health needs assignment

Health Needs Assessment

• First Online: 27 April 2016

Cite this chapter

• Patrick Tobi 3  

4248 Accesses

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.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

• Available as PDF
• Read on any device
• Instant download
• Own it forever
• Available as EPUB and PDF
• Compact, lightweight edition
• Dispatched in 3 to 5 business days
• Free shipping worldwide - see info
• Durable hardcover edition

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

Community Needs Assessment: Bringing Real Voices to the Health Care System

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

People-Centered Public Health

Bradshaw, J. R. (1972). The taxonomy of social need. In G. McLachlan (Ed.), Problems and progress in medical care . Oxford: Oxford University Press.

Google Scholar  

Bradshaw, J. (1994). The conceptualisation and measurement of need: A social policy perspective. In J. Popay & G. Williams (Eds.), Researching the people’s health (pp. 45–57). London: Routledge.

Cavanagh, S., & Chadwick, K. (2005). Health needs assessment: A practical guide . London: National Institute for Health and Clinical Excellence.

Dahlgren, G., & Whitehead, M. (1991). Policies and strategies to promote social equity in health . Stockholm: Institute for Future Studies.

Department of Health. (2007). Guidance on joint strategic needs assessment . London: DoH.

Elkheir, R. (2007). Health needs assessment: A practical approach . Retrieved September 29, 2015, from http://www.sjph.net.sd/files/vol2i2p81-88.pdf.

Hooper, J., & Longworth, P. (2002). Health needs assessment workbook . London: Health Development Agency.

Powell, J. (2006). Health needs assessment: A systematic approach . London: National Library for Health.

Quigley, R., Cavanagh, S., Harrison, D., Taylor, L., & Pottle, M. (2005). Clarifying approaches to assessment: Health needs assessment, health impact assessment, integrated impact assessment, health equity audit, and race equality impact assessment . London: Health Development Agency.

Rogers, C., & Fox, R. (2005). Health needs assessment . Wales: National Public Health Service for Wales.

Stevens, A., & Gillam, S. (1998). Needs assessment: From theory to practice. British Medical Journal, 316 , 1448–1452.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Stevens, A., & Rafferty, J. (1994, 1997). Health care needs assessment: The epidemiologically based needs assessment reviews . Vol. 1 and 2. Oxford: Radcliffe Medical Press.

Stevens, A. J., & Rafferty, J. (1997). Health care needs assessment . Oxford: Radcliffe.

Stevens, A., Raftery, J., Mant, J., & Simpson, S. (2004). Health care needs assessment: The epidemiologically based needs assessment reviews (Vol. 1 and 2). Oxford: Radcliffe Medical Press.

Williams, R., & Wright, J. (1998). Epidemiological issues in health needs assessment. British Medical Journal, 316 , 1379–1382.

Wright, J. (2001). Assessing health needs. In D. Pencheon (Ed.), Oxford handbook of public health practice . Oxford: Oxford University Press.

Recommended Reading

Download references

Author information

Authors and affiliations.

Institute for Health and Human Development, University of East London, Water Lane, Stratford, UK

Patrick Tobi

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Patrick Tobi .

Editor information

Editors and affiliations.

University of Bedfordshire, Luton, United Kingdom

Krishna Regmi

Liverpool John Moores University, Liverpool, United Kingdom

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

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

Download citation

DOI : https://doi.org/10.1007/978-3-319-28326-5_9

Published : 27 April 2016

Publisher Name : Springer, Cham

Print ISBN : 978-3-319-28324-1

Online ISBN : 978-3-319-28326-5

eBook Packages : Medicine Medicine (R0)

Share this chapter

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Publish with us

Policies and ethics

• Find a journal
• Track your research

Cookies on GOV.UK

We use some essential cookies to make this website work.

We’d like to set additional cookies to understand how you use GOV.UK, remember your settings and improve government services.

We also use cookies set by other sites to help us deliver content from their services.

You have accepted additional cookies. You can change your cookie settings at any time.

You have rejected additional cookies. You can change your cookie settings at any time.

Register to vote Register by 18 June to vote in the General Election on 4 July.

• 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] .

Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.

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.

Is this page useful?

• Yes this page is useful
• No this page is not useful

Help us improve GOV.UK

Don’t include personal or financial information like your National Insurance number or credit card details.

To help us improve GOV.UK, we’d like to know more about your visit today. Please fill in this survey (opens in a new tab) .

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

Related Content

Preparing children with special healthcare needs for transition of care .

Transitioning from pediatric to adult care can be challenging for any young person, but those challenges are often amplified for children with special healthcare needs. Two young adults with complex medical conditions share their experience with transitioning from pediatric to adult care. 

TRANSCRIPT | Connecting Infant and Maternal Health Outcomes – Prematurity Awareness Month

 Our main story this episode highlights he links between maternal and infant health, and the impacts of preterm birth on health outcomes for mothers, birthing people, and babies. Hear from NICHQ VP of Equity and Innovation Dr. Stacy Scott, Ph.D. D, MPA, who shares some equity considerations regarding disparate rates of preterm birth, infant mortality, and maternal mortality. Dr. Zsakeba Henderson, MD, FACOG, NICHQ’s senior health advisor, also connects the impact of maternal health on infant health outcomes while shining a light on the U.S. maternal mortality crisis and current policy initiatives that can help reverse maternal mortality trends.  

TRANSCRIPT | Sickle Cell Awareness Month: Transitioning to College, Equity Considerations, and Resource Sharing

 Our main story this episode highlights the need for resources for people living with sickle cell disease and strategies for transitioning from pediatric to adult care. We also reflect on National Infant Mortality Awareness Month and hear from NICHQ team member about connecting their personal and professional passion for equity. Thanks for joining us!

For our main story in this episode we are joined by Summer 2023 NICHQ Communications & Digital Strategy interns Amalia Hirschhorn-Martinez and Katie McCormick. They speak with members of the NICHQ team about our upcoming webinar focused on infant safe sleep and breastfeeding messaging and NICHQ’s continued work to ensure health professionals and the communities they serve are supported with the necessary tools and resources to create safe sleeping environments and improve breastfeeding and chestfeeding rates. 

Inviting and Engaging Family Partners in Your Work

Patient and family partnerships are an essential element of health equity. By supporting patient and family voices and encouraging space for collaboration, public health professionals can help ensure shared vision and values are at the forefront of determining solutions to improve a community’s health outcomes.

Importance of Engaging Fathers in MCH Initiatives

Evidence demonstrates that fathers play a critical role in children’s health and development, beginning in the prenatal period and continuing through early childhood and adolescence. On this episode of Before Birth & Beyond, NICHQ honors Men's Health Month and Father's Day, both celebrated in June, by sitting down with two Black fatherhood experts to discuss the importance of including fathers in maternal and child health work, policy considerations to improve father engagement, and men's mental health and its impact on outcomes for children and families.

National Center for Rural Health Works

Improving the Health of Rural Communities

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

Health Needs Assessment

Ai generator.

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

1. community health needs assessment.

Size: 268 KB

2. Health Needs Assessment Template

Size: 90 KB

3. Health Needs Assessment Form

Size: 44 KB

4. Basic Health Needs Assessment

5. Public Health Needs Assessment

Size: 582 KB

6. Population Needs Assessment for Health

Size: 86 KB

7. Health Needs Assessment Report

8. Rural Health Needs Assessment

9. Health Needs Assessment Questionnaire

Size: 338 KB

10. Health Care Needs Assessment

Size: 473 KB

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.

Text prompt

• Instructive
• Professional

10 Examples of Public speaking

20 Examples of Gas lighting

Ohio State nav bar

The Ohio State University

• BuckeyeLink
• Find People
• Search Ohio State

Twinning implementation needs assessment published

Veterinarians are essential partners in advancing One Health and helping to ensure communities have food security, nutrition, poverty alleviation and global health security. Strengthening the capacity of veterinary services can ultimately safeguard animal and human health, grow economies and improve lives, and is a priority for the international community.

To improve the quality of veterinary education in Ethiopia, the colleges of veterinary medicine at Ohio State and the University of Gondar partnered in 2015 to develop and implement a curriculum that would provide graduating veterinarians with the skills that aligned with the World Organization for Animal Health (WOAH) recommendations. Launched in 2017, this new curriculum sought to improve the quality of veterinary education establishments (VEEs) and was the first of its kind in Africa.

In November 2020, Ethiopia’s Ministry of Education approved the University of Gondar College of Veterinary Medicine and Animal Science’s curriculum as the benchmark for a new national curriculum to be adopted by all Ethiopian veterinary education establishments (VEEs).

