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WHO/MSD/MSB 00.

2d

Workbook 3

Needs
Assessment

Workbook 3 · Needs Assessments 1


WHO/MSD/MSB 00.2d

c World Health Organization, 2000

WHO
World Health Organization

UNDCP
United Nations International Drug Control Programme

EMCDDA
European Monitoring Center on Drugs and Drug Addiction

This document is not a formal publication of the World Health Organization (WHO) and all rights are reserved by the
Organization. The document may, however, be freely reviewed, abstracted, reproduced and translated, in part or in
whole but not for sale nor for use in conjunction with commercial purposes. The views expressed in documents by
named authors are solely the responsibility of those authors.

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WHO/MSD/MSB 00.2d

Acknowledgements

The World Health Organization ited the workbook series in later


gratefully acknowledges the contri- stages. Munira Lalji (WHO, Sub-
butions of the numerous individu- stance Abuse Department) and Jen-
als involved in the preparation of nifer Hillebrand (WHO, Substance
this workbook series, including the Abuse Department) also edited the
experts who provided useful com- workbook series in later stages.
ments throughout its preparation for Maristela Monteiro (WHO, Sub-
the Substance Abuse Department, stance Abuse Department) pro-
directed by Dr. Mary Jansen. Finan- vided editorial input throughout the
cial assistance was provided by development of this workbook.
UNDCP/EMCDDA/Swiss Federal
Office of Public Health. Cam Wild Some of the material in this work-
(Canada) wrote the original text for book was adapted from a NIDA
this workbook and Brian Rush publication entitled “How Good is
(Canada) edited the workbook se- Your Drug Abuse Treatment Pro-
ries in earlier stages. JoAnne gram? A Guide to Evaluation.” Con-
Epping-Jordan (Switzerland) wrote tributions drawing from this report
further text modifications and ed- are gratefully acknowledged.

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WHO/MSD/MSB 00.2d

4 Evaluation of Psychoactive Substance Use Disorder Treatment


WHO/MSD/MSB 00.2d

Table of contents

Overview of workbook series 6

What is a needs assessment? 7

Why do a needs assessment? 7

How to do a needs assessment? 8

Question 1 10

Question 2 14

Question 3 16

Question 4 23

Comments about case examples 28

Case example of a needs assessment 29


Planning and evaluating outpatient care for drug
dependent patients in Barcelona (Spain)

Case example of a needs assessment 42


A study to determine the welfare service needs
in the Eastern Transvaal, Republic of South Africa

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WHO/MSD/MSB 00.2d

Overview of
workbook series
This workbook is part of a series in- and cost-effectiveness using the in-
tended to educate programme plan- formation that comes from these
ners, managers, staff and other deci- evaluation activities.
sion-makers about the evaluation of
services and systems for the treat- This workbook (Workbook 2) de-
ment of psychoactive substance use scribes step-by-step methods for
disorders. The objective of this se- implementing evaluations. These
ries is to enhance their capacity for steps span from starting the study, to
carrying out evaluation activities. collecting, analysing, and reporting
The broader goal of the workbooks the data, to putting the results into
is to enhance treatment efficiency action in your treatment programme.

Introductory Workbook
Framework Workbook

Foundation Workbooks
Workbook 1: Planning Evaluations
Workbook 2: Implementing Evaluations

Specialised Workbooks
Workbook 3: Needs Assessment Evaluations
Workbook 4: Process Evaluations
Workbook 5: Cost Evaluations
Workbook 6: Client Satisfaction Evaluations
Workbook 7: Outcome Evaluations
Workbook 8: Economic Evaluations

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WHO/MSD/MSB 00.2d

What is a needs
assesment?
Needs assessment is a tool
for program planning.
Needs assessments evaluate: verse needs associated with PSU
disorders
l The capacity of treatment services
in the community in relation to the l The co-ordination of services
prevalence and incidence of PSU within a system of care in order to
disorders facilitate entry into the system,
smooth transition across specific
l The appropriate mix of services components and appropriate fol-
required to respond to the di- low-up

Why do a needs
assesment?
Over the last two decades, the role needed. In other areas with avail-
of needs assessment in the planning able services, the focus is now to
of services and systems for PSU dis- ask about how existing services
orders has increased in importance. might be better co-ordinated and
Several factors have contributed to more efficient.
this development, including:
l The increasing diversity of com-
l Questions that arise about the rela- munity interventions that are avail-
tive priority of different commu- able. There is acceptance in most
nity needs. In some jurisdictions jurisdictions that a range of com-
with no services for PSU disor- munity services is needed and that
ders, the focus is now to ask about people coming into treatment
new services that might be should be appropriately assessed

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WHO/MSD/MSB 00.2d

and matched to treatment. How- prevention-oriented programmes


ever, information is needed to help in the community.
decide how much of what type of
treatment is required in a given In any case, the specific objectives
community or region. of the needs assessment must be
clarified and documented. These
l The increasing use of PS with po- objectives may include:
tential for harm among the general
population, and among people l to respond to an external mandate
seeking treatment. for needs assessment prior to ap-
proval and release of funds
l The desire to take a more preven-
tive approach to PSU disorders l to guide the allocation of new
and to improve the balance of funding among several new op-
treatment, early intervention and tions being considered

How to do a needs
assesment?
In this Most experts in the field of PSU dis- (DeWit and Rush, 1996). The four
workbook, orders agree that a single "all-pur- questions addressed are:
various
pose" needs assessment technique
approaches
to needs does not exist. This is because needs 1 How many people in the region
assessment assessment planners have different or community need treatment for
are described by goals for conducting assessments PSU disorders?
showing how making it unlikely that a single
they can be used method would suffice for all pur- 2 What is the relative need for treat-
to address four
poses. ment services across different re-
questions
most commonly gions or communities?
asked in In this workbook, various ap-
a needs proaches to needs assessment are 3 What types of services are needed
assessment described by showing how they can and what is the necessary capac-
project. be used to address four questions ity?
most commonly asked in a needs
assessment project. More details re- 4 Are existing services co-ordinated
garding many of these approaches and what is needed to improve the
can be found in recent reviews overall level of system functioning?

