Barriers and opportunities for evidence-based health service planning: the example of developing a Decision Analytic Model to plan services for sexually transmitted infections in the UK

ABSTRACT: BACKGROUND: Decision Analytic Models (DAMs) are established means of differentiating between health technologies. They have mainly been used to inform clinical decisions and health technology assessment at the national level, yet can also inform local health service planning. For this, a DAM must take into account the needs of the local population, but also the needs of those planning its services. Drawing on our experiences from stakeholder consultations, where we presented the potential utility of a DAM for planning local health services for sexually transmitted infections (STIs) in the UK, and the evidence it could use to inform decisions regarding different combinations of service provision, in terms of their costs, cost-effectiveness, and public health outcomes, we discuss the barriers perceived by stakeholders to the use of DAMs to inform service planning for local populations, including (1) a tension between individual and population perspectives; (2) reductionism; and (3) a lack of transparency regarding models, their assumptions, and the motivations of those generating models. DISCUSSION: Technological advances, including improvements in computing capability, are facilitating the development and use of models such as DAMs for health service planning. However, given the current scepticism among many stakeholders, encouraging informed critique and promoting trust in models to aid health service planning is vital, for example by making available and explicit the methods and assumptions underlying each model, and associated limitations. This can be achieved by consultation and training with the intended users, and by allowing access to the workings of the models (e.g. via the internet), to show how they actually work. SUMMARY: Constructive discussion and education will help build a consensus on the purposes of STI services, the need for service planning to be evidence-based, and the potential for mathematical tools like DAMs to facilitate this.     

Needs assessment and hospice planning in a rural setting

A needs assessment is a research and planning activity designed to determine a community's service needs and utilization patterns. One of the most practical ways to plan services is to gather information accurately about a defined population and use that information to revise existing programs or develop new ones. Unfortunately, needs assessment findings often go unused. This article describes how a needs assessment was designed to assess the need for hospice services in a rural Pennsylvania county and how the results of this assessment were useful in determining priorities for program planning and service development. The implications of a model needs assessment such as the one proposed are discussed.     

Homelessness—‘It will crumble men’: The views of staff and service users about facilitating the identification and support of people with an intellectual disability in homeless services

People with an intellectual disability (ID) face significant health inequalities and barriers to accessing appropriate support, which are made worse if the person is also homeless. An important barrier is that services may not recognise that the person has ID. This qualitative study explored the views of staff members and service users about the identification and support needs of homeless people with ID and the role of an ID screening questionnaire as a way to help improve service provision. Semi‐structured interviews were conducted with 16 staff members and 8 service users from homeless services in the South East of Scotland between March 2017 and 2018. Thematic analysis identified four themes: ‘not diagnosed or declared’, which explored the barriers to support due to the person's ID not being identified by others or disclosed by the person; ‘It will crumble men’, which reported on the additional challenges faced by homeless people with ID; ‘disabling environment’ which identified the ways in which organisations can make support difficult for people with ID to access; and ‘It's not against them, it's to help them’ which explored the benefits and issues associated with screening for ID in homeless services. The results identified the complex support needs likely to be experienced by many homeless people with ID and suggested a number of implications for practice. First, the screening tool was seen as having a number of benefits, if used where there is a process to provide the person with further specialist assessment and support. Second, staff members identified a need for training in relation to identifying and supporting this group of people. Third, the screening tool was seen as a way to help provide information about the prevalence and needs of people with ID, in order to inform and shape policy, service development, and delivery.     