Andrea Bessler, a veterinary public health resident at Ohio State, recently dived into the veterinary medicine curriculum in Ethiopia to conduct a needs assessment and evaluate the curriculum implementation. Results of the study are published on the Frontiers in Veterinary Science website in an article co-authored by Amanda Berrian, GOHi director of outreach and engagement and Armando Hoet, GOHi faculty advisory committee member, among others from Ohio State and the University of Gondar in Ethiopia.

This publication shares the needs assessment results, evaluating the curriculum implementation among 14 veterinary programs representing 93% of eligible programs nationwide. The purpose was to identify barriers and challenges Ethiopian veterinary medicine programs have faced while implementing the new curriculum.

Results found that key challenges with the new curriculum included the organization of veterinary services, inspection and certification procedures and practical applications of the regulatory framework for disease prevention and control. Instructional methodologies, particularly facilitating off-site student training, were also perceived as barriers. The focus group discussions identified challenges, including limitations in faculty expertise, resource constraints and limited access to off-site facilities for hands-on teaching. The focus group also noted the shortage of teaching materials/supplies for hands-on application.

Though some VEEs indicated leveraging key partnerships on and off campus as a strength, most identified it as a limitation, indicating an increasing need for capacity building through collaborations with national ministries, international agencies, public-private partnerships, academic institutions, One Health networks and donor organizations.

The results will be presented at a multi-stakeholder national workshop. Participants will discuss and prioritize solutions to the challenges identified in the needs assessment and condense them into a comprehensive action plan to modify the national curriculum.

Date: 5/29/2024 12:00:00 AM

Unit: System.String[]

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• BMC Health Serv Res

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

Hamid ravaghi.

1 Department of Universal Health Coverage/Health Systems (UHS), World Health Organization, Regional Office for the Eastern Mediterranean, Cairo, Egypt

Ann-Lise Guisset

2 Department of Integrated Health Services (IHS), World Health Organization, Headquarters, Geneva, Switzerland

Samar Elfeky

3 Department of Healthier Populations (DHP), World Health Organization, Regional Office of Eastern Mediterranean Region, Cairo, Egypt

Naima Nasir

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

Sedigheh Khani

5 National library and Archives of Iran, Tehran, Iran

Elham Ahmadnezhad

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

Zhaleh Abdi

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

Associated Data

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

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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08983-3.

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 – 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 – 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 – 30 ], impoverished urban sectors [ 31 ], the homeless [ 32 – 35 ], persons in poverty or of low socioeconomic status, vulnerable children and families [ 18 , 28 , 36 – 38 ], the elderly [ 8 , 39 – 42 ], women and girls [ 43 – 47 ], LGBT (Lesbian, gay, bisexual, and transgender) individuals [ 48 – 51 ], displaced populations, immigrants and racial, ethnic and religious minority groups [ 12 , 19 , 36 , 42 , 52 – 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 – 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 – 97 , 99 – 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 – 99 , 101 – 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 – 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 – 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 – 23 , 27 , 29 , 31 , 36 , 41 , 43 , 49 , 53 , 55 , 56 , 58 – 60 , 62 , 63 , 68 , 70 , 74 , 86 – 88 , 90 , 92 , 99 , 100 , 103 , 104 , 110 , 114 , 117 – 119 , 121 – 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 – 50 , 52 , 54 , 55 , 62 , 64 – 66 , 69 – 73 , 76 – 78 , 85 , 96 , 106 , 122 , 123 , 131 – 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 ​ (Table1). 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.

Depth of participation by assessment and planning activity type

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.

Acknowledgements

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

Authors’ 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.

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.

Availability of data and materials

Declarations.

Not applicable.

The authors have no competing interests. The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the World Health Organization (WHO).