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WHO/MSD/MSB 00.2d

Use this The two case examples at the end of tary to the general steps for evalu-
specialised this workbook present two very dif- ation outlined in Workbooks 1 and
workbook
ferent approaches to needs assess- 2. When doing a needs assessment,
together,
simultaneously ment. The first (from Spain) relies you should carry through each of
with the upon existing computerised data- the general steps for evaluation de-
foundation bases, whereas the second (from scribed in Workbooks 1 and 2. Use
workbooks to South Africa) uses interviews and this specialised workbook simul-
maximise the focus groups. Despite their differ- taneously with the foundation
information that
ences, both evaluations are appro- workbooks to maximise the infor-
is presented.
priate because they take into account mation that is presented.
the unique needs and resources of
their settings. Using Workbook 1 as a guide, de-
termine which one of the above four
Each of these questions, and the questions is most relevant for your
methods for answering them, are programme evaluation question.
addressed below. Keep in mind Review that section below.
that this information is supplemen-

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WHO/MSD/MSB 00.2d

Question 1
How many people in the
region or community
need treatment
for PSU disorders?
This workbook will briefly describe come with their unique advantages and
three approaches to answering this disadvantages. The selection will have
question. Unfortunately, there is no to depend on your unique circum-
easy answer to this question because the stances and the expertise, time and re-
various strategies available to you each sources that are available.

1. Mortality-based
prevalence models
This method is easy to use, if you have the O = the total number of deaths
necessary data. For alcohol, for example, from liver cirrhosis reported
the formula is: for a given year in the area
or region of interest
A = P*(D/K),
where K = the annual death rate from
A = the total number of alco liver cirrhosis among al
hol dependent persons in cohol dependent persons
an area or region with complications (e.g.,
rate of death from liver
P = the proportion of liver cirrho cirrhosis per 10,000 alcohol
sis deaths due to alcohol use dependent persons).

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WHO/MSD/MSB 00.2d

By collecting the necessary statistical in- to liver cirrhosis (or suicide and alco-
formation for a region or community, one hol use) occur infrequently
should be able to fill in the required infor-
mation and estimate the number of prob- l the need to supplement the resulting
lem alcohol users. This is used as the esti- estimates of the in-need population
mate of the number of people in need of with estimates based on PS other than
treatment. alcohol

Advantages include: l limited utility from prevention or early


intervention perspectives because esti-
l The simplicity of the formula, once the mates are based on the most severe con-
necessary statistical data are obtained sequences of alcohol use

Limitations include: l variations in the constants in the for-


mula across cultural and social settings
l inaccuracies in the statistical data due to
misclassification of the cause of death l inability to estimate the number of
people in need of treatment within spe-
l instability of the prevalence estimates cific population sub-groups (e.g., gen-
for small populations since deaths due der, age)

2. General population survey


In a general population survey, you con- ally occurs in a population survey; often
tact a random or representative sample underestimating actual consumption by as
of people in the region or community much as 50%-60%. Alternatively, you
and ask them questions about their may ask questions about problems the
PSU, related problems and perceived person has experienced related to their
need for treatment. A survey of this PSU and create a cut-off point on the list
type can be easy or difficult to com- of problems to define the need for treat-
plete, depending on the complexity of ment. Many people conducting a popu-
your evaluation. lation survey create their own problem
list but this raises significant questions
It is important to pay attention to the about the reliability and validity of the
questions you ask and to the criteria you survey items.
use to indicate whether the respondent
A ”needs” treatment for a PSU disorder. Various survey instruments have been de-
You may choose to ask questions about veloped that are appropriate for use in ei-
the amount and pattern of drinking over ther face-to-face or telephone interviews.
a recent time period (e.g., to calculate av- An excellent example for use in many cul-
erage weekly consumption, or the num- tural settings is the Composite Interna-
ber of respondents drinking more than a tional Diagnostic Interview (CIDI) devel-
certain number of drinks on a given day). oped by the World Health Organization
The main limitation of these data is the (Cottler et al., 1991; Robins et al., 1988;
under reporting of consumption that usu- Wittchen et al., 1991; WHO, 1990). The

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WHO/MSD/MSB 00.2d

basic approach is to establish the presence (e.g., incarcerated, institutionalised).


or absence of a set of A “symptoms”, Other strategies will be needed to esti-
which include both clinical manifestations mate the in-need treatment population
(e.g., tolerance, withdrawal, craving) and in these groups
social consequences (e.g.,PSU-related
problems with family, friends, job, and/or l results of surveys may be biased if the
the criminal justice system). To be assigned response rate is lower for particular
a particular diagnosis, an individual must sub-groups such as young adults, the
meet predetermined counts of such “symp- elderly, women or particular cultural/
tom”. ethnic groups

Advantages include: l there is a heavy reliance on the respon-


dents’ self-report of consumption, re-
l direct estimates of the number of people lated problems, and there will be a gen-
in need of treatment for PSU disorders. eral tendency to underestimate PSU and
related problems
Limitations Include:
l some survey methods are very expen-
l important segments of the population sive (e.g., face-to-face interviews) and
are difficult to reach in a population sur- require special expertise that may need
vey either because they are hard to lo- to be purchased on a consulting basis if
cate (e.g., homeless) or because they it is available (e.g., survey statistician,
are excluded in the sampling procedure trained interviewers, data analyst)

3. Capture-recapture models
The term This method requires that you have access estimates of the total population of PS
“capture - to computerised records and a certain level users.
recapture” is of statistical expertise. Its advantage is that
derived from this it overcomes the difficulty of accessing The case example from Spain, located at
process in which hard-to-reach segments of the PSU popu- the end of this workbook, uses the cap-
individuals in the lation by relying on sources of informa- ture-recapture method for a portion of its
first sample or tion that contain “naturalistic” samples of analyses. Their data sources included
list are captured known PS users. These sources of infor- records for treatment admissions, emer-
and identified mation might include police records of gency visits, and jail entrances.
(tagged), and arrest for possession of narcotics or court
then a certain convictions for PSU-related crime, hospi- The logic of the capture-recapture model
portion are re- tal emergency room admissions involving for estimating hidden populations of PS
captured or re- cases of PS overdose or admissions to PSU users is best understood by way of an ex-
identified on the treatment centres. Used in isolation, these ample. Suppose that for a given area or
second list. data sources are not particularly helpful region, one has two separate listings or
for estimating prevalence. However, com- naturalistic samples of known opioid us-
bining data from two or more sources of ers. The first list, which we will call list X
information can yield reliable and valid (sample 1), consists of opioid-related ar-

