Guidance

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

Updated 19 May 2021

Applies to England

Purpose

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)

• Outline questions should be devised in advance
• 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)
• Outline questions should be devised in advance
• Facilitator introduces topics for discussion

Other

• 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:

Needs	Person/Group 1 ranking	Person/Group 2 ranking	Person/Group 3 ranking	Total score	Overall priority
Obesity	3	2	1	6	2
Alcohol misuse	1	3	3	7	3
Teenage pregnancy	5	5	5	15	5
Mental health	2	1	2	5	1
Physical activity levels	4	4	4	12	4

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.

1. 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’
2. 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.
3. 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.

Reporting

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

Next steps

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.

Conclusion

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.