“So What?” History and Currency of

Needs Assessment in MCH as an Agent for

ChangeAMCHP Data Skills Session

MCH Epidemiology ConferenceDecember 7-8, 2008

Atlanta, GA

Public Health: MCH

• Public health is what we do collectively as a society to create those conditions in which we can be healthy

• Maternal and child health is a fundamental component of public health efforts worldwide

• Maternal and child health in the US seeks to promote the nation’s interest in improving the health and well-being of all children and their families

Public Health: MCH

• Focus is on the POPULATION• Emphasis is on PREVENTION• Orientation is toward the

COMMUNITY• Efforts are directed at SYSTEMS• Overarching role is one of

LEADERSHIP

Public Health Assessment

• As fundamental public health programs, MCH programs engage in the core functions of public health, as applied to these efforts to promote the health of MCH populations: – Assessment– Policy development– Assurance

Public Health Assessment

• “It is the responsibility of every public health agency to regularly and systematically collect, assemble, analyze and make available information on the health of the community, including statistics on health status, community health needs and epidemiologic and other studies of health problems”

IOM 1988 The Future of Public Health

MCH Essential Services

1. Assess and monitor MCH to identify and address problems2. Diagnose and investigate health problems and hazards3. Inform and educate the public and families about MCH issues4. Mobilize community partnerships between policymakers, health care providers, families, the general public to identify and solve MCH problems5. Provide leadership for priority-setting, planning and policy development to support community efforts

MCH Essential Services

6. Promote and enforce legal requirements

7. Link women, children and youth to health and other community and family services and assure access to comprehensive, quality systems of care

8. Assure the capacity and competency of the public health and personal health work force

9. Evaluate the effectiveness, accessibility and quality of personal health and population-based services

10. Support research and demonstrations

MCH Leadership

• We share the mission of public health but in many ways our task is both more intensive and more diffuse

• We are responsible, in some way, for every public health aspect of the lives of a large and often vulnerable population group

• Our successful advocacy and action for this population group can affect everyone

MCH Leadership

• MCH programs, with their tremendous responsibility and sweeping scope, must be meticulous in determining the best strategies for achieving the greatest outcomes with the fewest resources

• This means that program leaders must pay close and serious attention to each element of the assessment and planning process and monitor its progress and its success

MCH Assessment

• State Title V agencies are required to conduct comprehensive needs assessments every five years, to identify state MCH priorities, to arrange programmatic and policy activity around these priorities, and to develop state performance measures to monitor the success of their efforts

• MCH assessments are to be population-based and community-focused

MCH Assessment

• Assessment is not at all new to MCH• 1912 charter establishing the

Children’s Bureau states as its mission:“. . .to investigate and report upon

matters pertaining to the welfare of children and child life among all classes of people . . .”

• “investigate and report” = assessment!

MCH Assessment

• The nature of the mission of MCH “. . . to assure the health of all mothers and children . . .”

requires that MCH programs engage in ongoing monitoring and assessment of trends in population characteristics, health status indicators, risk factors, health system attributes, and the availability and accessibility of quality services for MCH populations

Get to Know your Tablemates

First Question:• Where were you in 1981? And why is

that year significant in the context of this discussion on needs assessment?

Second Question:• Where were you in 1989? And why is

that year significant in the context of this discussion on needs assessment?

1981: Block Grants

• In the spirit of state’s rights and “get the federal government off our backs” the old formula MCH funds were “blocked” with several MCH-related categorical programs and funds were awarded to each state based on its proportional share of the total amount of funding less 25%, because state’s were expected to make better decisions about how to spend their money

1981: Block Grants

• Because state’s were making their own decisions, there was no need for any federal interference or oversight

• So reporting requirements were removed as was the need for any real application

• So . . . add up the reduction in funds with the removal of any requirement to report data or submit a plan and what happened?