12 Evaluation of Psychoactive Substance Use Disorder Treatment


WHO/MSD/MSB 00.2d

rest cases and the second list called list Y With f22, an estimate of the total popula-
(sample 2), consists of opioid overdose tion of opioid users is given by:
cases presenting to hospital emergency
rooms. With two lists or samples, there
are four possible locations where any given
individual may appear: on list X and not
on list Y, on list Y and not on list X, on list There is no restriction on the number of
X and on list Y and finally on neither list lists (samples) that may be used in the cal-
X or list Y. Figure 1 presents the range of culation of the estimate. In fact, the greater
possible locations in the form of a contin- the number of independent listings or
gency table. samples of opioid users, the more accurate
the estimate becomes.
In the figure on the next page, the only
unknown is cell f22, the frequency count Case in list Y
of the number of cases appearing on ei- (sample 2)
ther list or sample. Once we obtain the
number of cases appearing in the first three Yes No
cells, it becomes possible to estimate cell
f22, and subsequently the total population Case in list X Yes f11 f12
of opioid users. (sample 1)
No f21 f22=?
Obtaining a value for the first cell (f11)
requires that researchers attach unique
identifiers to each case appearing on both Advantages include:
lists. Examples of unique identifiers in-
clude date of birth, gender, marital status l a low-cost approach for helping to esti-
or ethnicity. Once this procedure is com- mate the number of people in need of
plete, it becomes possible to match the treatment for PSU disorders in your re-
number of individuals or cases appearing gion or community.
on both lists. The term “capture-recap-
ture” is derived from this process in that Disadvantages include:
individuals in the first sample or list are
captured and identified (tagged), and then l potential violation of the assumptions
a certain portion are re-captured or re- underlying the model, for example, in-
identified on the second list. The larger dependence of the samples (i.e., being
the number of unique identifiers, the on one list doesn’t influence the prob-
greater the precision in matching cases. ability of being on the other)
Cells f12 and f21 are easily estimated us-
ing the same identifying procedures. With l contamination of the samples through at-
values for the first three cells determined, trition (e.g., death) or mis-classification
the following formula, known as the
Peterson estimator, may be used to esti- l the length of time required to clean the
mate cell f22: lists and match cases if the unique iden-
tifiers
With values for the first three cells deter-
mined, the following formula, known as l lack the required detail and specificity
the Peterson estimator, may be used to es-
l limited background information about the
timate cell f22:
PS users on the lists making it difficult to
determine the types of treatment services
that may be most appropriate for them

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WHO/MSD/MSB 00.2d

Question 2
What is the relative need
for treatment services
across different regions
or communities?

“Questions One way to answer this question is to com- 100,000 population); poverty (e.g., per-
about the pare the prevalence of the in-need treat- cent owner-occupied units with water sup-
relative need ment population as established with one ply and/or electricity), and drunk driving
for services for of the three methods described in the above and traffic accidents (e.g., rate of drivers
PSU disorders section. However, other, more easily ob- involved in personal injury accidents by
can be tained statistical data may also be avail- 100,000 licensed drivers).
answered with able that are correlated with PSU disor-
indices that ders in the community. Geographic areas Once the individual indicators have been
combine can then be ranked on the various indica- selected, you have different options for
information on tors and then all the indicators combined combining them into an overall index. Fairly
several into one index that reflects PSU disorders. sophisticated statistical procedures such as
problems The index may then be used to compare cluster analysis and factor analysis have
related to the the relative level of these disorders across been used to create this index (Beshai,
nature and the regions. This method requires that you 1984; Tweed and Ciarlo, 1992; Tweed et
prevalence of have access to computerised records and al., 1992). Adrian (1983) presents two less
these that you have the resources and expertise complicated methods. The first approach
disorders.” to perform computer-based statistical involves ranking each indicator across the
analyses. various geographic areas being compared.
A mean rank is then calculated for each
Examples of indicators include indices of indicator and the mean rank for the indica-
alcohol availability (e.g., number of liquor tor is then ranked across the areas into an
stores per 100,000 population); mortality overall rank. This approach weights each
(e.g., rate of alcohol-related deaths per indicator equally and has the advantage of

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being easy to calculate and interpret. The tive need for services for PSU disorders is
disadvantage is that the approach is rela- the reliability and validity of each of the
tively insensitive to the magnitude of the individual indicators. For example, many
difference between ranks. social indicators (e.g., income level, hous-
ing) have only indirect relationships to PS.
The second approach used by Adrian Other indicators, such as drunk driving
(1983) first gives a value of 100 to the arrests and convictions, will be influenced
overall rate for each indicator, for all ar- by the level of policing and judicial discre-
eas combined. The small area rates are tion. While it can be argued that the dis-
then calculated as a fraction relative to advantages of one indicator can be offset
the overall rate. For each area, the mean by the advantages of another, indicators
of the various indices is then calculated should only be selected if they are reliable,
to create the composite PSU index. Un- valid and of comparable meaning across
like the ranking method, this index ap- the regions.
proach is sensitive to the degree of dif-
ference in the ranks between the areas In summary, questions about the relative
being compared. The main disadvantage need for services for PSU disorders can
is that the mean of the individual indices be answered with indices that combine in-
is sensitive to extremely high values. The formation on several problems related to
index method is more helpful in assess- the nature and prevalence of these disor-
ing relative need because it retains the ders. After one has compared a region or
degree of difference across the areas community to other areas a stronger ar-
being compared, and thus the relative gument for reallocating resources may be
importance of different indicators. A possible. However, neither the estimates
map of the different areas being com- of the in-need population, nor the relative
pared can also be developed showing the need for services compared to other ar-
variation in the level of PSU disorders eas, provide much direction in determin-
in relation to the average for the entire ing the type of services or the amount of
region. these services that are needed. Other need
assessment strategies are required to an-
The main limitation of all these approaches swer such questions and these are de-
to comparing different areas on the rela- scribed below.