An exploration of help-seeking behaviour in older people with unmet needs

BACKGROUND: Despite decades of research showing high rates of unmet need in older people, there currently is little understanding of why these needs remain unmet. This study was performed as part of a larger feasibility study of a multidisciplinary needs assessment tool in primary care. OBJECTIVE: The aim of the present study was to explore patients' and carers' help-seeking behaviour and perceived barriers to meeting unmet needs. METHOD: Four general practices were selected purposefully in inner city and suburban London A random sample of 1 in 20 people aged 75 years and over registered with each practice was selected for a multidisciplinary needs assessment using the 'Camberwell Assessment of Need for the Elderly' (CANE) schedule and unmet needs identified by patients and their informal carers. For each unmet need, a further semi-structured interview was used to explore the help-seeking behaviour and perceived barriers to meeting their needs. Responses were recorded verbatim contemporaneously and a thematic analysis performed on perceived barriers following completion of all interviews. RESULTS: A total of 55/84 (65.5%) of patients and 15/17 (88%) of carers completed the initial needs assessment. For 104 unmet needs identified by 31 patients and 11 carers, a further interview was completed on the barriers to meeting that need. Help had been sought for only 25/104 (24%) of unmet needs and it had been offered in only 19/104 (18%). In those not seeking help, withdrawal, resignation and low expectations were dominant themes. In those that had sought help, there were issues of perceived failure of service delivery and rationing, with themes of resignation and withdrawal again emerging in those declining help offered. CONCLUSION: The majority of older people and their carers do not appear to seek help for their unmet needs for a range of complex reasons, often involving issues of withdrawal, resignation and low expectations. This complexity has implications for the commissioning of services for older people.     

Understanding living skills: first steps to evidence-based practice. Lessons learned from a practice-based journey in the Netherlands

Living skills training is a commonly used but sparsely described and researched - occupational therapy - intervention for people with severe mental health problems. A service improvement project was established in a mental health organization in the Netherlands starting in 2006 to design more effective living skills training courses for individuals and groups. The steps of the evidence-based practice process underpinned the project. Theoretical and empirical evidence was derived from an extensive literature review. This was supplemented by the preferences of clients and their families as an equally valued source of evidence as is the experience and knowledge of a range of mental health professionals. Information from these three sources provided building blocks for the development of living skills training, resulting in an individual process guideline and two group courses. Implications for practice is that living skills training needs to be part of multidisciplinary treatment and can be best provided in the client's natural context. Limitations of this study are the lack of an evaluation of both the group courses and of the individual process guideline, also due to the continuous implementation in an ever-changing context. There is further need for research into the clinical and cost effectiveness of living skills training, both for individuals and groups, to support evidence-based decision making and service planning.     

Health protection of health care workers from the prospective of ethics, science and good medical practice. Opinions from stakeholders in health care settings

Fitness for work (FFW) in health care workers poses multidisciplinary challenges because of management problems scientific and ethical implications and the implementation of preventive interventions in health care settings. All the relevant stakeholders, including the General Manager, Medical Director, worker's representative, the person responsible for prevention and protection, forensic medicine expert, the person responsible for prevention and health safety at public administration level, commented on: danger to third parties; FFW formulation; human resource management; stress; professional independence; role of the person responsible for prevention and protection and of the person responsible for prevention at public administration level; professional responsibilities. Opinions are reported regarding the main problems related to the role of the Occupational Physician in FFW formulation, such as the difficult balance between autonomy and independence, limited turnover and aging of workforce, need of confidentiality and respect for professional status of the HCW prevalence of susceptibility conditions, rights and duties of stakeholders. The most significant result was the request by the Lombardy Region for more quality in risk assessment and health surveillance; to maintain uniform conduct over all the local health authorities, to allow the board in charge of examining appeals against FFW to fully cooperate with the occupational physician; due attention to the person/worker; the opportunity to convene referral boards for complex FFW management; the challenge of stress management and the need for an observatory for psychological discomforts; the importance of the ICOH Code of Ethics and avoidance of conflicts of interests; the need for individual risk assessment and risk management; the concept of sharing responsibilities and of a real multidisciplinary approach.     