The 1980’s: The Dataless Decade

• No data, no problems!• The primary source of any

population data was vital records– Little surprise that the 1980’s was also

the decade of infant mortality reduction efforts

• Child advocates and an increasingly vocal group of parents of children with special health care needs demanded that this change

OBRA 89

• Major revision of the Block Grant legislation from 1981 to what you know and love today– Restored annual reporting

requirements– Restored the application (plan) process– Specified how funds were to be used– Required a comprehensive assessment

of need every five years– Etc, etc, etc

MCH Assessment

• Needs Assessment in MCH is essential to direct our decisions toward the most appropriate programs and policies to promote the health of women, children, adolescents, and children with special health care needs, and their families

• Needs Assessment in MCH is a fundamental element of any program planning activity

• Needs Assessment in MCH is about change

MCH Assessment and Planning

• Good!• Because MCH planning is also about

change– Changing direction– Changing efforts– Changing staffing– Changing resources– Changing outcomes– Changing lives

MCH Assessment and Planning

Needs Assessment is part of an ongoing planning cycle that enables us to

1. assess problems, needs, assets and strengths2. develop and implement solutions3. allocate resources4. evaluate activities5. monitor performance6. begin anew, back to #1

MCH Assessment

• Needs assessment is an inextricable part of planning and both are ongoing processes

• The five year needs assessment provides a point in time at which the process is revisited, constituents are re-engaged, plans and strategies are reassessed and a new course is charted based on newly analyzed information

• The plans that evolve from your assessment should also include focused assessment activities in the intervening years

MCH Needs Assessment

• We undertake needs assessments NOT– because “we have to”– to justify our current efforts– if we do not intend to act on the results

• We undertake needs assessments– because we recognize the dynamic

nature of MCH– because we wish to be good stewards of

the public’s trust– because we must address priorities

within limited resources

MCH Assessment

• Needs Assessments are data-driven because MCH, as part of public health, is science and evidence-based

• BUT, in recognition of the politics of policy-making, program development and resource allocation in public health, needs assessments must also engage and involve the community of interest, the stakeholders

MCH Assessment

MCH Needs Assessments bridge:

• The science and the politics• The data and the values of the

community• The needs and the strategies for

their solution

All within a comprehensive planning process that leads to change

MCH Data for Decision Making

• Essentially four sources of data for needs assessments:– Population-based data (vital records,

census)– Surveillance systems and survey data– Program or service data– Public forums or focus groups

• Assessment activities include identification of needs, assets and resource capacities across the state

MCH Data for Decision-Making

Population-based Data• Census• Vital Records

– Births– Deaths– Fetal Deaths– Abortions– Marriages, divorces, adoptions

MCH Data for Decision-Making

• Surveillance or Survey Data– Behavioral Risk Factor Surveillance System– Youth Risk Behavior Survey– SLAITS (children with special health care

needs)– PRAMS– Communicable Diseases– Registries– FIMR, Child Fatality Review – Specific surveys conducted for this or other

purposes

MCH Data for Decision-Making

• Program and Service Data– MCH programs that provide services

have data bases for program management purposes that can still provide important information for this needs assessment

– If services are funded via contract, contracted agencies are collecting service data that may be of interest

– Other sister programs and agencies will have data that may extend to a larger population that can be informative

MCH Data for Decision-Making

• Program and Service Data– Children with Special Health Care

Needs– Newborn Screening– WIC– Family Planning– School-based Clinics– Prenatal Clinics– Well-baby Clinics, Immunization

Programs– Lead Poisoning Prevention Programs

MCH Data for Decision-Making

• Program and Service Data– Disease Control– Chronic Disease Prevention– Injury Prevention– State Lab– Primary Care– Minority Health– Environmental Health– Facilities and Professional Licensure

MH Data for Decision-Making

• Program and Service Data– Medicaid– SCHIP– Education (special ed, lunch and breakfast

programs, graduation rates, enrollment, etc)– Social Services (child abuse and neglect,

adoption, foster care, child care, etc)– Mental Health and Substance Abuse– Justice (adult and juvenile)– Housing, Planning, Urban Affairs,

Transportation, etc

MCH Data for Decision-Making

Public Forums and Focus Groups• Town Meetings and Public Forums• Public Hearings• Focus Groups• Anecdotal Data

– Concerned citizens, complaints– Media reports, “Focusing” events– Elected officials

But is it Data?