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WHO/MSD/MSB 00.2d

Question 3
What types of services
are needed and what is
the necessary capacity?

Client-centered Community
Needs Assessment
Client-centred Community Needs Assess- l needs should be expressed as specific types
ment (CCCNA) is a prospective data col- of intervention (e.g., outpatient PSU disor-
lection procedure that assesses what cli- der counselling; life skills training) that can
ents or patients think about services that be established in the community
are needed. It has been applied in both
mental health (Cox et al., 1979) and sub- l relevant demographic and clinical in-
stance use treatment services (DiVillaer, formation on those individuals in need
1990 & 1996). It is easy to complete, and of the interventions should be collected
has the added advantage of assessing the
point-of-view of potential consumers of l there should be some assurance that those
programme services. There are four im- individuals in need of the interventions
portant assumptions underlying this ap- would actually use the interventions if
proach: established in the community

l community needs should be identified, This method asks about basic client infor-
at least in part, on the basis of compre- mation (e.g., gender, age), his/her PSU
hensive clinical assessment of a large behaviour, and information about the
and representative sample of individu- “ideal” intervention required by the client.
als in need The listed intervention is then coded as:

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WHO/MSD/MSB 00.2d

1 the intervention does not exist in the com- as well as the client’s own perception of
munity the suitability of different service options to
meet their needs. However, the CCCNA
2 the intervention exists but is not available method is limited in the following ways:
(i.e., agency admission criteria rule out this
client) or accessible (i.e., certain factors l needs of people presenting for treat-
such as transportation, hours of operation ment may not reflect the needs of all
rule out participation) people experiencing disorders in the
community
3 the intervention exists and is available and/
or accessible to the client l the lack of widely agreed upon criteria
for matching clients to treatment means
4 the intervention exists and is available that considerable judgement is in-
and/or accessible to the client, but the volved on the part of clinicians and cli-
client is unwilling to attend the agency ents in establishing the “ideal” treat-
that offers it in the community ment intervention

As the information accumulates about the sta- l depending on the number of agencies
tus of interventions needed for particular types involved, considerable time and re-
of clients, a profile emerges of important gaps sources may need to be dedicated to
in service in the community on region. training of personnel, monitoring the
quality of the data collection and
The main advantage of this needs assess- analysing and reporting the resulting
ment strategy is that it incorporates in- information
formation directly about the person in need,

Continuum of care approach


The rationale This approach is easy to complete and doesn’t prehensive assessment and matching to treat-
underlying the require sophisticated computer-based analyses. ment ensures effective use of each type of ser-
continuum of In this approach, you list the types of PSU dis- vice in the treatment system.Your list of ser-
care is that the order services that ideally should be available to vice types might include:
population in people in a region or community, and then con-
need of trast this ideal template with the actual state of l case identification
treatment for affairs. Although there is no international stan-
PSU disorders dard for the list of various services that should l comprehensive assessment
is highly varied be used as a template, there is wide agreement
and that many that the ideal treatment system should reflect a l case management
different types “continuum of care.” The rationale underlying
of services is the continuum of care is that the population in l withdrawal management (home/facility)
needed to meet need of treatment for PSU disorders is highly
these diverse varied and that many different types of services l brief intervention
needs. is needed to meet these diverse needs. Com-

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l methadone maintenance With your list completed, and appropriate


definitions developed, you then examine the
l outpatient counselling services in each region or community under
investigation and determine whether the ser-
l day/evening treatment vice is:

l short-term inpatient treatment l available; that is whether participa-


tion in the service is restricted by cer-
l long-term impatient treatment tain admission criteria (e.g., no legal
changes pending; must be male only);
l supportive housing
l accessible; that is whether factors
l continuing care make use of the program difficult (e.g.,
lack of public transportation, hours of
l mutual aid services, language of service provi-
sion).

Template to assess the availability and accessibility of services


along an ideal continuum of care
Region #1 Region #2 Region #3 Region #4
Avail Acc Avail Acc Avail Acc Avail Acc

Case identification
youth
Comprehensive assessment only

Case Management
Withdrawal/ Mgmt - (home)
Withdrawal/ Mgmt - (social)
Withdrawal/ Mgmt - (facility)
Methadone Maintenance
Brief Intervention
Outpatient Counseling
Day/ evening treatment female only

Short-term Inpatient treatment (medical)


Short-term Inpatient treatment (non medical)
cocaine uses
Long-term Inpatient treatment only
Supportive Housing
Continuing Care
Mutual Aid

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The information about availability and ac- Disadvantages include:


cessibility may come from a formal survey
of service providers, a review of previous l lack of standardisation across jurisdic-
service inventories or interviews with local tions concerning the components of an
key informants.A simple check-off proce- ideal treatment system and definitions of
dure will provide a crude overview of the the service categories
gaps in the treatment system in terms of the
availability and accessibility of specific types l insufficient attention to the quality of
of services. One should also provide a brief existing services and the evidence re-
written description of service availability and garding specific types of treatment in-
accessibility. The table on the previous page terventions that they offer (e.g., cog-
may serve as a template for those adopting nitive-behavioural vs. drug therapy)
this approach.
l insufficient attention to the flow of cli-
Advantages include: ents across these service components
and other dimensions of system-level
l easy to conceptualise and implement co-ordination

l allows for creative thinking about new l inability to quantify the required capac-
service options not previously adopted ity and resource complement (e.g.,
in the region(s) staff, beds) of the services considered
to be needed

Normative approach
Normative need assessment models are cluded death rates from liver cirrho-
essentially “demand-based”, that is pro- sis, alcohol dependence, alcohol poi-
jecting future needs on the basis of past soning, suicide, homicides, automobile
demand on, and performance of, the accidents and alcohol-related psycho-
treatment system. This approach is fairly sis. These indicators were factor-
complicated, and best for those with com- analysed and two separate indices of
puter and statistical resources. The most alcohol-related problems emerged.
sophisticated of these approaches also The first factor was called a Chronic
takes into account local variation in the Health Index and was used to estimate
profile of PSU disorders. the prevalence of chronic, long-term
alcohol-related problems. The second
The Alcohol Treatment Profile System factor, called the Alcohol Causality In-
(ATPS) developed in the U.S.A. is a dex, was used to estimate the preva-
good example of a normative needs lence of acute alcohol intoxication.
assessment model (Ryan, 1984/1985). The value of this index does not indi-
The ATPS has two main components. cate how many individuals suffer from
The first component, referred to as the acute intoxication or chronic long-term
“need” component, was developed problems, but rather indicates “relative”
based on seven mortality-based indi- prevalence ratings for individual coun-
cators reported as average annual ties. The mortality indicators are avail-
death rates per 100,000 population for able nationally at the county level. Con-
the age group 15 to 74, and for the sequently, an index value for each county
period 1975-1977. The indicators in- has been calculated and published.

