilimanjaro showed the positive effect of providing patient education and counselling in the diabetic clinic. Having a nurse counsellor present in the diabetic clinic at KCMC Hospital increased the uptake of screening for DR from 29 to 47 % [ 9 ]. However the fact that more than 50 % of patients did not take advantage of screening services in the same hospital could be explained by some of the findings of our needs assessment study that relate to self-efficacy, anxiety and depression.

Low self-efficacy

For most of the group the diagnosis of diabetes demonstrated low levels of SE. Dietary change was the area of the lowest self-efficacy, compounded by minimal dialogue between PLWD and health care workers who appeared to give instructions on life style changes without explanations that would lead to understanding, and in turn raise levels of self-efficacy. Low SE was clearly expressed when people were asked how diabetes had affected their lives. One person felt that diabetes had left her bereft of family, (ref 45:4) there was loss of employment and income, loss of mobility, a loss of vision and independence with an associated reliance on others. All of these affect people’s relationships with their families, their friends and their sense of self-worth. Low SE as part of engaging in dialogue about treatment may well be both a cultural phenomenon and the paternalistic approach to health care in Tanzania [ 41 ]. It may contribute to a large portion of those who did not attend for screening in our original study and needs to be addressed when planning DR screening services.

It is telling that as a measure of emotional distress the highest scoring item on the PAID scale [ 31 ] was feeling anxious about living with diabetes (items 3 = 4.7). This triangulated with findings on both the HSCL-25 and the structured interview. The emotional burden of living with diabetes cannot be under estimated especially in communities were resources are limited and poverty is also a factor. There is a need for comprehensive mental health care to be integrated into diabetes care [ 42 ].

Diabetes related stigma has received little attention worldwide [ 43 ] and none in Africa. Type two diabetics in Australia felt discriminated against with fewer opportunities in life, subject to negative stereotyping and felt blamed by others for their condition [ 44 ]. On the other hand type one diabetics did not experience similar social stigmatisation.

The group of PLWD in Tanzania were type two diabetics. In contrast to the Australian group of diabetics, the Tanzanian group was highly motivated to tell others about diabetes in order to raise community awareness about diabetes to prevent others suffering from diabetes without treatment and to ensure they received support for themselves for their on-going treatment and care. This shows a lack of stigma towards diabetes amongst this group. Following this initial NA patients being screened for DR were given a Kilimanjaro Diabetic Programme (KDP) sticker to place on their blouse, dress or shirt to indicate that they had received screening. The aim was to promote dialogue in the community about screening. Two things were observed about these stickers. Firstly, patients who had undergone screening continued to return to KCMC Hospital week after week still wearing their stickers. If the staff who conducted the DR screening forgot to give a sticker to a patient after screening, the patient would return and ask for a sticker. It seemed that amongst this group of PLWD that there was no stigma of being diabetic and the object of giving out the KDP stickers to raise awareness in the community by having people wear them worked. In a continent with a high prevalence of a more stigmatising disease such as HIV/AIDS, it may be a relief to PLWD to have a more socially acceptable explanation for their chronic illness.

This needs assessment reveals dissatisfaction with the health workers treating their condition and low self-efficacy in areas of managing their diabetes and preventing complications, as well as a lack of knowledge about DM and its complications. High levels of anxiety and depression are experienced by PLWD. On a positive note there seems to be little stigma attached to a diagnosis of DM. These insights are useful in planning diabetic retinopathy screening and treatment services.

The KDP has moved through 4 of the 5 phases of implementing a DR screening service as described by Poore et al. [ 45 ]. These start with screening in the eye clinic, move to screening in the hospital diabetic clinic, create a diabetes register and call for eye screening and identifying undiagnosed DR in the community.

The quantitative measures and qualitative interviews, together with the findings of the EHQ for PLWD and a NA conducted with health care workers in Kilimanjaro Region were of value in showing the need for the comprehensive health intervention programme that was subsequently developed by the KDP [ 11 ]. The KDP was established with the combined efforts of government representatives, hospital directors, epidemiologists, endocrinologists ophthalmologists and social scientists [ 11 ]. Clearly there was a need for both diabetes education and eye health services at district level in Kilimanjaro region. The KDP has taken diabetes education to health care providers in Kilimanjaro region at district level so that they can provide education to PLWD on all aspects of self-care and management of living with diabetes.

As was seen from the EHQ, knowledge that DM damages the eye did not mean that PLWD would go for DR screening. The KDP developed a diabetic diary that allows PLWD to record their regular clinic visits and review their blood pressure, blood glucose, and weight. The diary also contains useful information for patients including sections on diet, exercise, foot care and eye health. The KDP facilitators subsequently led 3 years of annual educational workshops at district level in Kilimanjaro region. Two cartoons on DR were developed to provide patient information to PLWD when they attended for DR screening.

The DR screening programme is supported by an electronic database. The KDP electronic database of all known diabetics in Kilimanjaro was set up so that all PLWD, in Kilimanjaro region, can be registered and their clinic, and hospital attendance, screening and treatment for DR are electronically recorded. This allows for recording and review of retinal photographs and reminders to be sent automatically for review and treatment.

By the beginning of 2015, 3463 (60·4 %) of the 5729 individuals registered with the KDP, had been screened for retinopathy. The prevalence of any diabetic retinopathy was 27·9 % in those screened. Proliferative retinopathy was present in 2·9 % and maculopathy in 16·1 % of individuals who were screened [ 11 , 12 ].

The KDP aimed to make screening for DR more accessible to PLWD by taking DR screening to the district level. The KDP helped to establish dedicated diabetes clinics in 18 peripheral hospitals, with the aim of providing knowledge based teaching, clinical support, resources and action plans that health care workers could use to empower PLWD. The mobile diabetic retinopathy screening team work through these centres.

Limitations and strengths

We conducted a large number of interviews and believe that this constitutes a reasonable representation of the views of people living with diabetes in the Kilimanjaro Region. However the subjects were not randomly recruited and there is the possibility of bias with for example subjects with a higher level of self-efficacy in managing their diabetes presenting for the needs assessment interviews.

Authors’ contributions

CH contributed to the research, data analysis, and wrote the manuscript*, AH contributed to the concept, proposals, discussions, analysis and revised the manuscript, JM researched data and contributed to discussions, GK reviewed the manuscript, PC supervised, advised and reviewed the manuscript. All authors read and approved of the final manuscript.

Acknowledgements

We are grateful to cbm and AusAid for funding of the Kilimanjaro Diabetic Programme. Thanks to Herman Schaalma, from Maastricht University for advice and supervision, he is sadly missed.

Competing interests

The authors declare that they have no competing interests. Oral presentation of some of this material was made at the International Society of Geographical and Epidemiological Ophthalmology, Hyderabad, India, 21st September, 2012.

Availability of data and materials

Abbreviations, contributor information.

Claudette E. Hall, Email: moc.liamg@llahgettedualc .

Anthony B. Hall, Email: moc.liamg@llahtennebynohtna .

Gerjo Kok, Email: [email protected] .

Joyse Mallya, Email: moc.oohay@lameecoj .

Paul Courtright, Email: ten.occk@thgirtruocp .