Urban planning and public health at CDC

Urban planning, also called city and regional planning, is a multidisciplinary field in which professionals work to improve the welfare of persons and communities by creating more convenient, equitable, healthful, efficient, and attractive places now and for the future. The centerpiece of urban planning activities is a "master plan," which can take many forms, including comprehensive plans, neighborhood plans, community action plans, regulatory and incentive strategies, economic development plans, and disaster preparedness plans. Traditionally, these plans include assessing and planning for community needs in some or all of the following areas: transportation, housing, commercial/office buildings, natural resource utilization, environmental protection, and health-care infrastructure. Urban planning and public health share common missions and perspectives. Both aim to improve human well-being, emphasize needs assessment and service delivery, manage complex social systems, focus at the population level, and rely on community-based participatory methods. Both fields focus on the needs of vulnerable populations. Throughout their development, both fields have broadened their perspectives. Initially, public health most often used a biomedical model (examining normal/abnormal functioning of the human organism), and urban planning often relied on a geographic model (analysis of human needs or interactions in a spatial context). However, both fields have expanded their tools and perspectives, in part because of the influence of the other. Urban planning and public health have been intertwined for most of their histories. In 1854, British physician John Snow used geographic mapping of an outbreak of cholera in London to identify a public water pump as the outbreak's source. Geographic analysis is a key planning tool shared by urban planning and public health. In the mid-1800s, planners such as Frederick Law Olmsted bridged the gap between the fields by advancing the concept that community design contributes to physical and mental health; serving as President Lincoln's U.S. Sanitary Commission Secretary; and designing hundreds of places, including New York's Central Park. By 1872, the disciplines were so aligned that two of the seven founders of the American Public Health Association were urban designers (an architect and a housing specialist). In 1926, the U.S. Supreme Court, in validating zoning and land-use law as a legal government authority in Village of Euclid v. Ambler Realty, cited the protection of public health as part of its justification. Other connections have included 1) pioneering urbanist Jane Jacobs, who during the 1960s, called for community design that offered safe and convenient options for walking, biking, and impromptu social interaction; and 2) the Healthy Cities movement, which began in Europe and the United States during the 1980s and now includes projects in approximately 1,000 cities that in various ways highlight the role of health as much more than the presence of medical care.     

Multidisciplinary Assessment of Learning Problems - School Nurse's Role

C lark, 7 years old, had multiple school problems, but these didn't seem to be explained by his bilateral neurosensory hearing loss. Though seemingly bright, preferential seating and the help of an itinerant teacher for the Aurally Handicapped were not enough to meet the needs of this child. Other factors were poor coordination, frequent tardiness and disruptive behavior. A medical evaluation which utilized a whole child approach was initiated by the school nurse. Unilateral aural amplification was found to help Clark's distractibility and inattentiveness. An occupational therapist's assessment of his coordination led to the development of an individual sensory integration treatment program. A recommendation for parent and child counseling was also made. S haron, 11 years old, was progressing poorly as a transfer student into an Educationally Handicapped tutorial program. A review of available information revealed an incomplete multidisciplinary evaluation with no pertinent medical investigation ever being done. Her history and behavior suggested possible central nervous system injury. There were also indications of need for an indepth study of her language development. The follow-up activities started by the school nurse led not only to the school better meeting Sharon's educational needs, but also to the parent's request for a similar medical evaluation of a younger sibling. The latter child had repeated a grade, but her slow progress was yet to be of major concern for the involved teacher. This younger (6 year old) sibling's evaluation resulted in early special education assistance. T ony, 5 years old, concerned his kindergarten teacher who wanted help in planning to meet his needs. Neither retention nor promotion by themselves presented problems. His situation was complicated by glaring gaps in readiness for academic activities, a confusing home situation and unrealistic parental expectations. A detailed health and developmental assessment by the school nurse facilitated parental cooperation with an educational evaluation. It also made available to the mother an objective, medically oriented community resource where she could discuss differences with the teacher. A basis was thus established for constructive planning.     

Older persons’ experience of being assessed for and receiving public home help: do they have any influence over it?