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

• Search Menu

Sign in through your institution

• Browse content in Arts and Humanities
• Browse content in Archaeology
• Anglo-Saxon and Medieval Archaeology
• Archaeological Methodology and Techniques
• Archaeology by Region
• Archaeology of Religion
• Archaeology of Trade and Exchange
• Biblical Archaeology
• Contemporary and Public Archaeology
• Environmental Archaeology
• Historical Archaeology
• History and Theory of Archaeology
• Industrial Archaeology
• Landscape Archaeology
• Mortuary Archaeology
• Prehistoric Archaeology
• Underwater Archaeology
• Zooarchaeology
• Browse content in Architecture
• Architectural Structure and Design
• History of Architecture
• Residential and Domestic Buildings
• Theory of Architecture
• Browse content in Art
• Art Subjects and Themes
• History of Art
• Industrial and Commercial Art
• Theory of Art
• Biographical Studies
• Byzantine Studies
• Browse content in Classical Studies
• Classical Literature
• Classical Reception
• Classical History
• Classical Philosophy
• Classical Mythology
• Classical Art and Architecture
• Classical Oratory and Rhetoric
• Greek and Roman Archaeology
• Greek and Roman Epigraphy
• Greek and Roman Law
• Greek and Roman Papyrology
• Late Antiquity
• Religion in the Ancient World
• Digital Humanities
• Browse content in History
• Colonialism and Imperialism
• Diplomatic History
• Environmental History
• Genealogy, Heraldry, Names, and Honours
• Genocide and Ethnic Cleansing
• Historical Geography
• History by Period
• History of Agriculture
• History of Education
• History of Emotions
• History of Gender and Sexuality
• Industrial History
• Intellectual History
• International History
• Labour History
• Legal and Constitutional History
• Local and Family History
• Maritime History
• Military History
• National Liberation and Post-Colonialism
• Oral History
• Political History
• Public History
• Regional and National History
• Revolutions and Rebellions
• Slavery and Abolition of Slavery
• Social and Cultural History
• Theory, Methods, and Historiography
• Urban History
• World History
• Browse content in Language Teaching and Learning
• Language Learning (Specific Skills)
• Language Teaching Theory and Methods
• Browse content in Linguistics
• Applied Linguistics
• Cognitive Linguistics
• Computational Linguistics
• Forensic Linguistics
• Grammar, Syntax and Morphology
• Historical and Diachronic Linguistics
• History of English
• Language Variation
• Language Families
• Language Acquisition
• Language Evolution
• Language Reference
• Lexicography
• Linguistic Theories
• Linguistic Typology
• Linguistic Anthropology
• Phonetics and Phonology
• Psycholinguistics
• Sociolinguistics
• Translation and Interpretation
• Writing Systems
• Browse content in Literature
• Bibliography
• Children's Literature Studies
• Literary Studies (Modernism)
• Literary Studies (Asian)
• Literary Studies (European)
• Literary Studies (Eco-criticism)
• Literary Studies (Romanticism)
• Literary Studies (American)
• Literary Studies - World
• Literary Studies (1500 to 1800)
• Literary Studies (19th Century)
• Literary Studies (20th Century onwards)
• Literary Studies (African American Literature)
• Literary Studies (British and Irish)
• Literary Studies (Early and Medieval)
• Literary Studies (Fiction, Novelists, and Prose Writers)
• Literary Studies (Gender Studies)
• Literary Studies (Graphic Novels)
• Literary Studies (History of the Book)
• Literary Studies (Plays and Playwrights)
• Literary Studies (Poetry and Poets)
• Literary Studies (Postcolonial Literature)
• Literary Studies (Queer Studies)
• Literary Studies (Science Fiction)
• Literary Studies (Travel Literature)
• Literary Studies (War Literature)
• Literary Studies (Women's Writing)
• Literary Theory and Cultural Studies
• Mythology and Folklore
• Shakespeare Studies and Criticism
• Browse content in Media Studies
• Browse content in Music
• Applied Music
• Dance and Music
• Ethics in Music
• Ethnomusicology
• Gender and Sexuality in Music
• Medicine and Music
• Music Cultures
• Music and Culture
• Music and Religion
• Music and Media
• Music Education and Pedagogy
• Music Theory and Analysis
• Musical Scores, Lyrics, and Libretti
• Musical Structures, Styles, and Techniques
• Musicology and Music History
• Performance Practice and Studies
• Race and Ethnicity in Music
• Sound Studies
• Browse content in Performing Arts
• Browse content in Philosophy
• Aesthetics and Philosophy of Art
• Epistemology
• Feminist Philosophy
• History of Western Philosophy
• Metaphysics
• Moral Philosophy
• Non-Western Philosophy
• Philosophy of Action
• Philosophy of Law
• Philosophy of Religion
• Philosophy of Science
• Philosophy of Language
• Philosophy of Mind
• Philosophy of Perception
• Philosophy of Mathematics and Logic
• Practical Ethics
• Social and Political Philosophy
• Browse content in Religion
• Biblical Studies
• Christianity
• East Asian Religions
• History of Religion
• Judaism and Jewish Studies
• Qumran Studies
• Religion and Education
• Religion and Health
• Religion and Politics
• Religion and Science
• Religion and Law
• Religion and Art, Literature, and Music
• Religious Studies
• Browse content in Society and Culture
• Cookery, Food, and Drink
• Cultural Studies
• Customs and Traditions
• Ethical Issues and Debates
• Hobbies, Games, Arts and Crafts
• Natural world, Country Life, and Pets
• Popular Beliefs and Controversial Knowledge
• Sports and Outdoor Recreation
• Technology and Society
• Travel and Holiday
• Visual Culture
• Browse content in Law
• Arbitration
• Browse content in Company and Commercial Law
• Commercial Law
• Company Law
• Browse content in Comparative Law
• Systems of Law
• Competition Law
• Browse content in Constitutional and Administrative Law
• Government Powers
• Judicial Review
• Local Government Law
• Military and Defence Law
• Parliamentary and Legislative Practice
• Construction Law
• Contract Law
• Browse content in Criminal Law
• Criminal Procedure
• Criminal Evidence Law
• Sentencing and Punishment
• Employment and Labour Law
• Environment and Energy Law
• Browse content in Financial Law
• Banking Law
• Insolvency Law
• History of Law
• Human Rights and Immigration
• Intellectual Property Law
• Browse content in International Law
• Private International Law and Conflict of Laws
• Public International Law
• IT and Communications Law
• Jurisprudence and Philosophy of Law
• Law and Society
• Law and Politics
• Browse content in Legal System and Practice
• Courts and Procedure
• Legal Skills and Practice
• Primary Sources of Law
• Regulation of Legal Profession
• Medical and Healthcare Law
• Browse content in Policing
• Criminal Investigation and Detection
• Police and Security Services
• Police Procedure and Law
• Police Regional Planning
• Browse content in Property Law
• Personal Property Law
• Study and Revision
• Terrorism and National Security Law
• Browse content in Trusts Law
• Wills and Probate or Succession
• Browse content in Medicine and Health
• Browse content in Allied Health Professions
• Arts Therapies
• Clinical Science
• Dietetics and Nutrition
• Occupational Therapy
• Operating Department Practice
• Physiotherapy
• Radiography
• Speech and Language Therapy
• Browse content in Anaesthetics
• General Anaesthesia
• Neuroanaesthesia
• Browse content in Clinical Medicine
• Acute Medicine
• Cardiovascular Medicine
• Clinical Genetics
• Clinical Pharmacology and Therapeutics
• Dermatology
• Endocrinology and Diabetes
• Gastroenterology
• Genito-urinary Medicine
• Geriatric Medicine
• Infectious Diseases
• Medical Oncology
• Medical Toxicology
• Pain Medicine
• Palliative Medicine
• Rehabilitation Medicine
• Respiratory Medicine and Pulmonology
• Rheumatology
• Sleep Medicine
• Sports and Exercise Medicine
• Clinical Neuroscience
• Community Medical Services
• Critical Care
• Emergency Medicine
• Forensic Medicine
• Haematology
• History of Medicine
• Medical Ethics
• Browse content in Medical Dentistry
• Oral and Maxillofacial Surgery
• Paediatric Dentistry
• Restorative Dentistry and Orthodontics
• Surgical Dentistry
• Browse content in Medical Skills
• Clinical Skills
• Communication Skills
• Nursing Skills
• Surgical Skills
• Medical Statistics and Methodology
• Browse content in Neurology
• Clinical Neurophysiology
• Neuropathology
• Nursing Studies
• Browse content in Obstetrics and Gynaecology
• Gynaecology
• Occupational Medicine
• Ophthalmology
• Otolaryngology (ENT)
• Browse content in Paediatrics
• Neonatology
• Browse content in Pathology
• Chemical Pathology
• Clinical Cytogenetics and Molecular Genetics
• Histopathology
• Medical Microbiology and Virology
• Patient Education and Information
• Browse content in Pharmacology
• Psychopharmacology
• Browse content in Popular Health
• Caring for Others
• Complementary and Alternative Medicine
• Self-help and Personal Development
• Browse content in Preclinical Medicine
• Cell Biology
• Molecular Biology and Genetics
• Reproduction, Growth and Development
• Primary Care
• Professional Development in Medicine
• Browse content in Psychiatry
• Addiction Medicine
• Child and Adolescent Psychiatry
• Forensic Psychiatry
• Learning Disabilities
• Old Age Psychiatry
• Psychotherapy
• Browse content in Public Health and Epidemiology
• Epidemiology
• Public Health
• Browse content in Radiology
• Clinical Radiology
• Interventional Radiology
• Nuclear Medicine
• Radiation Oncology
• Reproductive Medicine
• Browse content in Surgery
• Cardiothoracic Surgery
• Gastro-intestinal and Colorectal Surgery
• General Surgery
• Neurosurgery
• Paediatric Surgery
• Peri-operative Care
• Plastic and Reconstructive Surgery
• Surgical Oncology
• Transplant Surgery
• Trauma and Orthopaedic Surgery
• Vascular Surgery
• Browse content in Science and Mathematics
• Browse content in Biological Sciences
• Aquatic Biology
• Biochemistry
• Bioinformatics and Computational Biology
• Developmental Biology
• Ecology and Conservation
• Evolutionary Biology
• Genetics and Genomics
• Microbiology
• Molecular and Cell Biology
• Natural History
• Plant Sciences and Forestry
• Research Methods in Life Sciences
• Structural Biology
• Systems Biology
• Zoology and Animal Sciences
• Browse content in Chemistry
• Analytical Chemistry
• Computational Chemistry
• Crystallography
• Environmental Chemistry
• Industrial Chemistry
• Inorganic Chemistry
• Materials Chemistry
• Medicinal Chemistry
• Mineralogy and Gems
• Organic Chemistry
• Physical Chemistry
• Polymer Chemistry
• Study and Communication Skills in Chemistry
• Theoretical Chemistry
• Browse content in Computer Science
• Artificial Intelligence
• Computer Architecture and Logic Design
• Game Studies
• Human-Computer Interaction
• Mathematical Theory of Computation
• Programming Languages
• Software Engineering
• Systems Analysis and Design
• Virtual Reality
• Browse content in Computing
• Business Applications
• Computer Games
• Computer Security
• Computer Networking and Communications
• Digital Lifestyle
• Graphical and Digital Media Applications
• Operating Systems
• Browse content in Earth Sciences and Geography
• Atmospheric Sciences
• Environmental Geography
• Geology and the Lithosphere
• Maps and Map-making
• Meteorology and Climatology
• Oceanography and Hydrology
• Palaeontology
• Physical Geography and Topography
• Regional Geography
• Soil Science
• Urban Geography
• Browse content in Engineering and Technology
• Agriculture and Farming
• Biological Engineering
• Civil Engineering, Surveying, and Building
• Electronics and Communications Engineering
• Energy Technology
• Engineering (General)
• Environmental Science, Engineering, and Technology
• History of Engineering and Technology
• Mechanical Engineering and Materials
• Technology of Industrial Chemistry
• Transport Technology and Trades
• Browse content in Environmental Science
• Applied Ecology (Environmental Science)
• Conservation of the Environment (Environmental Science)
• Environmental Sustainability
• Environmentalist Thought and Ideology (Environmental Science)
• Management of Land and Natural Resources (Environmental Science)
• Natural Disasters (Environmental Science)
• Nuclear Issues (Environmental Science)
• Pollution and Threats to the Environment (Environmental Science)
• Social Impact of Environmental Issues (Environmental Science)
• History of Science and Technology
• Browse content in Materials Science
• Ceramics and Glasses
• Composite Materials
• Metals, Alloying, and Corrosion
• Nanotechnology
• Browse content in Mathematics
• Applied Mathematics
• Biomathematics and Statistics
• History of Mathematics
• Mathematical Education
• Mathematical Finance
• Mathematical Analysis
• Numerical and Computational Mathematics
• Probability and Statistics
• Pure Mathematics
• Browse content in Neuroscience
• Cognition and Behavioural Neuroscience
• Development of the Nervous System
• Disorders of the Nervous System
• History of Neuroscience
• Invertebrate Neurobiology
• Molecular and Cellular Systems
• Neuroendocrinology and Autonomic Nervous System
• Neuroscientific Techniques
• Sensory and Motor Systems
• Browse content in Physics
• Astronomy and Astrophysics
• Atomic, Molecular, and Optical Physics
• Biological and Medical Physics
• Classical Mechanics
• Computational Physics
• Condensed Matter Physics
• Electromagnetism, Optics, and Acoustics
• History of Physics
• Mathematical and Statistical Physics
• Measurement Science
• Nuclear Physics
• Particles and Fields
• Plasma Physics
• Quantum Physics
• Relativity and Gravitation
• Semiconductor and Mesoscopic Physics
• Browse content in Psychology
• Affective Sciences
• Clinical Psychology
• Cognitive Neuroscience
• Cognitive Psychology
• Criminal and Forensic Psychology
• Developmental Psychology
• Educational Psychology
• Evolutionary Psychology
• Health Psychology
• History and Systems in Psychology
• Music Psychology
• Neuropsychology
• Organizational Psychology
• Psychological Assessment and Testing
• Psychology of Human-Technology Interaction
• Psychology Professional Development and Training
• Research Methods in Psychology
• Social Psychology
• Browse content in Social Sciences
• Browse content in Anthropology
• Anthropology of Religion
• Human Evolution
• Medical Anthropology
• Physical Anthropology
• Regional Anthropology
• Social and Cultural Anthropology
• Theory and Practice of Anthropology
• Browse content in Business and Management
• Business History
• Business Strategy
• Business Ethics
• Business and Government
• Business and Technology
• Business and the Environment
• Comparative Management
• Corporate Governance
• Corporate Social Responsibility
• Entrepreneurship
• Health Management
• Human Resource Management
• Industrial and Employment Relations
• Industry Studies
• Information and Communication Technologies
• International Business
• Knowledge Management
• Management and Management Techniques
• Operations Management
• Organizational Theory and Behaviour
• Pensions and Pension Management
• Public and Nonprofit Management
• Strategic Management
• Supply Chain Management
• Browse content in Criminology and Criminal Justice
• Criminal Justice
• Criminology
• Forms of Crime
• International and Comparative Criminology
• Youth Violence and Juvenile Justice
• Development Studies
• Browse content in Economics
• Agricultural, Environmental, and Natural Resource Economics
• Asian Economics
• Behavioural Finance
• Behavioural Economics and Neuroeconomics
• Econometrics and Mathematical Economics
• Economic Methodology
• Economic Systems
• Economic History
• Economic Development and Growth
• Financial Markets
• Financial Institutions and Services
• General Economics and Teaching
• Health, Education, and Welfare
• History of Economic Thought
• International Economics
• Labour and Demographic Economics
• Law and Economics
• Macroeconomics and Monetary Economics
• Microeconomics
• Public Economics
• Urban, Rural, and Regional Economics
• Welfare Economics
• Browse content in Education
• Adult Education and Continuous Learning
• Care and Counselling of Students
• Early Childhood and Elementary Education
• Educational Equipment and Technology
• Educational Strategies and Policy
• Higher and Further Education
• Organization and Management of Education
• Philosophy and Theory of Education
• Schools Studies
• Secondary Education
• Teaching of a Specific Subject
• Teaching of Specific Groups and Special Educational Needs
• Teaching Skills and Techniques
• Browse content in Environment
• Applied Ecology (Social Science)
• Climate Change
• Conservation of the Environment (Social Science)
• Environmentalist Thought and Ideology (Social Science)
• Natural Disasters (Environment)
• Social Impact of Environmental Issues (Social Science)
• Browse content in Human Geography
• Cultural Geography
• Economic Geography
• Political Geography
• Browse content in Interdisciplinary Studies
• Communication Studies
• Museums, Libraries, and Information Sciences
• Browse content in Politics
• African Politics
• Asian Politics
• Chinese Politics
• Comparative Politics
• Conflict Politics
• Elections and Electoral Studies
• Environmental Politics
• European Union
• Foreign Policy
• Gender and Politics
• Human Rights and Politics
• Indian Politics
• International Relations
• International Organization (Politics)
• International Political Economy
• Irish Politics
• Latin American Politics
• Middle Eastern Politics
• Political Theory
• Political Methodology
• Political Communication
• Political Philosophy
• Political Sociology
• Political Behaviour
• Political Economy
• Political Institutions
• Politics and Law
• Politics of Development
• Public Administration
• Public Policy
• Quantitative Political Methodology
• Regional Political Studies
• Russian Politics
• Security Studies
• State and Local Government
• UK Politics
• US Politics
• Browse content in Regional and Area Studies
• African Studies
• Asian Studies
• East Asian Studies
• Japanese Studies
• Latin American Studies
• Middle Eastern Studies
• Native American Studies
• Scottish Studies
• Browse content in Research and Information
• Research Methods
• Browse content in Social Work
• Addictions and Substance Misuse
• Adoption and Fostering
• Care of the Elderly
• Child and Adolescent Social Work
• Couple and Family Social Work
• Direct Practice and Clinical Social Work
• Emergency Services
• Human Behaviour and the Social Environment
• International and Global Issues in Social Work
• Mental and Behavioural Health
• Social Justice and Human Rights
• Social Policy and Advocacy
• Social Work and Crime and Justice
• Social Work Macro Practice
• Social Work Practice Settings
• Social Work Research and Evidence-based Practice
• Welfare and Benefit Systems
• Browse content in Sociology
• Childhood Studies
• Community Development
• Comparative and Historical Sociology
• Economic Sociology
• Gender and Sexuality
• Gerontology and Ageing
• Health, Illness, and Medicine
• Marriage and the Family
• Migration Studies
• Occupations, Professions, and Work
• Organizations
• Population and Demography
• Race and Ethnicity
• Social Theory
• Social Movements and Social Change
• Social Research and Statistics
• Social Stratification, Inequality, and Mobility
• Sociology of Religion
• Sociology of Education
• Sport and Leisure
• Urban and Rural Studies
• Browse content in Warfare and Defence
• Defence Strategy, Planning, and Research
• Land Forces and Warfare
• Military Administration
• Military Life and Institutions
• Naval Forces and Warfare
• Other Warfare and Defence Issues
• Peace Studies and Conflict Resolution
• Weapons and Equipment

