Health needs & primary care: validation of the needs assessment tool

Abstracts

O estudo objetivou validar dois instrumentos, para identificar como os serviços de saúde e as equipes de saúde da família reconhecem as necessidades de saúde da população. Trata-se de um estudo de desenvolvimento metodológico, para o qual foram elaborados instrumentos baseados em um guia de captação da realidade objetiva, adaptado para caracterizar a realidade de serviços de saúde e equipes de saúde da família. Para validação dos instrumentos, estabeleceu-se o grau de concordância mínimo de 85%, participando como juízes docentes pesquisadores do tema Necessidade em Saúde e enfermeiros que atuam em unidades de saúde da família, totalizando 11 juízes. A validação ocorreu em duas etapas pois, na primeira, alguns itens não atingiram a meta de concordância proposta. Após a segunda validação, obteve-se concordância acima de 85% nos itens avaliados. Os Instrumentos de captação propostos visam contribuir para a prática dos serviços de saúde na identificação de necessidades em saúde da população.

Determinação das necessidades de cuidados de saúde; Necessidades e demandas de Serviços de Saúde; Estudo de validação

ORIGINAL ARTICLE

Health needs & primary care: validation of the needs assessment tool^*

Necesidades en salud & atención primaria: validación de instrumentos de captación

Paula Hino^I; Suely Itsuko Ciosak^II; Rosa Maria Godoy Serpa da Fonseca^III; Emiko Yoshikawa Egry^IV

^IRN. Post-doctoral fellow at Collective Health Nursing Department, School of Nursing at University of São Paulo. CNPq Grantholder. São Paulo, SP, Brazil. [e-mail]

^IIRN. Associate Professor at Collective Health Nursing Departmen, School of Nursing at University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^IIIRN. Full Professor at Collective Health Nursing Department, School of Nursing at University of São Paulo. CNPq Researcher 1D. São Paulo, SP, Brazil. [e-mail]

^IVRN. Full Professor at Collective Health Nursing Department, School of Nursing at University of São Paulo. CNPq Researcher 1A. São Paulo, SP, Brazil. [e-mail]

Correspondence addressed to

ABSTRACT

Health needs is easy to say but it is very difficult to recognize and do something about in health services in Brazil. This study aimed to validate needs assessments' tools built to be use to know how primary care services and family health team recognize population health needs. As a methodological study, we built tools based on a guide adopted to characterize primary care services and their family health team. We established a minimum percentage agreement of 85% among the 11 peers who participated in the study. It comprehended two phases: first was general validation and second the validation of items that didn't reach agreement score. The results allow to considerer validated the Tools to assess how primary care services and family health team recognize health needs of territory population. Finally these Tools will contribute to best practice in primary care services to qualify health assistance.

Key words: Needs assessment. Health Services needs and demand. Validation studies.

RESUMEN

Este estudio de desarrollo metodológico buscó validar instrumentos para conocer las herramientas utilizadas, por servicios de salud y equipos del programa salud familiar brasileño, para reconocer las necesidades en salud de la población. Se crearon instrumentos, basados en una guía de captación de la realidad objetiva, adaptada para caracterizar la realidad de servicios y equipos de salud familiar. Para validar los instrumentos, se estableció 85% como porcentaje mínimo de concordancia entre los 11 jueces participantes, que fueron docentes, investigadores del tema necesidades en salud y enfermeros de unidades de salud familiar. La validación ocurrió en dos etapas, dado que en la primera, algunos ítems no alcanzaron 85% de concordancia. En la segunda etapa se obtuvo 85% de concordancia. Los resultados permiten considerar validados los instrumentos para alcanzar los fines propuestos. Se espera contribuir para que los servicios de salud mejoren el reconocimiento de las necesidades en salud de la población.

Descriptores: Evaluación de necesidades. Necesidades y demandas de Servicios de Salud. Estudios de validación.

