Needs assessments: an example

The current limitations of effectiveness reviews suggest that there should be better attempts to define the aims and objectives of prevention efforts. A more outcome-focused set of aims and objectives would allow purchasers and providers to think through the implications of different interventions with more attention to establishing realistic measures of efficacy.

For example, take a town with a rapidly increasing at-risk population, which currently has a limited range of HIV-/STI-prevention activities. Gonorrhoea or chlamydia reports could be used as a medium-term indicator, and, if possible over the longer-term, HIV incidence in a cohort recruited from the local population.

The aim of local prevention activities would be to bring about a reduction in both these indicators within a given budget. But what should the package of local prevention activities consist of? To define this package, a purchaser could take one of several approaches, such as funding strategies capable of generating data about a number of different short-term outcomes. These could include:

• number of condoms distributed
• number of HIV-positive and HIV-negative individuals and serodiscordant couples attending counselling sessions for partners having unprotected sex
• number of workshop sessions provided for people having risky sex
• number of peer educators/volunteers trained according to the overall aims of the local HIV-prevention strategy
• indicators of knowledge or awareness within a sample (or ideally a cohort) of the local population
• awareness of, and learning from, small-media resources distributed.

The evaluation of projects funded under this strategy should follow two tracks: firstly, process investigation of service delivery to measure efficiency; and secondly, self–reported behavioural and cognitive changes amongst a sample of service users, as a surrogate and interim measure of effectiveness (pending longer-term investigations of STI and HIV incidence). Waiting-list control groups for some of these interventions could also be required as additional back up.

This strategy takes account of several different models of the ways in which people change their behaviour, and seeks to deploy these in a mesh of prevention activities to be targeted at the local at-risk population.

However, employing a strategy only capable of generating such data does not help purchasers judge where to spend their money in terms of cost-per-infection averted.

What is the factor leading to most new infections in the locality? Is it unprotected sex in relationships? Is it unprotected sex in casual and commercial situations? Is it needle sharing? Are there particular groups, such as users of alcohol or recreational drugs, who need targeting? Do men need different interventions than women?

These factors can be extrapolated from the research literature, but local-action research and ethnography will be a vital precursor to funding a really cost-effective local strategy.

Local-needs assessment need not reproduce national behavioural data, but it can often give an idea of particular local factors which are facilitating new infections – or, more likely, local opportunities for exploiting social networks. For example, a local-needs assessment need not investigate what sort of risk-taking activity is going on amongst local men who have sex with men, but it will need to map local networks.