The aim of this qualitative study was to explore older persons' experience of participation in and influence on decisions about public home help/care when undergoing needs assessment and receiving public home help. A purposive sample of 28 home help recipients over the age of 75 were selected. Data were collected by means of in-depth interviews. A content analysis revealed one overarching category: 'Having to be satisfied, adjust, and walk a fine line when balancing between needs and available help'; and three principal categories: Balancing the comfort and guilt--receiving help from the family at the limits of their capacity; 'A necessary evil'--balancing feelings and resources against having no choice but to accept; Incorporating the home help into daily life to gain a sense of continuity. The findings indicate that older persons have difficulties coping and adapting to their new life situation and have no actual influence over the decisions about their home help. The officer told them what was available. This implies a need to pay attention to the frail persons' mental state in the needs assessment and to ensure adequate understanding of information. Further, it suggests that the needs assessment and the home help officer should to a larger extent focus on individual needs as a whole, involve and encourage the older person to strengthen his or her sense of being in control.     

Durable data. A rehabilitation center collects and distributes information for functional assessment and program evaluation

As physical rehabilitation services have expanded nationwide, both payers and providers have increasingly felt the need for adequate outcome data. In 1988 organizers at Marianjoy Rehabilitation Center, Wheaton, IL, launched the Center for Rehabilitation Outcome Analysis-a service for rehabilitation facilities that want to develop in-house functional assessment and program evaluation systems. The center has focused on meeting three major needs of rehabilitation providers: outcome data analysis and reporting, education, and research. It uses the Patient Evaluation and Conference System for a variety of needs from planning programs to establishing functional outcome expectations. The center also educates participants on the use and meaning of outcome data. In addition, it has enlisted the help of the profession's behavioral scientists, evaluators, and statisticians to scrutinize and enhance program evaluation and measurement models.     

A community based lesbian sexual health service - clinically justified or politically correct?

Lesbian sexual health care is still a neglected issue. In order to address this, a needs assessment was carried out in Glasgow amongst the lesbian community and 200 responses were received. More than 40% of the respondents said they were unable to disclose their sexual orientation to their GP and were unable to discuss sexual health issues with them. Eighty-one percent said there was a need for a lesbian sexual health service and 71% said they would use such a service if it existed. Therefore a pilot clinic was set up in Glasgow and was co-ordinated by a multidisciplinary advisory group. The clinical component of the service was audited and it was found that gynaecology and fertility issues were the most common presenting condition (52%), followed by psychosocial issues (26%). Genitourinary problems, such as vaginal discharge, constituted 20% of presentations. Client satisfaction with the clinic was high. This pilot service showed that areas of sexual health care, such as the need for inclusion in cervical smear programmes and equality of access to assisted conception, are issues which are important to this minority group and which need to be addressed. The clinic is now ongoing as a result of the pilot scheme and is the only family planning based lesbian health service in the UK.     

论农村卫生事业的发展与卫生政治学

卫生工作具有政治性,发展卫生事业必须讲政治。一个国家整个人群的健康不是取决于单个的公民或医生,而是取决于社会制度和社会关系。只有通过政治才能改变社会制度和社会关系。解放后我国农村卫生事业取得了令国际社会赞赏的辉煌成就,根本原因在于中国共产党注重从政治的高度认识并开展农村卫生工作。市场经济条件下,我国农村卫生事业发展遇到了挫折,需要我们重新审视农村卫生与政治的关系,探索建立卫生政治学新学科,为农村卫生工作提供理论指导。     

Structuring health needs assessments: the medicalisation of health visiting

This paper draws on Foucault to understand the changing discourse and impact of structured 'health needs assessments' on health visiting practice. Literature about this activity makes little mention of the long-standing social purposes of health visiting, which include surveillance of vulnerable and invisible populations, providing them, where needed, with help and support to access protective and supportive services. Instead, the discourse has been concerned primarily with an epidemiological focus and public health, which is associated with risk factors and assessments. The use of pre-defined needs assessment schedules suggests that health visiting activity can be sanctioned and clients' needs serviced only if they reach the threshold of pre-determined, epidemiologically-defined risk. Their effect on practice is examined through a conversation analysis of ten health visitor/client interactions using two different structured needs assessment tools. The study indicates that the health visitors, like their clients, were controlled by institutional expectations of their role; analysis of their conversations shows how they achieved the requirements of the organisational agenda. Structuring client needs and health visiting practice through the use of formal needs assessment tools emphasises the epidemiological focus of the health service above the need to arrange support for vulnerable individuals. In this respect, it serves as a marker in the continued medicalisation of health visiting.     