• < Previous chapter
• Next chapter >

11.1 Health needs assessment

• Published: November 2021
• Cite Icon Cite
• Permissions Icon Permissions

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.

Signed in as

Institutional accounts.

• Google Scholar Indexing
• GoogleCrawler [DO NOT DELETE]

Personal account

• Sign in with email/username & password
• Get email alerts
• Save searches
• Purchase content
• Activate your purchase/trial code
• Add your ORCID iD

Institutional access

Sign in with a library card.

• Sign in with username/password
• Recommend to your librarian
• Institutional account management
• Get help with access

Access to content on Oxford Academic is often provided through institutional subscriptions and purchases. If you are a member of an institution with an active account, you may be able to access content in one of the following ways:

IP based access

Typically, access is provided across an institutional network to a range of IP addresses. This authentication occurs automatically, and it is not possible to sign out of an IP authenticated account.

Choose this option to get remote access when outside your institution. Shibboleth/Open Athens technology is used to provide single sign-on between your institution’s website and Oxford Academic.

• Click Sign in through your institution.
• Select your institution from the list provided, which will take you to your institution's website to sign in.
• When on the institution site, please use the credentials provided by your institution. Do not use an Oxford Academic personal account.
• Following successful sign in, you will be returned to Oxford Academic.

If your institution is not listed or you cannot sign in to your institution’s website, please contact your librarian or administrator.

Enter your library card number to sign in. If you cannot sign in, please contact your librarian.

Society Members

Society member access to a journal is achieved in one of the following ways:

Sign in through society site

Many societies offer single sign-on between the society website and Oxford Academic. If you see ‘Sign in through society site’ in the sign in pane within a journal:

• Click Sign in through society site.
• When on the society site, please use the credentials provided by that society. Do not use an Oxford Academic personal account.

If you do not have a society account or have forgotten your username or password, please contact your society.

Sign in using a personal account

Some societies use Oxford Academic personal accounts to provide access to their members. See below.

A personal account can be used to get email alerts, save searches, purchase content, and activate subscriptions.

Some societies use Oxford Academic personal accounts to provide access to their members.

Viewing your signed in accounts

Click the account icon in the top right to:

• View your signed in personal account and access account management features.
• View the institutional accounts that are providing access.

Signed in but can't access content

Oxford Academic is home to a wide variety of products. The institutional subscription may not cover the content that you are trying to access. If you believe you should have access to that content, please contact your librarian.

For librarians and administrators, your personal account also provides access to institutional account management. Here you will find options to view and activate subscriptions, manage institutional settings and access options, access usage statistics, and more.

Our books are available by subscription or purchase to libraries and institutions.

• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Rights and permissions
• Accessibility
• Advertising
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

• Kansas State University
• K-State Online

Status of ITS resources

• » K-State Research and Extension
• » KSRE Tuesday Letter
• » National Needs Assessment: Please Complete!

KSRE Tuesday Letter

• Current Issue

Other publications

• Kansas 4-H Tip Sheet

May 28, 2024

• National Needs Assessment: Please Complete!

Submitted by Erin Martinez

The North Central Region Aging Network (NCRAN), a network of Extension specialists and educators supporting programming efforts on aging-related topics, is conducting an online needs assessment survey. This 10 minute survey is designed to be taken by all Extension educators, specialists, and administrators across the United States, regardless of areas of focus (i.e., 4-H, agriculture, community development, family & consumer sciences). The goal of the survey is to inform and guide aging-related work and professional development within the national Cooperative Extension System.