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WHO/MSD/MSB 00.2d

The second component of the ATPS nor- ners use these tables to compare the ex-
mative model is the “demand” component pected treatment capacity of a county im-
and is based on treatment data collected plied by the normative model with the
at the national level by the National Drug county’s actual or observed capacity.
and Alcohol Treatment Survey
(NDATUS) (Harris & Colliver, 1989). The Advantages include:
survey data provide estimates of the levels
and patterns of existing service use and ser- l ease of use once the necessary informa-
vice capacities for each planning area across tion has been compiled
the country. Level of use is expressed as
the number of clients served. Service ca- l for each estimate, the model provides
pacity is expressed as the number of treat- a high and low range for a given plan-
ment slots. NDATUS classifies treatment ning area and this is helpful in applying
into seven different modalities: medical the results in the decision-making pro-
detoxification, social detoxification, rehabili- cess
tation, custodial, ambulatory, limited care
and outpatient. Service use and capacity are Disadvantages include:
estimated separately for each of these treat-
ment modalities. l the social and health indicators that
comprise the problem indices in the
In the ATPS model, the NDATUS data model are subject to a wide variety of
form the dependent variable. “Observed” biases
treatment service levels and capacities for
an area are therefore modelled as a func- l the data on past treatment service
tion of the two indices of alcohol-related utilisation may not be based on all
problems. Because the relationship be- existing treatment facilities since
tween need and demand varies substan- some may not have participated in
tially according to different population the survey or otherwise have been
sizes, population size is included as a third excluded (e.g., treatment in the pri-
independent variable in the model. Esti- vate sector)
mates of total expected clients and total
treatment capacities and estimates bro- l the assumption that current or past
ken down by treatment modality, are re- treatment service utilisation patterns
lated to an area’s Chronic Health Index, are an adequate reflection of current
its Alcohol Causality Index and its popu- client needs at the time services are
lation size. For planning purposes, esti- provided and in the near future. For
mates of expected clients and treatment example, the needs of the potential
capacities are presented in a series of population of service users may not
tables according to an area’s population be identical to the needs of the client
size, Chronic Health Index and Alcohol population who have sought treat-
Causality Index. Needs assessment plan- ment in the past

20 Evaluation of Psychoactive Substance Use Disorder Treatment


WHO/MSD/MSB 00.2d

Prescriptive approach

Unlike the demand-based ATPS normative 3 Considering the rate of recidivism and to
model, which relies on what actually exists in keep even with this 10 percent rate of in-
the treatment system in terms of service crease, 30 percent of all alcohol depen-
utilisation patterns, prescriptive models dent persons should be treated in a given
Unlike demand- specify the level of treatment services that year.
based normative should or “ought” to be provided to the resi-
models, which dents of a given planning region. This ap- 4 This figure should be divided into two
rely on what proach can be seen as an extension of the because alcohol dependent persons
actually exists in “continuum of care” approach described constitute only half of the in-need popu-
the treatment above, but more complicated and requiring lation. Thus, 15 percent of the overall
system in terms more computer resources. in-need population should be treated in
of service a year.
utilisation Prescriptive models usually begin with a
patterns, prevalence estimate of the size of the popu- 5 Add a 5 percent buffer to do more than
prescriptive lation in need. It is realistic to assume that keep pace with the growth of the prob-
models specify not all of these individuals will voluntarily lem. Therefore, 20 percent of the prob-
the level of seek treatment and that there are only lim- lem drinkers per year are considered as
treatment ited resources available to treat those who the target population.
services that come to the attention of treatment special-
should or ists. An objective, then, is to determine what One of the most serious problems with pre-
“ought” to be proportion of the in-need population should scriptive models is that the assignment of
provided to the receive treatment in a given year. Many pre- assumptive values to the estimated popu-
residents of a scriptive models arrive at a figure of 20% lation “in-need” of services is a rather arbi-
given planning based on a series of “assumptive” values or trary procedure based on empirical data
region. proportions assigned to the population with which are questionable in terms of reliabil-
alcohol use disorders in a region or area (see ity and validity. For example, rates of re-
below). This final value, indicating the level cidivism are estimated from treatment data.
of “demand” for treatment services, is then The figure of 10% to represent the increase
apportioned throughout various components in the number of alcohol dependent persons
of the ideal treatment system (detoxification, from one year to the next is not likely to be
case management, etc.). a constant. These proportions can be con-
sidered at best as very rough guesses. More-
Ford (1985) describes a standard set of over, the values are likely to vary across
procedures to arrive at the 20% estimate different planning regions and over time.
of the proportion of the in-need popula- Another problem with the prescriptive
tion to be treated each year: model is that it can be value laden, espe-
cially in those aspects of the model where
1 Two-thirds of alcohol dependent per- little empirical data exist to guide the se-
sons drink again within one year of lection of various parameters. For example,
treatment. treatment practitioners will have different
opinions concerning how the demand popu-
2 The rate of increase in alcohol depen- lation should be apportioned throughout the
dence is around 10 percent per year. treatment syste.