INTRODUCTION

The organization of a health system based on the dialectics of need satisfaction expresses the viewpoint of the universal protection of health, based on the premise of social wellbeing⁽¹⁾.

Need can be defined as a

conscious desire, aspiration, intention directed at any time towards a certain object and that motivates the action as such. The object in question is a social product, independently of the fact that it refers to goods, a way of life or another person⁽²⁾.

Two types of needs can be distinguished: natural needs, related to the conservation and perpetuation of life, and necessary, radical or characteristically human needs; both are socially determined. The former include food, shelter, sexual, social contact and cooperation needs, related to self-conservation and preservation of the species. They cannot be considered natural because they are produced in social contexts, as well as their volume and the way they are satisfied. Necessary needs include freedom, autonomy, self-accomplishment, self-determination, moral activity and reflection, among others. Hence, not all needs are lacks because, what necessary needs is concerned, their continuous improvement makes us progressively human².

With regard to health needs, they are also social and historically determined and are located between nature and culture, that is, they do not only refer to the preservation of life, but to the accomplishment of a project in which the individual, as a bridge between the private and the generic, becomes progressively human. Health needs cannot be considered mere medical needs, nor can health problems be considered diseases, suffering or risks. Instead, they also refer to lacks or vulnerabilities that express ways of life and identities, expressed in the question about what is necessary to be healthy and involving the conditions needed to enjoy life to the full⁽³⁾. The complexity of these Collective Health practice objects requires that health professionals be equipped so as to adequately respond to its collective nature⁽⁴⁾.

Needs can function as analysts of health practices, as recognizing and coping with health needs is linked with the principles of the Single Health System (SUS), which implies that health teams need to make efforts to translate and respond to the needs the population presents⁽⁶⁾. When they get organized with a focus on the population's needs, it is believed that health services can or tend to be more efficient, in the sense of greater capacity to listen and respond to the health needs⁽⁵⁾. Adopting instruments that can recognize the needs of different social groups can contribute to recognize health practices, so that these are put in practice in response to the needs that originated them, in a circular relation between health needs and health work. At the same time, by permitting the complementariness between objective aspects of reality and the population's subjective conceptions, this also values the possibilities of expression the involved subjects have at their disposal and the meanings attributed to their ways of life, health and suffering⁽⁵⁾.

It is in the spaces where articulations between health services and the population are put in practice that health needs are defined, distinguished, objectified and recognized. It is also in these spaces, integrated with other parts of the health care network, that efforts are made to respond to health needs⁽⁶⁾.

OBJECTIVE

This study aimed to validate instruments to get to know health services' practice and the tools health professionals use to recognize the health needs and vulnerabilities of the population in a given territory.

METHOD

This methodological development study focuses on the elaboration, assessment and improvement of instruments and methodological strategies⁽⁷⁾. To verify the validity of the proposed instruments, they were submitted to the assessment of judges who are considered specialists on the theme of health needs. Judges are persons who are considered properly prepared to analyze the content, presentation, clarity and understanding of the instrument. Content validity represents the domain of a given content construct or universe that provides the structure and base to formulate questions that adequately represent the contents. Concerns with whether the questions contained in the tool are representative of the content domain the researcher intends to measure can be solved by submitted the tool to a group of judges who are considered specialists on this concept⁽⁸⁾.

The instruments proposed in this study were elaborated based on the experience of the researchers involved in this investigation and on the qualitative script to capture the objective reality⁽⁹⁾, adapted to the realities of the research areas, aimed at characterizing the health services and family health teams, and complemented by questions related to the recognition of health needs and vulnerabilities, as mentioned. Starting from the script to capture the objective reality, two instruments were elaborated, one for health teams and the other for health service managers.

The first version of the instruments consisted of open questions, which the participants could answer freely. A pilot study was carried out in two administrative districts of São Paulo City in the context of the Family Health Strategy (FHS): Butantã and Capão Redondo. The range of results found, including incomplete and ignored answers made data analysis more difficult. This implied the need to improve the instruments. Therefore, closed questions were used.