Twenty participants will be randomly selected to receive a $50 amazon.com gift card. To be eligible, you must complete the survey by May 31st, 2024.

To complete the survey, please click here . It is recommended that you use a tablet or computer rather than a smart phone.

Thank you for your participation!

The North Central Region Aging Network

For questions or comments, please contact Dr. Erin Martinez, project lead, [email protected] . The full survey link is: https://kstate.qualtrics.com/jfe/form/SV_086hdKDsvksrQea

In this issue

From ksre administration.

• The Extension Journey
• Shout Out: Eastern Agents KACAA

Local, Regional and Statewide Extension Events

• K-State Highlights Ongoing Engagement from Two Years of Presidential Community Visits
• May 2024 News from K-State 105

Human Resource Information

• Updated FMLA Process (Family Medical Leave Act)

Health and Wellness

• Exciting Updates from the HAPp Program
• The Community Health Corner

Publications Update

• Extension Updates

Calendar of Events

• From the KSRE Calendar
• Statements and disclosures
• Manhattan, KS 66506
• 785-532-6011
• © Kansas State University
• Updated: 3/16/16

• Open access
• Published: 27 May 2024

Human and financial resource needs for universal access to WHO-PEN interventions for diabetes and hypertension care in Eswatini: results from a time-and-motion and bottom-up costing study

• Harsh Vivek Harkare   ORCID: orcid.org/0009-0002-6365-2930 1 , 2 ,
• Brianna Osetinsky 1 , 2 ,
• Ntombifuthi Ginindza 3 ,
• Bongekile Thobekile Cindzi 4 ,
• Nomfundo Mncina 4 ,
• Babatunde Akomolafe 4 ,
• Lisa-Rufaro Marowa 4 ,
• Nyasatu Ntshalintshali 4 &
• Fabrizio Tediosi 1 , 2  

Human Resources for Health volume  22 , Article number:  32 ( 2024 ) Cite this article

151 Accesses

2 Altmetric

Metrics details

Eswatini faces persistent challenges in providing care for diabetes and hypertension, exacerbated by a shortage of healthcare workers. The implementation of WHO-PEN interventions aimed to address these issues, yet their effects on healthcare worker time requirements and associated costs remain unclear.

This study employed a time-and-motion analysis and a bottom-up cost assessment to quantify the human and financial resources required for scaling up WHO-PEN interventions nationally in Eswatini for all estimated diabetic and hypertensive patients.

Findings reveal that healthcare workers in intervention-arm clinics reported longer workday durations compared to those in control-arm clinics, yet spent less time per patient while seeing more patients. The implementation of WHO-PEN interventions increased the workload on healthcare workers but also led to a notable increase in patient care utilization. Furthermore, a morning peak in patient visits was identified, suggesting potential opportunities for optimizing patient flow. Notably, scaling up care provision nationally with WHO-PEN interventions proved to be more cost saving than expanding standard-of-care treatment.

WHO-PEN interventions hold promise in improving access to diabetes and hypertension care in Eswatini while offering an efficient solution. However, addressing challenges in healthcare workforce creation and retention is crucial for sustained effectiveness. Policy makers must consider all aspects of the WHO-PEN intervention for informed decision-making.

Trial registration US Clinical Trials Registry. NCT04183413. Trial registration date: December 3, 2019. https://ichgcp.net/clinical-trials-registry/NCT04183413

Peer Review reports

The increasing prevalence of non-communicable diseases (NCDs), notably diabetes mellitus (DM) and hypertension (HTN), presents a burgeoning public health crisis in the Kingdom of Eswatini, located in Southern Africa. Estimates of disease burden vary widely, with figures suggesting that between 25 to 60% of individuals aged 40 and above suffer from some degree of diabetes or hypertension [ 3 , 17 , 18 ]. Compounding this issue, Eswatini, akin to many sub-Saharan African (SSA) nations, grapples with a critical shortage of healthcare professionals [ 16 ]. Access to primary healthcare clinics (PHCs) remains a significant challenge, particularly for rural populations [ 13 ].

Recognizing the barriers to care for DM/HTN, the Ministry of Health in Eswatini has identified several challenges, including the concentration of disease management in urban tertiary care clinics and hospitals [ 15 ]. In response to the COVID-19 pandemic and its strain on tertiary healthcare facilities, the Government of Eswatini decentralized diabetes and hypertension care to PHCs. Furthermore, the economic burden of managing diabetes and hypertension affects both patients and the healthcare systems that provide their care. While patient costs have been extensively documented [ 14 ], the financial implications for health systems and healthcare providers remain less understood, particularly within the African context [ 1 , 6 , 11 ].

As part of the WHO-PEN@Scale consortium, we implemented the World Health Organization (WHO) Package of Essential Non-Communicable Disease (NCD) (WHO-PEN) interventions in Eswatini to enhance access to diabetes and hypertension care. While WHO-PEN interventions are anticipated to be cost-effective, the decentralization of care and the projected surge in patient volume due to improved accessibility are expected to strain an already burdened healthcare system. Accurately quantifying this strain is essential for appropriate health system budgeting and ensuring continued care provision. Given the scarcity of healthcare personnel, the remote nature of PHCs, and the affordability of WHO-PEN, we conducted a time-and-motion analysis (TMS) to estimate the impact of these interventions on healthcare worker (HCW) time requirements. As these interventions focus on actual care delivery, we anticipate changes in care delivery for follow-up patients, as new patients will still undergo screening and initiation. The findings from the TMS analysis, combined with cost data, facilitated a comprehensive bottom-up costing assessment, providing estimates of the costs associated with delivering diabetes and hypertension care at PHCs from the provider’s perspective in low-resource settings.

Detailed description of the study objectives, setting, design, and participant enrolment can be found in the protocol paper [ 15 ].

Time-and-motion analysis

Data collection.

Data collection took place at 28 randomly selected PHCs across Eswatini’s four regions. Each clinic was visited twice during a 17-day period in June–July 2022, except for one clinic where permission was denied. A team of four collectors covered four different PHCs each day. Collectors performed direct and continuous observations of tasks using timekeeping devices to record activities throughout the workday.

Amongst the nursing cadre observed at PHCs, the ‘expert client’ is a specialized cadre of healthcare personnel, which were initially recruited to cater to patients affected by the human immunodeficiency virus (HIV), as well as those with a DM-HTN comorbidity. Observed nursing cadres include general nurses, nursing sisters, and nurse assistants.

A paper-based Time Management System (TMS) data collection tool was used to monitor healthcare workers’ (HCWs) time utilization across selected facilities, segmented into three sections: healthcare personnel data (A), facility characteristics (B), and the HCW time-tracking tool (C). The tool identified 19 activities related to patient care, administration/meetings, and idle time/breaks, noting that breaks and idle times—spanning lunch, coffee breaks, downtime from low patient volume, and facility cleaning—are essential for productivity and influenced by factors like patient flow. Section C specifically documented the activities of all employee cadres directly involved in patient care, grouping all care activities per patient for data entry.

Estimating the total number of patient visits

Our data collection primarily focused on characterizing the composition of care including categorizing new patient visits, DM/HTN patient care, non-DM/non-HTN related patient care, and observed patient visit numbers during the hours the data collectors were present. The TMS data-collection tool and further details on collection procedure and estimation of total patients are provided in Supplement A and B (Additional files 1 and 2).

Bottom-up costing

We conducted bottom-up costing exercise to assess the financial implications of scaling-up the WHO-PEN interventions for diabetes and hypertension care in Eswatini on a national scale. This analysis was conducted separately for clinics implementing the interventions and those following standard-of-care protocols.

Using demographic, programmatic, financial, and incidence data, we conducted a comprehensive cost assessment for the calendar year 2022–2023. The individual cost estimates derived from the bottom-up costing approach were aggregated to yield comprehensive summary totals. This detailed breakdown includes costs associated with the use of various diagnostic devices for diabetes and hypertension care on a per-patient basis. In addition, it takes into account the need for oral medication and quantifies the time spent by healthcare professionals in providing these interventions. Costs were converted from Eswatini Lilangeni (SZL) to United States Dollar (USD) using the exchange rate from June 2023 ($1 = SZL 18.867) [ 7 ].

The aim of this study was to calculate the cost of providing NCD care for diabetes and hypertension in PHCs (excluding the rural health motivators and Public Health Units) in Eswatini from the government’s perspective with the WHO-PEN@Scale interventions. Therefore, we only look at care provision in publicly run PHCs and not private clinics.