Workbook 3 · Needs Assessments 21


WHO/MSD/MSB 00.2d

Efforts have been made to minimise this Another significant problem with this prescrip-
subjective component. A comprehensive tive approach is similar to that identified for
forecasting model for estimating the ca- the more basic continuum of care approach.
pacity of alcohol treatment services in Specifically, the model will project needs only
Ontario, Canada (Rush, 1990) bases for services identified a priori as being key
these estimates on six different sources components of the ideal treatment system. This
of information: published research litera- approach may restrict innovation in the plan-
ture on patient characteristics; cost-effec- ning and delivery of services for PSU disor-
tiveness of treatment, and rates of comple- ders if an outdated, or otherwise inappropri-
tion of treatment; a preliminary client ately structured, treatment system is used as
monitoring system for assessment and re- the foundation for model development.
ferral services; a detoxification reporting sys-
tem; a triennial provincial survey of alcohol
and drug programmes; informed opinion
from clinical and research experts and an
American forecasting model.

22 Evaluation of Psychoactive Substance Use Disorder Treatment


WHO/MSD/MSB 00.2d

Question 4
Are existing services
co-ordinated and what is
needed to improve the
overall level of system
functioning?
Workbook 4 provides information about l staff sharing or exchange - staff of dif-
process evaluation of treatment services ferent services are permanently or tem-
and systems for PSU disorders. It includes porarily shared or loaned
a brief discussion of the evaluation of sys-
tem co-ordination. The issues to be ad- l other resource exchanges - the extent
dressed, and the measures of co-ordina- to which services share funds, meeting
tion that may be used, are similar for rooms, materials or other resources
process evaluation and community need
assessment. System co-ordination is typi- l consultations and case conferences -
cally assessed using reports and ratings exchanges that concern the treatment
from directors or managers of agencies of specific clients
that are expected to work together in ser-
vice planning and delivery. Ratings are l overlapping boards - the number of
typically given on: members in common to community
boards of different services
l mutual awareness - the extent to which
staff know about each other and their l normalisation of agreements - the extent
respective programmes to which services have developed formal
agreements to co-ordinate activities
l frequency of interaction - how often key
staff meet to discuss work-related issues Specific measures of service co-ordination
that may be used in a community needs
l frequency of cross referrals - how often assessment are not well-developed in
or how many clients are referred to and terms of reliability and validity. One often
from different services in the network takes a more qualitative approach based
on key informant or focus group interviews.
l information exchange - the extent to Such qualitative data collection procedures
which services exchange information are described in Workbook 1.

Workbook 3 · Needs Assessments 23


WHO/MSD/MSB 00.2d

It’s your turn


Put the information from this workbook to help you complete a full evaluation
to use for your own setting. Complete plan. Review that information now, if you
these exercises below. Remember to use have not already done so.
the information from Workbooks 1 and 2

Exercise 1
Think about your treatment programme. Example: What types of services are
List five general areas in which you want needed for cocaine users in the community?
to know more about the needs of the com- 1)
munity. 2)
3)
4)
5)

Exercise 2
Assess the availability of existing records l number of patients receiving treatment
for each of the areas that you listed above. within a certain area and/or treatment
system
Do you have access to:
Your answers to these questions will help
l morbidity data you to choose needs assessment that
maximise use of existing data.
l mortality data

Exercise 3
Using the information provided in this l Choose a sampling procedure for
workbook, make the following decisions: choosing specific clients/data to
survey
l Decide what method you will use
to collect the data (e.g., general l Decide the timing of the evaluation
population survey, mortality-based
l Develop a procedure for ensuring con-
prevalence model). Review the infor-
fidentiality and promoting honesty
mation in this workbook as needed
to help you decide. l Decide who will help you collect data

Exercise 4
You will need to prepare an introduc- age Ethical Issues, for more informa-
tory letter and consent form that explains tion about the important topic of par-
the purpose of your study. Review Sec- ticipants rights in evaluation research.
tion 1A of Workbook 2, entitled, Man-

24 Evaluation of Psychoactive Substance Use Disorder Treatment


WHO/MSD/MSB 00.2d

In general, all participants should be asked If you agree to participate, please read and
permission ahead of time before being en- sign the consent form (attached) and re-
rolled in the study. When you do this, your turn it in the stamped envelope with the
should explain the purpose, nature, and completed questionnaire. Thank you for
time involved in their participation. No your time.
person should be forced or coerced to Sincerely,
participate in the study. Dr. X

The standard practice is to have each par- Consent Form:


ticipant sign a consent form, which:
You agree to participate in a survey of
l describes the purpose and methods of substance use patterns. You will complete
the study a 2 page questionnaire, which will take
about 10 minutes to complete. Your par-
l explains what they will need to do if ticipation is completely voluntary. You can
they participate refuse to answer any questions and/or
withdraw from the study at any time with-
l explains that participation is voluntary out a problem to you. All your responses
will remain strictly confidential: your name
Example (from above): will not appear on your questionnaire and
your responses will not be linked to your
Introductory Letter: identity at any time.

We are asking your help in understanding I have read the information above and
the needs of the community by filling out agree to participate.
a 2 page questionnaire about your sub- Signature:
stance use patterns. The questions will ask Date:
about your substance use and any effects
that it might have on your life. They will Now it’s your turn. Using the example
take about 10 minutes to complete. All above, and the information provided in
information that you provide us will re- Workbook 2, section 1A, write your own
main strictly private and confidential. introductory letter and consent form.

Exercise 5
Run a pilot test of your evaluation mea- l Can the questions be administered prop-
surement and procedures on 10-15 sample erly? For example, is it too long or too
participants to ensure that everything runs complicated to be filled out properly?
smoothly. Review section 1c of Work-
book 2 entitled Conduct a Pilot Test for l Can the information be easily managed
specific information about how to do this. by people responsible for tallying the
In general, pilot tests assess these ques- data?
tions:
l Does other information need to be col-
l Do the questions provide useful infor- lected?
mation?