A convenience sample was used for this research and data were collected in the first semester of 2009. Judges were selected according to the following criteria: faculty members in the Collective Health area with a Ph.D. degree, researchers on health needs and nurses working in the FHS. Initially, they were contacted formally through an invitation letter. When they accepted to participate in the study, participants signed the Free and Informed Consent Term and received the two instruments for assessment. The judges were asked to return the material, including their suggestions, within four weeks. The collected data were organized in an Excel 2000 worksheet and subject to descriptive treatment. An interrater agreement level of 85% or higher was set to consider items as validated. In compliance with Resolution 196/96, the Research Ethics Committee at EEUSP approved the project (opinion No 783/2008).

RESULTS

Fourteen judges received the material to participate in the study, 11 of whom responded. Hence, the research involved nine Collective Health faculty members and health needs researchers, as well as two FHS nurses. All judges were women and nurses, the mean age was 44.5 years, with a minimum of 31 and maximum of 58 years. Time since graduation ranged from 4 to 38 years and mean activity time in Collective Health was 16.6 years. For each part of the instrument, space was provided where the judges could make the corrections and recommendations they considered necessary. The instruments were validated in two phases as, in the first validation, some instrument items did not reach the 85% agreement level. The results of the instrument validation will be presented according to the data obtained during the first and second validation phase.

Analysis of first validation

As for the first part of the data collection instrument for the team, which refers to the identification of the health service, the interrater agreement level for the instrument items was 72.7%. The unit nurse was set as the standardized person to respond to this instrument, to be replaced by another health team member in her absence only. This decision was made in the belief that nurses are the health unit professionals able to answer the instrument questions more completely. With respect to the participant's identification, one judge added that it would be interesting to include how long that professional had been working at the unit, as some experience in the team and territory was needed for some of the questions asked.

The second part of the instrument aims to characterize the population and coverage area. This received the largest number of suggestions that were considered pertinent and referred to all items, which were later reformulated. As the initial mean agreement level was merely 50%, comments on the changes made are considered important. Two judges suggested clearly including that information were based on the most recent Basic Care System (SIAB) records, so as to standardize the data.

With a 36.4% agreement level, the item that characterizes the work situation in the area was reformulated. Suggestions referred to the need to clarify that this item aimed to identify the income and job situation of people living in the coverage area, considering that the alternatives mentioned retired and unemployed people, situations that are not considered as work, as well as drugs traffic. Another judge found it convenient to add the option household work, so as to include people who took care of their household activities at home.

The item related to the house includes alternatives related to state of conservation, health conditions, number of dwellers, also considering realities that could be present in the study reality, such as alleys and popular housing blocks. As for the item about the neighborhood, one judge thought it was pertinent to add risks for flood, run-over and landslide. The item about morbidity in the family and house dwellers in the last 12 months reached a 63.6% agreement level. Suggestions referred to including malnutrition and cerebrovascular accident. The latter was responsible for the large number of bedridden individuals at home. Distinguishing between types of violence was suggested, as these indicate distinct needs and interventions.

The third part of the instrument is the broadest, asking about infrastructure and organization activities for care delivery to the population, such as activity organization (scheduling, programs, community actions), existing human resources and their activities and ways to involve the population in the health system. All items attained the proposed interrater agreement level of 85%. As for the health professionals' activities, suggestions were made to add other activities not mentioned in the instrument. About the questions related to the responsible for training, supervision or assessment, one judge suggested including the alternatives manager (Social Health Organization, Municipal Health Secretariat) and partner as, in some regions, management contracts and public-private and public-public partnerships coexist.

The last part of the team instrument to collect information about health needs obtained a mean interrater agreement level of 90.9%. Only one of the items in this part, related to the identification of health vulnerabilities, did not reach the proposed level and only scored 72.7%. One judge suggested considering population data (IBGE and others). Two judges mentioned the need for a note to explain the definition of vulnerability adopted in the study.