Our cost estimates rely on patient volume data derived from the TMS model. Our bottom-up costing analysis is tailored to the number of new-patient DM/HTN visits and follow-up DM/HTN patient visits observed at the facilities in the TMS study. This distinction enhances the precision of our estimates, as new-patient visits are more time-consuming and expensive. Additionally, we conducted a probabilistic uncertainty analysis to establish an expected range for the average DM/HTN patient capacity across PHCs in Eswatini. Further information on data sources, medications, diagnostics tools, sensitivity analysis, and costing procedures are provided in supplement C.

Data analysis

The analysis involved calculating HCW time per patient, patient volume, workday duration, average break time, and the proportion of time across different activities. We considered both time of day (morning and afternoon) and patient type (new vs. follow-up) in this analysis. To assess differences in means for critical variables between the two arms, we employed an ANOVA test. All analyses were conducted using STATA (version 16) and Microsoft Excel.

Sample characteristics

Overall, 141 different HCWs were monitored providing care to 1171 patients over 17 days of observation for a total of 279 h of HCW shadowing. Of the 1171 patients seen, 353 were DM/HTN or DM/HTN comorbid patients and 818 were non-NCD patients. The share of patients with HIV and DM/HTN comorbidities was less than 2% (23). 864 patients visited the PHCs and were observed in the morning hours before 12:00 while the rest 307 were observed in the afternoon.

Primary healthcare clinics

Table 1 gives an overview of the characteristics of the PHCs included in the TMS analysis. A total of 28 facilities were visited twice for combined data on 56 visits, apart from Mgazini Nazarene clinic which was visited thrice and Lavumisa clinic which was visited only once. These facilities were evenly distributed across Eswatini’s four regions, with an equal split between control and intervention groups. 327 employees were observed across these facilities, averaging 12 per facility. Specifically, there were 105 nurses across various cadres, averaging four per PHC. The distribution of employee cadres was consistent across intervention arms, regions, and clinic volumes, as confirmed by a one-way ANOVA test.

Human resource needs

Table 2 presents the reported workday duration of HCWs and observed idle time. We observed a statistically significant difference in the reported workday duration between HCWs in the control and intervention-arm clinic, with the latter group spending, on average, 19 min more at a PHC. This difference was consistent among all nursing staff and expert client employees in intervention-arm clinics, with each spending on average, 27 and 26 more minutes, respectively, as compared to their counterparts in the control-arm clinics.

Idle time observations revealed no significant difference in total duration between the two implementation arms. Additionally, the average idle-time duration was 7 min shorter at facilities offering the WHO-PEN interventions. Idle time increased significantly in the afternoon, with HCWs spending 19 more minutes per idle time session after 12:00 compared to morning hours.

The time spent by HCWs per patient stratified by patient type and type of visit are presented in Table  3 . HCWs in PHCs implementing the WHO-PEN interventions spent 2 min less per patient seen on average as compared to those in the control-arm clinics. Stratifying the impact of the interventions by patient visit type, we can see that HCWs need on average 1.8 min more to cater to patients visiting the clinic for the first time as compared to those coming in for a follow-up visit. This effect is more pronounced for DM/HTN patients (5.5 min) as they need to undergo screening and counselling before they can be enrolled and provided with care at the facility. The trend in increased average workday duration as seen in Table  1 is reflected in the average number of all patients seen (24 and 18 in the intervention and control-arm, respectively).

Table 4 shows the proportion of observed time spent by HCWs on different activities. On average, a HCW spends 71% of their time attending to patients and on provision of care. This was higher in intervention clinics where HCWs spent close to 73% of their time on patient care as compared to 69% in control-arm clinics. A third of the time of a HCW was spent, on average, on idle time.

Estimated number of total patient visits

We estimated the total anticipated number of DM/HTN patient visits at TMS facilities for both the control and implementation arms over a 2-day period. Specifically, we projected 1098 patient visits for the control-arm TMS facilities and 1445 for the intervention-arm facilities. Modelled patient visit numbers at the TMS facilities can be seen in Fig.  1 .

Modelled patient visits by arm at TMS facilities

Human resource costs

With a 61% combined prevalence rate, Eswatini has an estimated 123,472 adult cases (aged 40 and above) of diabetes and hypertension, including comorbidities. Out of these, 14,736 are estimated to have diabetes (10%), 122,133 to have hypertension (90%), and 13,397 to suffer from comorbid conditions (10%). According to 2022 CMIS data, there were 145,764 visits for diabetes/hypertension care at PHCs, by 34,803 unique patients, averaging 6.52 visits per patient. This indicates that only 25% of the estimated patient population sought care in 2022. Projecting a full implementation of the WHO-PEN initiative, assuming an average of 6.52 annual visits per estimated patient, could result in 805,039 DM/HTN patient visits at PHCs yearly, marking a 5.5-fold increase from 2022’s patient volume, or realizing only 18% of potential patient visits. Table 5 provides detailed demographics for this population in Eswatini.

From the TMS analysis, we know that new-patient visits for DM/HTN care are more time-consuming compared to follow-up patient visits, and WHO-PEN interventions streamline care delivery, requiring less time than the control-arm approach. In a scenario of universal scale-up, we estimate that providing DM/HTN care to all estimated patients would require at least 558 nurses with the WHO-PEN interventions, and 981 nurses with standard-of-care. These numbers exclude comprehensive care for non-diabetes and non-hypertension patients, which would necessitate more resources. Considering economic opportunity cost of training the required nurses, the personnel costs of a universal scale-up amount to $4.5 million for the intervention arm and $8.05 million for the control arm, respectively.

The annual costs for supplying diabetes and hypertension medications per estimated patient were calculated $7.71 and $3.15 (Additional file 3 : Supplement C Table S4). Given the larger burden of hypertensive patients, the total costs of providing hypertension drugs to all patients was estimated at $384,780. For all diabetic patients, the total annual drug costs were estimated to be $113,420.

The overall costs for diagnostic equipment varied between the control and intervention arms, contingent upon the number of facilities needed to accommodate all projected patients. For a national-level scale-up, the annual diagnostic costs for a sphygmomanometer, a glucometer, and glucose test strips would amount to $173,310 and $174,900 for the intervention- and control-arm, respectively. The decomposition of these costs is graphed in Fig.  2 .

Annual cost of scale-up of WHO-PEN interventions in Eswatini (million USD)

Table 6 presents an overview of the cost of scaling up WHO-PEN interventions in Eswatini under a high-prevalence scenario. The total annual cost of scaling up WHO-PEN interventions to all estimated DM/HTN patients in Eswatini is $5.25 million, equivalent to 6% of the 2022–23 budget of the Eswatini Ministry of Health [ 4 ]. Expanding standard-of-care coverage would cost 66% more at $8.73 million. The cost per DM/HTN patient visit amounts to $6.53 with a scale-up and $10.85 in the control-arm scale-up. Additional details on cost of scale-up with different approaches under alternative disease-prevalence scenarios are provided in the Appendix (Additional file 3 : Supplement C).

This study offers a comprehensive analysis of the human and financial resources required for implementing WHO-PEN interventions in resource-constrained settings. Through a comparative evaluation with standard-of-care approaches, we explore the feasibility of expanding care provision, quantify the human resource needs, and present an in-depth breakdown of HCW time requirements both within and beyond the WHO-PEN framework.

Summary of findings

Our results suggest that there is an increased burden on HCWs of the WHO-PEN interventions in implementing clinics as compared to the standard-of-care arm, especially on nurses and expert clients who are significantly impacted. The results also indicate that these two cadres of care bear the brunt of the intervention, underlining the important role of the expert clients in supporting the implementation of the interventions. Average total break duration does not differ between the two arms of the study, but the difference in the duration of a single break shows that HCWs in intervention clinics were taking shorter but more frequent breaks, further underlying the increased workload of HCWs.

PHCs with WHO-PEN interventions saw more patients but spent less time per patient, suggesting the interventions improve care efficiency, particularly with the fast-track differentiated service delivery (DSD) model for quicker medication access. This efficiency benefit appears to extend to non-DM/non-HTN patients as well, indicating broader impacts of the interventions that warrant further investigation.

Observing patient visits at the HCW and facility levels revealed several key findings. At the HCW level, we did not observe any significant differences in the number of patient visits. This might be attributed to the lower total observation time in intervention-arm clinics (Additional file 2 : Supplement B Table S1). At the facility level, we observed a significant difference in the number of patients seen between intervention- ( n  = 24) and control-arm facilities ( n  = 18). The trend of a ‘morning peak’ in patient volume was evident at this level, with an average of 13 patients seen in the morning and four in the afternoon at PHCs (Additional file 3 : Supplement C Table S6). This trend held for both DM/HTN and non-DM/non-HTN patients, though it was more pronounced for DM/HTN patients. Furthermore, HCWs also experienced lower idle time and took shorter breaks during the morning hours, reflecting this morning peak in patient visits.