Adapting needs assessment methodologies to build integrated health pathways for people in the criminal justice system

Criminal justice health services should be underpinned with good public health evidence about the population's health needs. Health needs assessment methodologies can provide valuable intelligence for commissioners to evaluate the quality of services and innovate according to need. However, health needs assessment can be limited if it takes a conventional epidemiological approach, focussing on individuals' healthcare needs in criminal justice settings. Techniques used to measure health and social need could be more widely applied and appropriately employed in the planning of health and social care services, especially if the intention is to be effective in reducing social exclusion and tackling health inequalities. Assessment tools are available that capture individual, social and environmental risk factors and determinants predisposing people to health and criminogenic risks. Good evidence gathering can mean that public health practitioners not only improve health, reduce inequalities and tackle social exclusion, but contribute to reducing re-offending. This paper suggests a new approach to assessment that integrates the full range of assessment methodologies available to practitioners. An integrated approach may be the way to enhance and enrich the public health function in providing evidence to improve the quality of local public services.     

Peer Reviewed: Optimizing Women��s Health in a Title X Family Planning Program, Baltimore County, Maryland, 2001-2004

Background

Although women usually obtain family planning services during their reproductive years, their need for comprehensive preventive services that promote wellness beyond reproductive health is often ignored.

Community Context

The Maryland Department of Health and Mental Hygiene sought to improve the general health of women and reduce their risk for adverse pregnancy outcomes by integrating women''s health services into the Baltimore County Title X program. Title X is a federal family planning grant program primarily serving low-income, uninsured people.

Methods

After completing a needs assessment, we addressed gaps in women''s wellness services in 3 family planning clinics. On-site services included counseling, screening, and referral for nutrition and physical activity, adult vaccination, depression, domestic violence, smoking cessation, substance abuse, and general medical disorders. A local multidisciplinary task force provided leadership for the clinical infrastructure of the project and served as a resource for women''s health referrals.

Outcome

Every staff person surveyed reported that the project had a positive effect on the community and should be continued. Clients identified non–reproductive health services they needed but would not have received otherwise. During the 3-year period, patient volume increased 28% for the pilot sites, compared to 1% for the state family planning program overall.

Interpretation

With collaboration from a multidisciplinary community task force, the Title X family planning program can help provide needed preconception, interconception, and general women''s health services, especially for women who have difficulty accessing care.     

A prospective study of patient identified unmet activity of daily living needs among cancer patients at a comprehensive cancer care centre

Cancer, as a chronic illness, demands a new focus in physical and emotional support. Thus, an assessment of activities of daily living needs among cancer patients was completed. A 1-week, cross-sectional survey of patients was undertaken, by using the Modified Barthel Index, the Eastern Co-operative Oncology Group performance status, a Modified Instrumental Activities of Daily Living Scale and a screening tool. As functional status declined, the number of unmet needs per patient increased. At least one-third of patients who would benefit from assessment were not referred. Without simple screening tools, the needs of this population are not always being recognised or met. Patient identified needs, when analysed by functional level and treatment intent, challenge existing assumptions of service provision. In conclusion, there is an unmet need in this cancer population. By using the Screening Tool on referral, and with each change in level of function (as measured by the Eastern Co-operative Oncology Group), it would help identify patients who may benefit more from occupational therapy assessment.     