• Yes, MCH is data-driven but because it is public health it must involve the community of interest because their wishes matter, sometimes more than the data!

• What stakeholders bring to the process is the reality check – what really matters to them?

• The assessment will have no credibility if it does not reflect what affected constituencies believe is important

Needs as Values

• Needs are value judgments that suggest that problems exist for specific population groups or in specific communities

• Needs, as reflections of our values, are subject to disagreement and debate

• For needs to be useful in policy and program planning there has to be agreement that they reflect real and important problems– Data and politics . . .

Involving Stakeholders

Who are “stakeholders”?• Anyone representing a group with a

particular interest in the process and its outcomes

• Anyone with a “stake” in the process and its outcomes, anyone with a vested interest (beware the conflicts of interest that will arise . . .)

• As needs assessment is about change, lots of folks will have something to say about the process and its outcomes . . .

Stakeholders as Partners

• Many of the needs you will identify “belong” to other agencies who may not share your population-, prevention-, systems philosophy

• Part of your leadership role is engaging other partner agencies to assume their own leadership roles with these issues – difficult to do

• Part of your job is figuring out who should take the lead on what issue

• Engaging them early and often can help

Involving StakeholdersStakeholders are essential in multiple

areas:• Helping identify the full scope of needs• Helping interpret available data or

collect new• Helping sort out priorities• Helping identify and select

solutions• Helping build awareness of your

program• Helping to build consensus• Helping advocate for needed changes• Supporting the overall efforts of the

larger program

Needs Assessment and Planning

• Needs assessment is not done until the priorities are established, the strategies have been identified, the program has been planned (with measurable objectives), the resources are allocated, and the state performance measures have been determined

• It is NOT sufficient to “complete” an assessment of need, bind it, and put it on a shelf

• You might as well have not done it at all• Remember, needs assessment is all

about change

Performance Measures

• The data you have gathered through your needs assessment, from which you determined your priorities, provides critical information from which to set measurable program objectives, which then allow you to evaluate your efforts

• State Performance Measures are one important tool we use to document our intent and ultimately evaluate our success

Resource Allocation

• The data you have gathered through your needs assessment, from which you have determined your priorities, also provides the basis from which to allocate resources, either to localities, if you have such a structure, or through any grants or contract mechanism you employ

• Per county? Per capita? Based on level of need? Based on capacity?

Organizational Structure and Work

• The priorities you identify from the needs assessment will shape your agenda for the next several years

• This should also cause you to consider changes in the nature of the work done within your offices and may necessitate structural changes in order to achieve the change desired in health status and outcomes

• The data can help you do this as well

Evaluation• The monitoring and evaluation

strategy should be designed at the time you are devising the program strategy

• Measurable objectives for each area of activity and level of effort must be developed– Specific, time-framed and measurable

• Data systems are needed for monitoring process, intermediate outcome and ultimate outcome objectives

• Establish timeframes for evaluation reports

“So What?”

• Basing our efforts on the evidence is part of our heritage and one of the great legacies left us by the leaders of the Children’s Bureau

• Seriously engaging the data AND the community provides you incredibly important “strength in numbers”, both of which can help you realize your vision and bring your plans to reality

“So What?”

• As leaders in your states, you must manage this large planning effort in recognition of the inter-related nature of each of these efforts

• You can delegate tasks, but they must be managed collectively and with a great deal of communication, support and celebration

• Needs assessment is not a data exercise, it is a leadership exercise (perhaps a survival exercise!)

• Maybe, needs assessment is about change

“So What?”

• It is to be expected that you will need resources, authority, direction from your legislatures and perhaps even internally within your agency to effect the change you seek

• It’s very hard to argue with the powerful combination of data and public advocacy

• Good needs assessments can set you free to succeed!