As for the instrument for data collection among unit managers, the interrater agreement level for the first part of the instrument was 67.9%, aimed at identifying and characterizing the Basic Health Unit (BHU). Most of the suggestions were accepted. Only one of these was not incorporated, which referred to opening up the question goal and objective to permit reflections that could provide information about the line of work the interviewees base their activities on. However, the researchers decided to maintain the question with alternative answers so as to facilitate data analysis.

Six judges suggested clarifying whether questions such as the number of family health teams, families attended by the FHS and population in the coverage area referred to a specific health team or to the health unit as a whole. The health team was chosen, which allows respondents to interpret their own coverage area only in case they are not managers. This part of the instrument included questions like participant's profession, activity time at the unit, responsible for data collection and service time. The second part of the instrument, related to infrastructure and organization activities, reached an interrater agreement level of 91.2%. Items related to referral and counter-referral were reformulated according to the suggestions of five judges. Alternatives for the item asking whether the BHU is a referral unit included knowing whether the BHU is a referral unit for the district or for the city, as well as the option is not a referral unit. As to the identification of team professionals and the activities they develop, dental surgeons and speech therapists were included, as well as the alternative others for the remaining professionals. Reaching interrater agreement levels of 87.8%, some items with questions about the pharmacy were reformulated due to the pertinence of the suggestions. With respect to the documents needed to have access to distributed drugs, one judge suggested including the alternative prescription with copy, as one copy should remain at the pharmacy and the user should get the other copy. Another judge questioned whether the prescription should come exclusively from the public network. The researchers decided to include the alternatives prescription and prescription with copy.

The third part of the instrument for data collection about health services refers to Nursing, asking questions about the existence of specific Nursing Care Systemization (NCS) instruments, which theoretical base is adopted at the unit and where nursing actions are registered, with an interrater agreement level of 90.9%. Two judges suggested replacing the acronym SAE by the full term.

In the initial proposal, only the team instrument covered questions about health needs. However, after the validation process, the researchers decided to include the fourth item, as one judge had suggested, asking only one question about health needs. An open question was used: According to you, which activities does the service perform to identify and attend to users' needs? This decision was made because asking questions about the theme in both instruments was considered fundamental.

Analysis of second validation

In this phase, the researchers worked with the instruments sent by the 11 judges who participated in the first validation. The analysis of their answers revealed that all items reached or exceeded the proposed interrater agreement target level. In the first part, agreement for the team instrument increased from 72.7% to 90.9%. Only one judge suggested that the question about work time at the unit should include closed alternatives so as to facilitate results processing. This alteration was not made due to the importance of knowing the participants' time of work at the health service and also because, if this time were determined according to pre-established periods, reliability would decrease.

For the second part, aimed at characterizing the population and the coverage area, after the reformulation, the agreement level increased from 50% to 94%. However, one judge suggested including the alternative disease aid by the social security service in the item about the income and job situation. After the reformulation, the item about housing reached a 100% interrater agreement level. As for morbidity, suggestions were made to evidence domestic violence and other types in distinct items. Although interrater agreement levels for the third part were already higher than 85%, items with suggestions were changed because of the suggestions' relevance. In the item about the programs developed at the health service, one judge suggested including the program Mãe Paulistana. About the forwarding institution or service, as suggested, the Reference Center for Sexually Transmitted Diseases/Aids was included, as this can occur quite frequently. Despite the interrater agreement level of 90.9% on the first validation, two judges suggested including the following alternatives in the item about the health needs identification instrument: team meeting to discuss cases, screening and welcoming.