The observed “morning peak” in patient volume at healthcare facilities, particularly among diabetes (DM) and hypertension (HTN) patients, can be attributed to several key factors. First, a large majority (94%) of these patients are returning for follow-up visits, with DM patients often advised to fast before screenings, prompting them to visit early. Additionally, the lack of fixed appointment times leads patients to arrive early to minimize waiting. Other factors, such as long travel distances and the desire to have the rest of the day free, also contribute to early arrivals.

We also observe shorter break durations and a faster processing time of patients in the morning hours for non-DM and non-HTN patients in the DSD arm, potentially indicating the task-shifting HCWs might be undertaking to deal with the larger volume of DM and HTN patients (Additional file 3 : Supplement C Table S6). Similarly, intervention-arm clinics experience shorter break durations and faster patient-processing times compared to control-arm clinics, indicating that the maintenance of care quality comes at the cost of HCWs’ idle time. Without an influx of more HCWs, this performance would be difficult to sustain over time. A variety of possibilities to this effect has been explored previously in the SSA context [ 8 ].

Our cost estimates focus specifically on the resources allocated to diabetes and hypertension care. The results indicate that scaling-up diabetes and hypertension care to all estimated patients in Eswatini is cheaper with the WHO-PEN interventions as compared to the standard-of-care. Personnel costs represent the most substantial portion of both scenarios’ overall costs. However, there is a notable disparity in personnel costs under the intervention arm, primarily due to the higher patient volume seen at the intervention-arm facilities.

Findings in context

We expected to see no significant impact of the intervention on the time spent per new DM/HTN patient as they need to undergo screening, testing, diagnosis, and enrolment before they can be provided care. None of these activities were affected by the WHO-PEN interventions. Our results conform to our hypothesis as well as with similar literature. Other TMS studies in Eswatini have quantified the impact of screening for diabetes and hypertension in Eswatini, which leads to a significant rise in time requirement from 4 to 12 min per patient [ 12 ]. Our findings complement those from other countries in similar settings as well, in terms of the proportion of time spent on different activities of care and idle time [ 9 ].

A literature review on the costs of treating hypertension in 11 SSA countries found a large variation in the treatment costs from both patient and provider perspective across countries, underlining the difficulty in generalizing such data [ 5 ]. Additionally, only 25% of all SSA countries reported such data, further highlighting the need to quantify human resource costs for provision of care in such settings. Costs of regular outpatient treatment for hypertensive patients (from a provider’s perspective) ranged from under $10 in Ghana and Kenya to over $15 in Guinea and Rwanda. The same study found costs of treatment for outpatient visits at PHCs to be significantly lower than both outpatient visits at hospitals and inpatient visit costs. Another study in the South African context quantifying the costs for scaling up treatment for diabetes and hypertension according to the WHO-PEN guidelines found the annual per patient cost for treating diabetes and hypertension to be $134 and $27, respectively [ 2 ]. However, these were calculated as the lifetime costs for each patient borne by the provider and included insulin treatment as a cost.

Practical implications

Our findings on the human resource needs and costs for expanding care under the WHO-PEN interventions can guide policy to provide efficient care for DM and HTN patients in Eswatini and countries with comparable care settings. Data on workday duration of a HCW and the time required for administering care to patients by type of visit can be used to optimize workflow, as well as to effectively plan any future programmes involving screening for cardiovascular diseases.

Policies aimed at smoothening and redistributing the patient load from the morning to the afternoon hours might free-up HCW time in the morning hours and further boost efficiency. Since DM/HTN patients (especially diabetes patients) cannot arrive later in the day due to constraints on their eating times, focusing on DM/HTN patients in the morning by having special DM/HTN-only hours might help decongest demand for healthcare by patients seeking non-diabetes care. Similarly, having non-DM/non-HTN hours in the afternoons where they are prioritized might generate the same effect with the addition of boosting healthcare demand in the afternoons.

By strategically implementing such policies, healthcare facilities can aim to optimize HCW productivity, streamline patient flow, and enhance overall healthcare service delivery, ultimately contributing to improved outcomes for DM and HTN patients and the broader community.

Strengths and limitations

Our study is the first to present a detailed description of the human resource needs for providing and expanding care to DM/HTN patients in Eswatini under a standard-of-care scenario and under the WHO-PEN@Scale interventions. Our data collection, which randomly selected 28 PHCs while accounting for the treatment arm, patient volume, and geographic location, ensures our data to be representative for a small country such as Eswatini.

We also addressed the possibility of a Hawthorne Effect (HE) among HCWs during observation. HCWs were informed beforehand that data collection was for research purposes only, not performance evaluation. Previous research suggests that factors like observation duration, task complexity, and workload influence HE potential [ 10 ]. Given the high patient volume, relatively simple tasks observed, and multiple observation sessions over two days, we believe any HE effect was minimal. Additionally, since HCWs from both study arms were observed, any differences observed are likely due to the intervention rather than HE.

There are certain limitations to consider regarding the TMS data and our analysis. Firstly, our data collection does not directly incorporate non-nursing staff contributions to patient care, potentially underestimating the actual time needed for care provision. Additionally, we do not account for the varied implementation strategies of WHO-PEN in our analysis, which could impact outcomes. Moreover, our modelling assumptions, such as consistent patient behavior and visit patterns, may not fully capture real-world complexities, necessitating further research to refine these parameters.

Further information on individual, detailed tasks of providing DM/HTN care such as drawing blood glucose, obtaining vital signs and blood pressure, providing consultation, etc., are needed to identify opportunities for improving care provision at the individual nurse level. Assistance and contribution of non-nursing cadres in providing DM/HTN care can be ascertained by expanding the TMS data collection tool to include their support. Estimating the time required to achieve a complete scale-up of the coverage of our interventions is currently outside the scope of our study, as this is influenced by a variety of factors ranging from infrastructural challenges to cultural practices.

Our study offers valuable insights for SSA countries with low-resource settings and healthcare workforce shortages, especially those operating in rural areas. However, we must acknowledge limitations in generalizability due to the experimental nature of our study and the dynamic health system landscape, including challenges from COVID-19, which affected the Eswatini government's capacity to fully integrate WHO-PEN interventions is affected. These factors call for caution when applying our findings beyond our specific context.

We assessed the impact of implementing WHO-PEN interventions for diabetes and hypertension care in PHCs in Eswatini on HCWs’ time. Our findings reveal increased efficiency in delivering care for these diseases, accompanied by an increased workload for HCWs, with no adverse effects on non-DM/non-HTN care. Without an increase in the healthcare workforce in the country, the positive performance of the interventions might not be sustainable in the long-term, thus highlighting the issues of challenges in the creation and retention of healthcare professionals Eswatini and in SSA. While the national-level scale implementation of these interventions holds high potential for enhancing healthcare access in the country, further research is needed to understand how the three DSD arms impact HCW time and to identify the best-performing arm.

The WHO-PEN interventions for diabetes and hypertension control in Eswatini have the potential to alleviate the disease burden at tertiary healthcare facilities in the country. The implementation of WHO-PEN interventions in Eswatini could enable the primary healthcare system to accommodate more patients at a lower cost. Nevertheless, the decision to scale-up these interventions should also consider factors such as their impact on population health, health equity, and the cost-effectiveness of the different intervention arms.

Availability of data and materials

The deidentified full dataset from our household survey for the overall WHO-PEN@Scale in Eswatini, along with all code for data management and analysis will be posted in a publicly accessible data repository upon publication of the findings for the primary endpoints.  The specific dataset analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Analysis of variance

Confidence interval

Clinton Health Access Initiative

Coronavirus disease 2019

Client management information system

Diabetes mellitus

• Differentiated service delivery

Global burden of disease

Healthcare worker

Hawthorne effect

Human immunodeficiency viruses

• Hypertension

Non-communicable diseases

Primary healthcare clinic

Standard of care

Sub-Saharan Africa

Eswatini Lilangeni

Time-and-motion study

United States Dollar

World Health Organization’s Package of Essential Non-Communicable Disease (NCD) Interventions

Ansari-Moghaddam A, Setoodehzadeh F, Khammarnia M, et al. Economic cost of diabetes in the Eastern Mediterranean region countries: a meta-analysis. Diabetes Metab Syndr Clin Res Rev. 2020;14(5):1101–8. https://doi.org/10.1016/j.dsx.2020.06.044 . ( ISSN 1871-4021 ).

Article   Google Scholar  

Basu S, Wagner RG, Sewpaul R, Reddy P, Davies J. Implications of scaling up cardiovascular disease treatment in South Africa: a microsimulation and cost-effectiveness analysis. Lancet Glob Health. 2019;7(2):e270–80. https://doi.org/10.1016/S2214-109X(18)30450-9 .

Article   PubMed   Google Scholar  

Eswatini Ministry of Health. WHO STEPS Non-communicable disease risk factor surveillance report, Swaziland. Geneva: WHO Press; 2014. https://extranet.who.int/ncdsmicrodata/index.php/catalog/688/related-materials . Accessed 13 Dec 2023.

