Assessing health needs and identifying risk factors: if Plunket nurses are to meet the needs of families effectively, they must assess all risk factors, including those outside strict contractual obligations.

Assessing health need is a fundamental nursing skill. (1) The Plunker Society promotes a socio-ecological model of health needs assessment, which involves considering biological, social, cultural, economic and environmental determinants of health, alongside clinical findings.

At each contact Plunket nurses have with families, they assign a low, medium or high rating which represents the relative need of the child and family. This rating takes into account population health need, which includes the health determinants and deprivation scores for a specific population in a specific Location. (2)

Plunket's funding contract stipulates the provision of service to clients based on the deprivation (dep) area where they live. This is a government funding model that has never been tested as a service delivery model until now. Within this framework, families living in dep areas 8-10 (the poorest areas) receive more service than those living in dep areas 1-7, with the exception of first-time parents. Plunket supports the well child framework's desire to place additional resources with high-needs families.

However, there are significant risks to using the dep index as the sole method of identifying high need. A 2001 report states that more than 10 percent of people living in dep 10 areas have none of the personal characteristics of deprivation, while one in 12 living in dep 1 areas suffer multiple deprivation factors lie five or more of the nine factors that make up the dep index score). (2) This report also found that if dep 8, 9 and 10 deciles are used to target resources, 55 percent of the population experiencing multiple deprivation would miss out on service.

While literature shows that populations Living in areas of higher deprivation generally experience poorer health, (3) there are health needs unrelated to socio-economic disadvantage, such as family violence and mental ill-health, that exist in families across all deprivation levels. Furthermore, from a nursing perspective, using geocoding and deprivation scores as the sole method of attributing service means client contact numbers (based on deficit models and rationalisation) are more highly regarded than family-centred outcomes achieved through a caring therapeutic relationship. (4) Nurses will not philosophically or morally abandon assessment skills, clinical analysis and professional judgment in favour of rigid service delivery frameworks.

Therefore a balanced approach, which acknowledges nurses' assessment skills, usefulness of health needs assessment data, client need and contractual requirements, is needed to clear up the confusion that exists about the place of health needs assessment within current contract specifications. Researching the health needs assessment practices of Plunket nurses would help achieve this.

Collecting data for research

In 2004, Plunket nurses from eight areas around New Zealand participated in collecting data for a research project on health needs assessment practices. This project aimed to find:

* what indicators/risk factors Plunket nurses did identify;

* what areas of health need Plunket nurses considered to be priorities;

* in what circumstances Plunker nurses considered health needs to be medium or high; and

* how closely the results of health need assessment aligned with the individual clients' deprivation score.

The Plunket ethics committee approved the research proposal in May 2004. Two branches from each region (the one with the most clients living in areas of high deprivation and the one with the Least number of clients living in highly deprived areas) were selected for inclusion. Plunket nurses in these areas consented to participate.

Data collection consisted of identifying applicable risk and protective factors that existed for families with children receiving their core 3 contact (when the infant is approximately three months old). For each client, this list of risk and protective factors was then compared with the Plunker health record documentation, needs assessment score and deprivation score for the area where the clients lived. A pilot group tested the tool over a two-week period and collected information on 92 contacts. Changes were then made to the research tool before the eight-week data collection period, which gathered information from 240 contacts.

Findings of specific risk factors

As expected, clients assessed as having low needs had significantly more protective factors than clients assessed as having medium or high needs. Key protective factors included willingness to access services, connection to services and support networks, no family violence, safety awareness with subsequent parental action, and early recognition and treatment of illness.

Clients assessed as having high needs and living in high deprivation areas were less likely to have protective factors, especially those listed in the section on preventable childhood illnesses and conditions. These protective factors included full immunisation, early treatment of illness, safety awareness, back sleeping, established breast-feeding, car seat use, early childhood education, seamless surveillance by well child services--all issues addressed through education and health promotion. Consistent, high quality and appropriate health promotion and health education interventions are needed to address the scarcity of protective factors in this client group.

Although the incidence of risk factors started to increase for clients living in areas of dep level 5-7, clients living in higher deprivation (dep 8-10) had significantly higher numbers of risk factors. For example, when comparing clients living in dep 6 areas and those living in dep 10 areas, lack of antenatal education was identified as a risk factor four times more often; the risk factor of the baby's sleeping position was nine times higher; overcrowding was 17 times higher; and respiratory illness in children was six times higher. Lack of essential services, low parental education and low income were identified risk factors that increased in number, as deprivation levels increased. Data showed that families living in dep 10 areas were likely to have an increased number of risk factors, especially socio-economic risk factors. These were more Likely to have a cumulative effect on the health and well-being of their children. (4) Despite the small sample size of 240 child clients, this finding confirmed the view that children Living in dep 10 areas were more Likely to experience the effects of disadvantage, which leads to health inequities. These results confirmed the Legitimacy of focusing on areas of higher deprivation and socio-economic disadvantage, as a general indication of risk.