Interrater agreement levels on all parts of the health service data collection instrument were higher than 85% during the second validation phase. The level for the first part of the instrument was 100%, without any suggestions. Although the second part had reached the proposed level of 85% during the first validation phase, the changes made were forwarded to the judges. However, only two judges returned some considerations about including the option to other BHU in the neighborhood when asked whether the BHU is a referral unit. Other suggestions were to include the option Emergency Care and to remove the Social Organization in the question about the forwarding service. As for the examinations collected at the BHU, one judge suggested including the option Electrocardiogram. It should be highlighted that all suggestions given in the second validation phase were taken into account with a view to improving the instrument. The third and fourth parts were also considered validated, as they reached an interrater agreement level of 100% after the second validation phase.

DISCUSSION

As evidenced during the first validation phase, most suggestions referred to changing some terms or expressions that were difficult to understand. Both the instrument construction and validation considered the importance of content objectiveness and clearness. In the second validation phase, all judges approved the changes made. This moment was important to analyze whether the instrument can comply with the proposed objectives.

The researchers believe that the validated instruments can facilitate and support decision making, to the extent that they systematically permit the collection of data that recognize the population's health needs, and also contribute to cope with these needs in the practice of family health teams.

The National Basic Care Policy highlights the role of Family Health in health promotion actions, as teams can often offer an immediate response to the health needs, risk and protection factors present within their territory⁽¹⁰⁾. It is considered a priority strategy to redirect health practices and the traditional basic care service network should be replaced with a view to its consolidation, so as to influence the qualification of the care model based on the work of multiprofessional teams⁽¹¹⁾.

However, family health teams face difficulties to identify the population's health needs and systemize care actions based on these needs. The pilot study of the instruments evidenced that the interviewed family health teams used no specific instruments to recognize the population's health needs.

It should be highlighted that the instruments consisted of open questions, which were adapted to closed questionnaires in the attempt to homogenize answers with a view to data processing. Thus, they can better picture the health needs profiles in the collective health dimension, and not just in the singularity of users presenting those needs. Answers of judges who suggested that some questions should be open will be considered in another instrument.

CONCLUSION

The expert analysis method demonstrated its usefulness to elaborate and improve the instruments aimed at getting to know health services' characteristics, practices and tools health professionals use to recognize the population's health needs, strengthening the findings of different other studies^(12-16) .

The instrument was intended to be practicable in the care practice of Collective Health professionals, as health services do not have a technological apparatus to contribute to the recognition of the population's health needs. The incorporation of specific instruments to recognize the population's health needs in the activity area of family health demands efforts and awareness from health professionals and should be articulated between the community and health teams. This is so because a tool to read the population's health needs demands a reflection on the work logic that approximates the health team to the users, permitting listening that is qualified by the understanding of the health needs the population presents.

To broaden the understanding of the health-disease process as a social and historical product, as the base for the understanding, recognition and satisfaction of health needs - in line with fundamental conceptions of collective health - a technological apparatus is needed that systemizes pieces of information and establishes relations so as to recompose knowledge about the objective reality of services and of the territory they aim to cover. Instruments as such are fundamental for the work process to be guided by the goal of truly satisfying needs. If the intentionality present in the work processes is not individual but social, so that work is directed at the social needs that justify it⁽¹⁷⁾, the use of instruments also permits knowing and transforming the social reality. The fact is that the elaboration and application of these instruments do not guarantee their success. They need to be presented and exposed to criticism with a view to their improvement according to their goal.

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Correspondência:

Paula Hino

Av. Dr. Enéas de Carvalho Aguiar, 419 - Cerqueira César

CEP 05403-000 - São Paulo, SP, Brasil

*

Extraído do Projeto "Limites e possibilidades dos sistemas de saúde locais no reconhecimento e enfrentamento das necessidades de saúde da população: o PSF no município de São Paulo", 2008.

(a

) Daqui para frente a referência aos juízes será feita no feminino - juízas.

Publication Dates

• Publication in this collection
  07 Apr 2010
• Date of issue
  Dec 2009

History

• Received
  15 Sept 2009
• Accepted
  12 Dec 2009