Government of the Kingdom of Eswatini. Budget Estimates 2022–23; 2022. https://www.gov.sz/index.php/budget-monetary-affairs/budget-estimates . Accessed 23 Nov 2023.

Gnugesser E, Chwila C, Brenner S, et al. The economic burden of treating uncomplicated hypertension in Sub-Saharan Africa: a systematic literature review. BMC Public Health. 2022;22:1507. https://doi.org/10.1186/s12889-022-13877-4 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Husain MJ, Haider MS, Tarannum R, et al. Cost of primary care approaches for hypertension management and risk-based cardiovascular disease prevention in Bangladesh: a HEARTS costing tool application. BMJ Open. 2022;2022(12): e061467. https://doi.org/10.1136/bmjopen-2022-061467 .

International Monetary Fund. World economic outlook database: October 2023 Edition; 2023. https://www.imf.org/en/Publications/WEO/weo-database/2023/October . Accessed 28 Nov 2023.

Kasper J, Bajunirwe F. Brain drain in sub-Saharan Africa: contributing factors, potential remedies and the role of academic medical centres. Arch Dis Child. 2012;2012(97):973–9.

Krishna A, Murali S, Moran AE, et al. Understanding the role of staff nurses in hypertension management in primary care facilities in India: a time-motion study. Prev Chronic Dis. 2023;20:E39. https://doi.org/10.5888/pcd20.220232 . ( Published 2023 May 18 ).

Article   PubMed   PubMed Central   Google Scholar  

Kurtz SL. Measuring and accounting for the Hawthorne effect during a direct overt observational study of intensive care unit nurses. Am J Infect Control. 2017;45(9):0196–6553. https://doi.org/10.1016/j.ajic.2017.03.022 .

Moucheraud C, Lenz C, Latkovic M, Wirtz VJ. The costs of diabetes treatment in low- and middle-income countries: a systematic review. BMJ Glob Health. 2019;4(1): e001258. https://doi.org/10.1136/bmjgh-2018-001258 .

Palma AM, Rabkin M, Simelane S, et al. A time-motion study of cardiovascular disease risk factor screening integrated into HIV clinic visits in Swaziland. JIAS. 2018;21(3): e25099. https://doi.org/10.1002/jia2.25099 .

Peresu E, Heunis JC, Kigozi NG, De Graeve D. Task-shifting directly observed treatment and multidrug-resistant tuberculosis injection administration to lay health workers: stakeholder perceptions in rural Eswatini. Hum Resour Health. 2020;18(1):97. https://doi.org/10.1186/s12960-020-00541-4 .

Subramanian S, Gakunga R, Kibachio J, et al. Cost and affordability of non-communicable disease screening, diagnosis and treatment in Kenya: patient payments in the private and public sectors. PLoS ONE. 2018;13(1): e0190113. https://doi.org/10.1371/journal.pone.0190113 .

Theilmann M, Ginindza N, Myeni J, et al. Strengthening primary care for diabetes and hypertension in Eswatini: study protocol for a nationwide cluster-randomized controlled trial. Trials. 2023;24:210. https://doi.org/10.1186/s13063-023-07096-4 .

WHO. The National Health Workforce Accounts database. Geneva: World Health Organization; 2018. https://www.who.int/data/gho/data/themes/topics/health-workforce . Accessed 22 Mar 2024.

WHO country profile. Eswatini diabetes factsheet; 2020. https://www.who.int/publications/m/item/diabetes-swz-country-profile-2016 . Accessed 4 July 2023.

WHO country profile. Eswatini hypertension factsheet; 2020. https://www.who.int/publications/m/item/hypertension-swz-country-profile-eswatini-2020 . Accessed 4 July 2023.

Download references

Acknowledgements

The research leading to these results was conducted as part of the WHO-PEN@scale project with funding from the European Union’s Horizon 2020 Grant.

The WHO-PEN@Scale Consortium would like to thank the health workers and community members who actively participated in the implementation of the WHO-PEN@Scale project.

We would like to extend our gratitude to Mrs. Ntombifuthi Ginindza-Mdluli and the Ministry of Health in Eswatini for all the data they provided as well as for their support and guidance.

We would also like to thank Dr Fortunate Shabala and her team at the University of Eswatini for their support with the interviews on acceptability of the WHO-PEN interventions for the healthcare personnel in Eswatini.

Open access funding provided by University of Basel This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No. 825823. The funders had no role in the study design, data collection, management, manuscript writing, or decision to submit the protocol for publication. The implementation of the health service decentralization is funded by the Eswatini Ministry of Health.

Author information

Authors and affiliations.

Swiss Tropical and Public Health Institute, Kreuzstrasse 2, 4123, Allschwil, Switzerland

Harsh Vivek Harkare, Brianna Osetinsky & Fabrizio Tediosi

University of Basel, Basel, Switzerland

Ministry of Health in Eswatini, Ministry of Justice & Constitutional Affairs Building, Mhlambanyatsi Road, Mbabane, Eswatini

Ntombifuthi Ginindza

Clinton Health Access Initiative, Mbhilibhi House, Plot 170, Corner Tsekwane/Mbhilibhi Street, Mbabane, Eswatini

Bongekile Thobekile Cindzi, Nomfundo Mncina, Babatunde Akomolafe, Lisa-Rufaro Marowa & Nyasatu Ntshalintshali

You can also search for this author in PubMed   Google Scholar

Contributions

HVH prepared the data collection tool, led the data analysis, interpretation of results, and wrote the manuscript. BO contributed substantially in preparing the data collection tool and data analysis. NG, BTC, NM, BA, LRM, and NN contributed to the data collection tool, acquisition of critical data, interpretation of results, and provided critical revision. FT provided overall supervision on the data collection tool, analysis, interpretation of results, and manuscript preparation. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Harsh Vivek Harkare .

Ethics declarations

Ethics approval and consent to participate.

The WHO-PEN@Scale study was approved by the Institutional Review Boards at the University of Heidelberg, the University of Eswatini, and the EHHRRB. Furthermore, the EHHRRB reviews the project on a yearly basis and has approved all submitted requests as well as an ethics amendment request, which was required due to a change in the design of the study arms.

In the household survey, members of the selected households will be approached by a survey team (data collector and sample collector) trained in research methods and good clinical practice. The data collector will explain the risks and benefits of the survey using a standardized information sheet and consent form in SiSwati or English. Participants will be informed that participation is fully voluntary, and refusal to participate or discontinuation in the survey will not have any influence on any aspect of their lives. The potential participant will be given the opportunity to ask questions. Special attention will be given to the elderly or other vulnerable individuals interviewed to ensure that they have the mental capacity to provide informed consent. Informed consent from the legally authorized representative will be sought if needed. If potential participants are non- or minimally literate, the survey team will read out the consent form and consent will be provided with a thumbprint with a literate witness present.

Data protection: All participants will be given a study-specific identifier. No identifying information will be reported on study forms apart from the consent form. The link between identifiers and participant’s names will be held by a designated person at the CHAI who will not be involved directly in data analysis. Field staff will never have access to data after collection. Data collection procedures will be conducted at participants’ homes on encrypted mobile tablet computers using the KOBO Toolbox platform. Questionnaires will be locked once validated and finalized by the research managers in the field, so that they cannot be re-opened in the field. At this point, data forms are encrypted using asymmetric public key encryption. Once collected, data will be transferred to a secure server located at CHAI. This server is located in a locked room. In order to export data from the server, an asymmetric private key is used.

Data collection for TMS data: Permission to collect TMS data at the PHCs was obtained from the Ministry of Health through the Eswatini Health & Human Research Review Board Individual consent was additionally obtained from the healthcare providers at each facility visited. HCW shadowing was done in an anonymized manner such that neither patient nor HCW data can be used for identification. In addition, the data collectors were instructed to leave the examination room for sensitive discussions between patients and HCWs.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Supplementary material 1. supplement a: tms data collection tool., supplementary material 2. supplement b: additional details for time-and-motion analysis., supplementary material 3. supplement c: additional details for bottom-up costing., rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Harkare, H.V., Osetinsky, B., Ginindza, N. et al. Human and financial resource needs for universal access to WHO-PEN interventions for diabetes and hypertension care in Eswatini: results from a time-and-motion and bottom-up costing study. Hum Resour Health 22 , 32 (2024). https://doi.org/10.1186/s12960-024-00913-0

Download citation

Received : 13 January 2024

Accepted : 16 May 2024

Published : 27 May 2024

DOI : https://doi.org/10.1186/s12960-024-00913-0

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Human resources
• Time-and-motion
• Community outreach

Human Resources for Health

ISSN: 1478-4491

• Submission enquiries: Access here and click Contact Us
• General enquiries: [email protected]