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Health needs assessment
Part 1
“Overcoming poverty is not a gesture of charity. It is an act of justice. It is the protection of a fundamental human right, the right to dignity and a decent life.” said Nelson Mandela at a speech in Trafalgar Square in 2005. Currently homelessness is increasing in the United Kingdom and poses a significant health challenge. Oral health of people experiencing homelessness is important as it is frequently overlooked by these individuals and may lead to other poor health and social outcomes. A health needs assessment is a structured system used to determine health inequalities within a population and ways of reducing these inequalities (NICE, n.d). This essay will define terms underpinning a health needs assessment such as health, health promotion, health education, empowerment, and public health; thereafter a health needs assessment will be conducted using the Hooper and Longworth (2002) method; and finally, a lay summary of the intervention will be presented.
The definition of the term health has been the subject of much debate. Health has been defined by the World Health Organisation (WHO) in 1946 as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 2001). Currently, this definition has been accepted by the 194-member states of the WHO. One question that needs to be asked, however, is whether this definition of health is practical and achievable. Dubos (1987) viewed complete health to be unachievable and did not fit with the human experience of life, which is attested to by the current struggle to achieve health even though cures are available. Huber et al. (2011), have defined health as “as the ability to adapt and to self-manage”, which is a more practical and achievable definition of health. Although the interpretation of health has been controversial, Huber et al. (2011) provides a definition that fits well with the concept of health promotion.
Health promotion arose out of the realisation that health professionals treating diseases in hospitals would not reduce the impact of behavioural and environmental risks to health (Lalonde, 1974). The health field, which supported looking at health from the physiological, environmental, lifestyle and health care organisation perspective was
suggested by Lalonde (1974). The World Health Organisation (WHO, 1986), defined health promotion as “the process of enabling people to increase control over, and to improve, their health”, which has shaped health promotion activities. The approach of health promotion advocates equity by representing disadvantaged groups. Prerequisites to health promotion are set out in the Ottawa Charter as: peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice, and equity (WHO, 1986). Two dimensions of health promotion are described in Beattie’s model, mode of intervention and focus of intervention (Beattie, 2002). Mode of intervention is either authoritative or bottom-up whereas focus of intervention is either individual or community. Various combinations of these two dimensions result in different approaches to health promotion. This model clarifies the relationship of bottom-up vs. top-down approaches and community vs. Individual interventions. For Tannahill (2008), health promotion refers to the overlap of the fields of health education, health protection and prevention. Although Tannahill’s (2008) idea of health promotion has been challenged by proponents of health improvement, it still represents the activities of health promotion in practice such as health education.
A large and growing body of literature has investigated the concept of health education. Tannahill (1985) defines health education as the communication of beneficial knowledge from those with expertise to the community in order to create health benefit. He emphasises that it should empower the community with a mutual exchange of ideas. This notion of health education has been further developed by Nutbeam (2018) to describe how expanding digital formats have increased access to health education. Health literacy is a vital aspect of health education that is required by the population to understand and correctly process information from health education (Nutbeam, 2018).
The four main models of health can be listed as follows: biomedical, biopsychosocial, and social. The biomedical approach strictly focuses on the biological and physical aspect of health. One major drawback of this approach is that it aims to restore healthy biological and chemical indicators through medical and surgical means only (Australian Institute of Health and Welfare, 2016). However, Engel (1977) points out that not all disease can be detected or managed via the biomedical approach. Engel (1977) proposed the
biopsychosocial model of health that included biological, psychological and social factors that should be the focus of health. Dahlgren and Whitehead (1991) have proposed the social model of health. This model looks at the health from the perspective of society. Dahlgren and Whitehead (1991) proposed that social determinants such as, individual lifestyle factors, community interaction, living and working conditions, and socio-economic status influence health. Frohlich et al. have challenged this model by countering that individuals still have agency within their social environment to determine their health in tandem with social influences and social influences, therefore, cannot determine health. However, the findings contained in the Marmot Review (2010), shows that people with low social status suffer health inequalities.