Helping Birmingham Families Early: The “Signs of Safety and Well-being” Practice Framework

Rising demand for early help services is currently taking place against a backdrop of closing or reduced services and shrinking public authority budgets across England. Complicating matters is the wide variety of service orientations and differences in assessments offered to vulnerable families. This can be confusing for them. Moreover, this is an inefficient approach to providing help. This article presents a methodology of early help practice with families, designed to ease any service orientation problems, while promoting a more uniformed approach to early help practice in Birmingham, England. This article is concerned with the wide variety of tools and approaches in early help practice and is critical to how risk and need exploration operates because practitioner anxiety about working with risk potentially fuels an escalation of referrals through to statutory services. To help build practitioner confidence about working with need and risk, a practice framework based on signs of safety has been developed for Birmingham’s early help services, replacing over 80 pre-existing assessment tools. Strengths-based practice debates provide the theoretical backdrop for this discussion.     

加强区域卫生规划建设 促进卫生事业发展

当前为保持卫生事业持续发展，必须加强区域卫生规划建设，充分发挥卫生资源作用。为此，树立区域卫生全局观、卫生效益观、区域卫生发展观，利用现有资源，采取改组、改制、改造措施，调整机构布局；调整投资思路，用好新增资源；改善卫生服务，使人民群众获得多层次医疗保健服务。当然，抓住机遇，形成共识，制定区域卫生规划，在机遇中调整，促进卫生事业可持续性发展。     

Building hospital capacity planning mechanisms in Poland: The impact of 2016/2017 regulatory changes

Capacity planning is a crucial component of modern health care governance. The aim of this paper is to analyze the requirements that need to be met to build effective hospital capacity planning mechanisms in Poland. In this context, the recent regulatory changes strongly influencing hospital sector functioning, including introduction of health care needs maps, capital investment assessment, and hospital network regulations, are analyzed. Some possible ways forward, based on review of international experiences in hospital capacity planning, are discussed. Applied methods include literature review and analysis of statistical data as well as desk analysis of key national regulations related to hospital sector. Results indicate that at the system level, the process of capacity planning involves 4 elements: capital investment in facilities, equipment, and technology; service delivery; allocation of staff; and financial resources. For hospital capacity planning to be effective, the strategic decision at the macrolevel must be complemented by appropriate management of individual hospitals. The major challenge of building hospital capacity planning mechanism in Poland is imbedding it into the overall health system strategy. Because of the lack of such a strategy, the practical implementation of the ad hoc changes, which have been introduced, shows some inconsistencies. The regulations implemented between 2016 and 2017 provided a basis for hospital capacity planning, yet still need evaluation and adjustments. Also, including a mechanism for human resources planning is of crucial importance. The regulations should provide incentives for reducing oversized hospital infrastructure with simultaneous development of the long‐term and coordinated care models.     

Die Bedeutung von Information für Krebspatienten und Erfahrungen aus der Arbeit des Krebsinformationsdienstes in Heidelberg

Cancer patients have a great need for information. Besides the attending physician as the most valued source of information they use various other sources. The broad avail-ability of information raises the need for "meta-information" for assessment, explanation and integration into the individual context. Here, a telephone information ser-vice meeting high quality standards can of-fer substantial support, combining the advantages of mass media with interpersonal communication.The cancer information ser-vice (KID), established at the German Can-cer Research Center in 1986 with funding by the Federal Ministry of Health, has implemented this concept of health information for the first time on a national basis. The KID provides comprehensive and up-to-date information on all cancer-related issues tailored to individual needs as well as address-es and resources of institutions and organisations of cancer care. Around 40% of KID users are patients. Major concerns are reassurance, assessment and integration of information from other sources, the need for guidance through the health care system and for supportive communication.Tele-phone information can bridge information gaps and deficits and enhance the doctor-patient relationship by building a basis for in-depth discussions. To meet the needs and new information preferences, the KID also publishes brochures and offers information via the Internet and an e-mail service.The KID is integrated in a network of can-cer care resources and, through documentation and evaluation of the calls, contributes to cancer information tailored to the needs of patients.