Workbook 3 · Needs Assessments 25


WHO/MSD/MSB 00.2d

Conclusion and
a practical
recommendation

In this workbook, a wide range of meth- however, to explore what the results mean
ods have been described that address four for your programme. Do changes need to
questions that are commonly asked in a happen? If so, what is the best way to ac-
needs assessment concerning PSU disor- complish this?
ders. These questions were:
Return to the expected user(s) of the evalu-
l How many people in the region or com- ation with specific recommendations based
munity need treatment for PSU disor- on your results. List your recommenda-
ders? tions, link them logically to your results,
and suggest a period for implementation
l What is the relative need for treatment of changes. The examples below illustrate
services across different regions or this technique.
communities?
Based on the finding that over 1/4 of ran-
l What types of services are needed and dom sample community respondents
what is the necessary capacity? had used cocaine in the past 90 days,
and among those, 58% were interested
l Are existing services co-ordinated and in receiving treatment, we recommend
what is needed to improve the overall that the programme institute a new co-
level of system functioning? caine treatment service. The service
should begin in March, which is tradi-
For each type of question, there are tionally a low-census month for the
choices to be made in selecting the spe- programme, and would allow for extra
cific need assessment models or methods. start-up time.
You must take into account the nature of
the decisions to be made with the result- Remember, needs assessments are a criti-
ing information and the time, expertise, cal first step to better understanding the
and resources available. Each model or PSU treatment requirements of the com-
method also has advantages and limita- munity. It isimportant to use the informa-
tions that must be carefully considered. tion that needs assessments provide to re-
direct treatment services. Through careful
After completing your evaluation, you examination of your results, you can de-
want to ensure that your results are put to velop helpful recommendations for your
practical use. One way is to report your programme. In this way, you can take im-
results in written form (described in Work- portant steps to create a ‘healthy culture
book 2, Step 4). It is equally important, for evaluation’ within your organisation.

26 Evaluation of Psychoactive Substance Use Disorder Treatment


WHO/MSD/MSB 00.2d

References

Adrian, M. Mapping the severity of alco- hol, Health and Research World, 1989,
hol and drug problems in Ontario. Cana- 13(2):178-182.
dian Journal of Public Health, 1983, 74,
(Sept-Oct):335-342. Robins, L.N., Wing, J., Wittchen, H-U. &
Helzer, J.E. The Composite International
Beshai, N. Assessing needs of alcohol-re- Diagnostic Interview: an epidemiologic
lated services: A social indicators ap- instrument suitable for use in conjunction
proach. American Journal of Drug and Al- with different diagnostic systems and in
cohol Abuse, 1984,10(3):417-427. different cultures. Archives of General
Psychiatry, 1988, 45:1069-1077.
Cottler, L.B., Robins, L.N., Grant, B.F.,
Blaine, J., Towle, L.H., Wittchen, H-U., Rush, B.R. Systems approach to estimat-
Sartorius, N., and Participants in the ing the required capacity of alcohol treat-
Multicentre WHO/ADAMHA Field Tri- ment services. British Journal of Addic-
als. The CID-core substance abuse and tions, 1990, 85(1):49-59.
dependence questions: cross-cultural and
nosological issues. British Journal of Psy- Ryan, K. Assessment of need for alcohol-
chiatry, 1991, 159:653-658. ism treatment services: Planning proce-
dures. Alcohol Health & Research World,
Cox, G.B., Carmichael, S.J., & Dightman, 1984/1985, 9(2):37-44.
C.R. The optimal treatment approach to
needs assessment. Evaluation and Program Tweed, D.L., & Ciarlo, J.A. Social-indi-
Planning, 1979, 2:269-275. cator models for indirectly assessing
mental health service needs. Epidemio-
DeVillaer, M. Client-centred community logic and statistical properties. Evalua-
needs assessment. Evaluation and Program tion and Program Planning, 1992,
Planning, 1990, 13:211-219. 15(2):165-179.

DeVillaer, M. Establishing and using a Tweed, D.L., Ciarlo, J.A., Kirkpatrick,


community inter-agency monitoring sys- L.E., & Shern, D.L.. Empirical validity
tem to develop addictions treatment pro- of indirect mental health needs-assess-
grams. Addiction, 1996, 91(5):701-710. ment models in Colorado. Evaluation and
Program Planning, 1992, 15(2):181-194.
DeWit, D., & Rush, B.R. Assessing the
need for substance abuse services: A criti- Wittchen, H.U., Robins, L.N., Cottler,
cal review of needs assessment models. L.B., Sartorius, N., Burke, J.D., Regiers,
Evaluation and Program Planning,1996, D.A. and Participants in the Multicentre
19(1):41-64. WHO/ADAMHA Field Trials. Cross-cul-
tural feasibility, reliability, and sources
Ford, W.E. Alcoholism and drug abuse of variance in the Composite International
services forecasting models: A compara- Diagnostic Interview (CIDI). British Jour-
tive discussion. The International Journal nal of Psychiatry, 1991, 159: 645-65.
of the Addictions, 1985, 20(2):233-252.
World Health Organization (WHO). Com-
Harris, J.R. & Colliver, J.D. Highlights from posite International Diagnostic Interview
the 1987 National Drug and Alcoholism (CIDI). Version 1.0. Geneva, Switzerland:
Treatment Unit Survey (NDATUS). Alco- World Health Organization, 1990.

Workbook 3 · Needs Assessments 27


WHO/MSD/MSB 00.2d

Comments about
case examples

The following case examples describe dif- The second case presents a needs assess-
ferent types of needs assessments. As noted ment that was conducted without the
earlier in the workbook, most experts agree availability of computerised data re-
that a single, all-purpose needs assessment sources. In this situation, evaluators
technique does not exist. This is because wanted to know the service needs for a
evaluation planners have different goals, and rural and underdeveloped area of South
have different data resources available. Africa. Official data were unavailable, so
evaluators decided to use key informant
The first case example describes an evalua- surveys and focus groups as their primary
tion of treatments for PSU dependence in mode of data collection. Through meet-
Barcelona, Spain. Several computerised da- ing and interviewing representatives from
tabases were already available, and were used government, police, commerce, and the
by evaluators to estimate PSU prevalence general community, evaluators were able
and treatment needs within Barcelona. In this to determine perceived PSU trends and
respect, this case is an excellent example of treatment needs.
how existing data can be used effectively to
conduct needs assessments. The overall Of note, neither case relied upon client
evaluation is complex, and includes aspects opinions to assess needs. Direct interview-
of needs assessment, cost analysis (Work- ing of PS users is another option for needs
book 5), and outcome evaluation (Workbook assessments, and can generate highly use-
7). The planners wanted to know trends in ful data. Of course, this type of data would
psychoactive substance use, characteristics be qualitatively distinct from computerised
of PSU users, costs of PSU treatment, and databases and community key informant
effectiveness of care. Other evaluators in- surveys. There is no single right or wrong
terested solely in needs assessment could use way to assess needs; each technique pro-
similar techniques in a narrower scope. To vides a unique and potentially useful type
use this technique, computerised data must of data.
be available.