The first discussions and analyses of modern public health emerged following the 1974 Lalonde Report that proposed interventions aimed at community level instead of individual level. The definition of public health by Winslow (1920) as “the science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals” is still widely used. However, more recently public health incorporates the principles of action over discussion. Wanless (2004) raised the issue that public health requires inputs from different stakeholders and that how this information is used to create health is the practice of public health. Specifically, Wanless (2004), described a public health practitioner as being able to analyse health problems, understand populations at risk, determine factors that precipitate this risk, plan implement strategies to combat these factors, and ascertain the effectiveness of these strategies.
The population to be assessed for the health needs assessment are people experiencing homelessness in XXXXXXXX County, Wales, who utilise homelessness services at St. Mary’s Hostel. These services are housing advice and support, accommodation, meals and supplies for rough sleeping. Homelessness is a broad term, and the definition by the European Federation of National Organisations Working with the Homeless, includes: rough sleepers, those squatting illegally, living in temporary accommodation, and living in accommodation that is unfit for occupation (Welsh Government, 2016). In 2016 North Wales had approximately 10,884 out of 1,302,676 households that were classified as
homeless. In XXXXXXXX County the total was 207 out of 52,473 households or 0.39%. Total homelessness according to Shelter, a homeless charity, may be as much as 320 000 individuals in Britain with numbers of rough sleepers in Wales alone increasing by 8% to 345 in 2018 (Jackson, 2018).
In order to successfully conduct a health needs assessment and develop an intervention, the input of various stakeholders would be required. These stakeholders are Community Dental Services (CDS), homelessness outreach and resettlement teams, case workers and volunteers at xxxxxxxxxxxxxxxx XXXXXXXX Council, law enforcement agencies, other charity and volunteer organisations that work with homeless people. Health providers are included as they are responsible for provision of services. The ability to reach hidden homeless and rough sleepers to become part of focus groups is difficult as the population is constantly moving or may not have fixed addresses. The inclusion of hostel staff and charities are necessary as they frequently encounter homeless people. Law enforcement agencies and homeless individuals have a difficult relationship and mostly contact each other on opposing sides of the law.
Barriers to identifying health priorities in this population mainly relate to the variable nature of homelessness. Portions of the homeless population such as rough sleepers and people in temporary short-term accommodation may be constantly on the move. Attempts to engage these groups via interviews or focus groups may prove expensive and time consuming. These can be overcome by gathering information about this group at location frequented by people experiencing homelessness such as soup-kitchens.
Studies can be conducted in XXXXXXXX county to understand how homelessness affects access to oral health care. Quantitative data from a survey and qualitative data from focus groups can be collected. This mixed method approach was undertaken by Groundswell, a charity in London, to measure the scale of the oral health status within the population as well as create a more detailed understanding of how homelessness affect access to oral health (Groundswell, 2016). Focus group participants should be recruited from the population that identifies themselves as homeless. These could be people attending the homeless shelters in XXXXXXXX, rough sleepers, those who have
registered with the XXXXXXXX Council as living in temporary or unsuitable accommodation.
Part 2
Shelton et al. (2009) found that homeless individuals were at greater risk to have a history of drug use, mental illness, poor academic achievement in school, and domestic abuse as a child. The Public Health Wales (2016) report showed that homeless people in North Wales were likely to suffer poor health as a result of not having a home or returning to a home unsuited for living. This in turn would place greater stress on hospital and emergency rooms (Public Health Wales, 2016). Homeless individuals are a higher risk for oral disease due to poor diets which consist of high sucrose snacks, poor oral hygiene and alcohol and drug abuse (Beaton, Coles, & Freeman, 2018). Homeless individuals being treated in hospital settings complained that doctors did not understand their situation as they did not have knowledge or understanding about the homeless experience (Public Health Wales, 2016).
Studies of homeless groups have shown that these populations have a higher burden of oral disease compared to the general population (Gibson et al., 2008). Homeless individuals are also more likely not to attend dental appointments which reduces the effectiveness of the current high street dentist system in preventing dental emergencies. Homeless individuals irregularly attend high street dentists or community dental centres due to inadequate information about charges, costs of transport to clinics, and are hesitant to use the service (Gibson et al, 2008).