However, this research also found that specific risk factors were evident throughout all deprivation areas. These included incomplete immunisation, poor maternal health and well-being, parental mental illness, attachment issues, parental relationship issues (including family violence) and lack of social connectedness. These were perceived to be significant issues that required more intensive intervention to maintain and improve child and family health and well-being. Therefore, flexibility is required to enable services to address high health needs regardless of deprivation area, in Line with the spirit of the well child framework.

This study appeared to show there are two distinct groups of clients assessed as high needs: those with risk factors such as family violence and severe parental mental illness, and who may Live in an area of 1-7 deprivation; and those with multiple risk factors which include poverty, low education, and/or reluctance to access services and support, and who usually live in dep 8-10 areas. The first group has situational need, usually without underlying socio-economic disadvantage, while the second group has situational need because of the underlying socio-economic disadvantage, which is enduring and more difficult to overcome. For both of these groups, intensive support and intervention is required to improve their overall health or prevent them from experiencing worsening health.

This research confirms what nurses know--health needs exist outside the funding model that are cause for concern, as they pose an increased risk to child and family health and well-being. Of interest to this research is the identification of deprivation levels similar to those found in areas of high deprivation, appearing in the dep 1-7 lower deprivation areas. Findings in this study indicate many of the risk factors generally associated with socioeconomic deprivation and disadvantage start to appear in dep 5 to 6 areas, but these are not covered by the funding contract. Care must be taken to ensure that clients with numerous risk factors living in these areas have their needs identified and addressed. Further investigation of this is required as increased numbers of risk factors equate to more intensive service delivery to address the presenting health needs in the 5-7 dep band.

Reviewing research findings

In reviewing the findings, there was some confusion about using a socio-ecological approach to health needs assessment (this includes a family's community and environmental contexts), and this can lead to inconsistency in assessment. While some nurses assessed needs according to the family's socio-ecological context, some assessed the child's developmental needs without relating these to the family context, and others assessed needs according to the service mode[ of how many contacts could be offered. Nurses in this Latter group were more likely to assess all first-time parents as medium needs, as first-time parents are funded to get more service contacts. Actual needs for this particular group, however, could be Low, medium or high. Consistency in health needs assessment between health practitioners is essential to fair and equitable provision of service. Education and support of consistent assessment practices should, therefore, be a high priority for well child services.

Despite international trends to develop lengthy assessment tools, many authors knowledgeable about primary health care nursing practice warn against developing specific assessment tools that restrict practice and client communication. (5,6,7) In this study, findings indicated that, instead of a needs assessment tool, a review of the current Plunket health record would be useful. A revised documentation tool that helps nurses communicate families' needs better, and meets Legal and quality documentation standard requirements, is desirable. Consideration of a format that allows identification of family capacity, risks, articulated and unarticulated needs, with space for relevant information and comments, could enable documentation to be completed while being cognisant of time restraints. Such a design feature would guide and prompt staff without being unnecessarily restrictive.

Health needs assessment is a fundamental nursing (and clinical) intervention that must occur, regardless of contractual obligations. It requires consideration of the family's situation, including social, financial, environmental, educational, cultural and political factors. Inherent in this intervention is the necessity to develop positive therapeutic relationships with clients, and to conduct assessment processes in a way that empowers clients to realise their capacity. Plunket's clinical adviser team continues to explore the issue of health needs assessment practices through research that examines trends in access to service, profiling practice examples where access has been successfully maintained, and analyses health outcomes to find how Plunket staff make a difference to the health and well-being of populations.

All children and families have needs and all needs matter. The consistent use of socio-ecological frameworks and capacity building approaches for health needs assessment will ensure all health needs will be identified. It will also ensure strategies to address health needs will be appropriate, contextual and effective.

This article was reviewed by Kai Tiaki Nursing New Zealand's editorial review committee in October 2005.

References

(1) Cowley, S. (2002) Public health in policy and practice: a source book for health visitors and community nurses. London: Harcourt Publishers.

(2) Salmond, C., & Crampton, P. (2001) NZDep96--what does it measure? Social Policy Journal of New Zealand. December, 82-101.

(3) Ministry of Health (2004) Child and Youth Health Toolkit. Downloaded May 2005. http://www.newhealth.govt.nz/toalkits/childhealth/ childandyouthhealthtoolkit.doc.

(4) Trout, F. The impact of geocoding in well child/tamariki ora health cure in New Zealand. Unpublished article.

(5) Cowley, S., Bergen, A., Young, K., & Kavanagh, A. (2000) A taxonomy of needs assessment, elicited from a multiple case study of community nursing education and practice. Journal of Advanced Nursing; 11, 640-650.

(6) Cowley, S., & Houston, A. (2003) A structured needs assessment tool: acceptability and effectiveness for health visiting. Journal of Advanced Nursing; 43: 1, 82-92.

(7) Mitcheson, J. & Cowley, S. (2003) Empowerment or control? An analysis of the extent to which client participation is enabled during health visitor/client interactions using a structured health needs assessment tool. International Journal of Nursing Studies; 40, 413-426.

Belinda Macfie, RN, BN, BSocSci, MMS, is clinical nurse director, primary, at the Waikato District Health Board. She wrote this article last year in her role as Midland clinical adviser for the Plunket Society.