Oral health as a priority for homeless people ranks quite highly. King et al. (2003), found that dental care ranked third after permanent housing and childcare in a homeless population in the United States. This combined with the findings of Ford et al. (2014) that oral health is poor in homeless people puts this population in greater need of oral health services. Hill and Remington (2011) found that homeless people found dental practices to be unwelcoming and accessed care only when in pain. Oral health advice given to homeless individuals in a more informal setting than a dental practice was deemed to be desirable (Pritchett et al, 2014). Coles and Freeman (2016), found that oral health neglect was part of the destructive mindset shift of becoming homeless and that restoring oral
health was part of the “reconstruction” process after homelessness. This reconstruction process is the ability of the person experiencing homelessness to take control of their lives by seeking treatment for oral pain (Coles & Freeman, 2016). The priority for this health needs assessment will be improving access to oral health care for people experiencing homelessness.
The intervention envisaged is dental mobile clinic visits to homeless shelters on a weekly basis. These visits will provide primary intervention in the form of oral health education particularly related to maintaining oral hygiene; secondary intervention by offering dental screening and examinations; and tertiary interventions by treating pain and sepsis caused by tooth decay. These visits will have to be at times to ensure maximum benefits. Currently there is a gate service that provides meals, advice, and equipment for homeless people. The timing of the mobile dental van visit should coincide with this gate service in order to have maximum exposure to homeless people using the shelter.
The aim of this health needs assessment intervention is to improve the oral health status of homeless individuals in XXXXXXXX County by expediting access to oral health care and improving uptake of services. This would prevent the need for dental treatment in the form of extractions to be managed at Emergency Departments.
Working hours of oral health professionals and associated staff that are needed for operating a mobile dental clinic will have to be adjusted to ensure availability at the gate service which runs from 1pm to 4pm.
The preconceptions that oral health professionals have about homelessness may be a barrier to gaining access to this group. (Tubert‐Jeannin, Loignon, Landry, & Bedos, 2009) found that oral health professionals became frustrated with homeless individuals missing appointments and this led to a perception that treatment plans will be futile. However, research by (Loignon, Landry, Allison, Richard, & Bedos, 2012) found that dentists treated patients from disadvantaged groups with empathy.
These barriers may be overcome by providing oral health professionals with the reasons why it is difficult for homeless people to access dental care. A more complete understanding of the complexities that underlie the behaviour of homeless people engage
in can change perceptions of oral health professionals. Empathy and understanding from dentists may allow for a better relationship with to oral health services for this group can be improved.
One of the barriers that may be encountered is parking for the mobile dental clinic as was experienced by Simons et al. (2012). This may necessitate earlier arrangements with the hostels to arrange parking.
Resource implications of the intervention must be considered. Mobile clinics to treat homeless people have been found to be costly due to logistical difficulties in locating these mobile clinics at places accessible to individuals experiencing homelessness (Simons et al, 2012). However, the benefits of reducing burden of oral disease and reducing lost resources from unattended appointments outweigh the costs of a mobile clinic for homeless people (Simons et al, 2012). The xxxxx Health Board currently uses a mobile dental clinic to visit people with disabilities for dental treatment (XXX CHC, 2011). The ambit of this service can be expanded to include services to homeless shelters as they are defined as vulnerable groups and are unable to attend high street or Community Dental Services.
Key indicators for this intervention are market value of oral health services provided by the dental mobile, true cost of providing dental treatment at St. Mary’s hostel, amount and variety of dental procedures undertaken, number of oral health education interactions, amount of people treated per day, amount of people treated by dentist per mobile visit, amount of days that the mobile works per year.
Targets will be matching costs of services provided by the dental mobile clinic to Community Dental Services (CDS) costs, achieving 80% coverage of the homeless population, achieving par number of individuals treated per dentist per visit as CDS, achieving 50 mobile dental visits per year.
Health empowerment is a vital component of this intervention. Health empowerment can be individual or community. Individual empowerment focuses on the capacity of the individual to make decisions and take command of their personal lives (WHO,1998). Community empowerment focuses on empowerment using the collective actions of
persons to “gain greater influence and control over the determinants of health and the quality of life in their community” (WHO, 1998). Adamson and Bromiley (2013) found that communities in Wales had an increased readiness to work together if structures were in place to facilitate the project. Furthermore, Adamson and Bromiley (2013) concluded that if local community suggestions and input are not well embedded in to formal policy and organisational procedures, they can negatively affect the viability of community empowerment projects.
The approach can be evaluated by measuring the stated objectives described in the aim of the health needs assessment namely access to oral health services and increasing uptake of oral health services. Evaluation of this intervention may prove difficult due to the transient nature of the homeless population. Attendance registers at mobile dental clinic visits can provide data on number of homeless people using the service. This can be compared to population estimates of homeless individuals to determine service uptake rates. Focus groups can be held with stakeholders mentioned in part one to determine if the mobile dental visits are expediting access to oral health services. Surveys of participants that attend the clinic can be used to determine if they experienced less barriers to access services. Costs of the type of treatment per individual can be compared to the costs of that type of treatment by CDS and can be obtained from Welsh Government Statistics. Costs per patient per dentist can be compared to CDS statistics to evaluate the technical efficiency of the service. Time frames to measure the indicators can be at three-month intervals.
This project will achieve the goals set out at the international, national and local level by providing services which foster inclusion of people experiencing homelessness. Partnerships formed by this intervention and bringing care to communities will also help reduce health inequalities experienced by those who are homeless by improving access to oral care.
The political dimensions to health promotion have a deep impact on the way public health policy is implemented. The World Health Organisation Conference 2016 reaffirmed that political power globally, nationally and at local level are responsible for promoting health to boost equitable access to health (WHO, 2016). According to Gardner (2014), the source of funding for health promotion budgets being mainly governments, and therefore taxpayer money, leads to ethical issues. She further argues that health promotion activities may impinge on the autonomy of the individual through coercion, persuasion or manipulation and that any infraction on autonomy be assessed (Gardner, 2014). A relevant example quoted is campaigns to promote fewer sexual partners to prevent the spread of HIV/AIDS which impinges on the rights of people who are polygamous and practice safe sex and are stigmatised as a result (Gardner, 2014). Currently, homelessness has been attracting media attention after a man experiencing homelessness died from exposure a few streets away from Parliament (Greenfield, 2018).
This health needs assessment details how health needs from the population will be collected and the nature of intervention. After considering the theoretical basis for a health needs assessment, the health priority people experiencing homelessness has been identified as access to oral health care. An intervention using mobile dental clinics to
provide screening and treatment at a hostel site will reduce inequalities faced by this population in accessing health. Further research into the viability of this health needs assessment is warranted to evaluate the success of this intervention after it has been implemented.
Part 3
Are you currently experiencing homelessness and aren't able to get to the dentist? Or do you encounter people who are experiencing homelessness in your workplace who can’t get to the dentist? If this is the case, the dentist will come to you. Mobile dental vans will be visiting St. Mary’s hostel on a weekly basis providing check-ups and treatment of painful teeth and gums. Information about how to keep your teeth and gums healthy will also be given by our highly trained team.
A team of dentists and dental nurses have been trained to understand the stresses that people experiencing homelessness go through when going to the dentist. They will offer the highest level of confidentiality and respect for your rights. They will visit St. Mary’s hostel in a fully equipped dental van every Wednesday during the gate service. This is from 1-4pm.
Researchers studying at Bangor University’s School of Health Science found that dentists and staff at Community Dental Services did not understand the complex difficulties that people who experience homelessness go through. Mental health problems, poor diets and worries about how dentists will treat them were some of these difficulties. Also, getting to the dentist and looking after your teeth is the least of your worries when you are worried about a place to sleep for the night.
Researchers conducted meetings with people experiencing homelessness and people who work with people experiencing homelessness. These meetings gave researchers an insight into the difficulties that people experiencing homelessness go through when trying to get to the dentist. Consultations with the health board, XXXXXXXX Council and Community Dental Services were also held. It was decided that a van providing dental services should provide services at a place where people who experience homelessness often visit. This was XXXX hostel in Bangor.
Shelter Cymru, which is a charity working with people experiencing homelessness have found that homelessness is increasing in Wales. This will eventually lead to greater strain on the NHS because this group of people are more at risk of falling ill. The purpose of going out to the community to provide services is to make sure that people experiencing homelessness are treated before they have to go to an Emergency Department.
An assessment of health needs was done to find out what could be done to improve the health of those who are homeless. It was found that the most pressing concern was that people experiencing homelessness found it difficult going to the dentist. Many recent laws make it the responsibility of local councils and health boards to make sure that health services are easy for communities to access. For more information please visit XXXXXX
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