28 Evaluation of Psychoactive Substance Use Disorder Treatment


WHO/MSD/MSB 00.2d

Case example of a
needs assessment

Planning and evaluating outpatient


care for drug dependent patients
in Barcelona (Spain)
by
The authors alone are Rodríguez-Martos, A*
responsible for the Solanes, P.*
views expressed in this Torralba, Ll*
case example.
Brugal, M.T.**
* Plan d’Acción sobre
Drogues de Barcelona.

** Servei Contact address:


d’Epidemiologia. Alicia Rodríguez-Martos
Institut Municipal de Plan d’Acción sobre Drogues de Barcelona
la Salut. Pl. Lesseps, 1
08023-Barcelona (Spain)

Who was asking guidelines for programme improvement.


The availability of a health information
the question(s) system incorporating data on both services
and why did and population should allow the assess-
ment of accessibility, coverage and effec-
they want tiveness of care.
the information?
The Care and Follow-up Centres (CFCs)
This report is based on the research done pertaining to the City Council, have of-
on effectiveness of care programmes for fered services since 1990, including the
drug dependents by the Barcelona munici- old drug-free programmes and substitu-
pal drug action plan (Pla d’Acción sobre tion programmes with drug administration
Drogues de Barcelona) during the last such as the methadone maintenance
decade. Thanks to Barcelona’s Informa- programme. Other therapeutical activities
tion Service data were available on the were offered including main health care,
utilisation of outpatient facilities, as well social, educational and support activities
as population morbidity and mortality sta- for families, as well as legal advice and
tistics. The goal in analysing these facility attention.
and population statistics was to develop

Workbook 3 · Needs Assessments 29


WHO/MSD/MSB 00.2d

Even though Spain had developed a valu-


able information system on drug depen- c) to get the most out of activities
dencies, the Sistema Estatal de favouring patient’s contact with treat-
Información sobre Toxicomanías (SEIT), ment resources as well as changes in
the managers of care centres and addicts life style and risk behaviours.
programmes needed complementary local
information. This included data obtained Objectives of the evaluation study were
from patients’ follow-up. Thus, a global to assess the efficacy and effectiveness of
perspective was adopted based on that services offered in order to accomplish
proposed by L‘ðnnqvist (1985), which these main care objectives.
starts with the classical analysis of struc-
ture, process and treatment results, con-
centrates on the assessment of objectives,
coverage and effectiveness of care, taking
into account its cost and secondary effects.
What resources were
needed to collect and
The information system on drugs of
Barcelona, the Servei d’Información sobre
interpret the
Drogodependéncies a Barcelona (SIDB), information?
set up in 1988 under the Pla d’Acción
sobre Drogues de Barcelona, is a The information system we used for mea-
programme devoted to the systematic suring and evaluating the achievement of
analysis of the size and evolution of drug objectives set up by the Pla d’Acción
abuse in Barcelona. It is designed to evalu- sobre Drogues de Barcelona was the
ate its size and evolution. SIDB. The objectives of the information
system had been already consolidated and
The observation of phenomena with validated and their widening was then
stigmatising characteristics makes it diffi- considered. The additional objectives
cult to develop direct measurement tech- were:
niques used for other health problems.
Therefore, it was necessary to create an a) to identify trends in drug abuse in the
information system that, using indirect in- city of Barcelona;
dicators, could enable us to understand and
monitor the drug addiction problem in b) to describe the basic characteristics of
Barcelona. The process of designing and identified addicts;
implanting SIDB indicators began in 1988
following the general outline proposed by c) to support the management, evaluation
the National Drug Plan and the Drug Ad- and implementation of programmes.
diction Plan of Catalonia.
The number of people detected by this
Main care objectives of the Pla d’Acción Information System included, for 1995,
sobre Drogues de Barcelona were: data on people assisted at emergency room
(3,519), treatment starts (4,119), overdose
a) to improve quality of life and life ex- (150), and new identified drug users
pectancy of Barcelona’s drug addicts; 2,495).

b) to offer enough treatment services so The global cost of this information system
that access could be guaranteed to ev- was 156,456 ECU for 1995.
ery person asking for it;

30 Evaluation of Psychoactive Substance Use Disorder Treatment


WHO/MSD/MSB 00.2d

How were the data their activity (type of interview, medical


check-up, social and psychological fol-
collected and low-up and referrals) and characteristics
analysed? of the users (demographic and socio-eco-
nomical data, toxic habits and health
characteristics). The amount of data
The SIDB is based on three fundamental gathered from this information network
indicators: allows the municipal drug action plan to
give priority to some activities, to evalu-
1) Treatment starts: with information ate and to control the management of
from first interviews (admissions to those centres belonging to the City
treatment) in Care and Follow-up Cen- Council.
tres (CFCs) devoted specifically to the
treatment of drug addicts;
Drug-related hospital emergencies
2) Drug-related emergencies - the infor-
mation of which is obtained from the The data are actively collected at the Emer-
Emergency Services of main urban gency Services of the main district hospi-
hospitals in the different districts; tals by the Epidemiology and Drug Ser-
vice nursing team. The information comes
3) Mortality - from an acute adverse reac- from the assistance reports recorded by the
tion to drugs or overdoses, recorded by Emergency Services. An emergency is con-
the Anatomic Forensic Institute and by sidered to be drug-related when the dis-
the National Toxicological Institute. charge report either states the person is
a user of illegal drugs or when the ini-
Treatment starts tials IDU or the words drug addictión
Concerning first interviews, this indica- appear on the report. In every identified
tor provides us with information about case, a standardised form for data col-
CFCs=ð activity carried out by ten city lection, including demographic informa-
centres empowered by local authorities tion and circumstances of the incident,
to care for addicts. These ten centres is filled in. The indicator refers to the
included four CFCs belonging to the number of episodes dealt with by hospi-
City Council, and six sponsored by other tals and to the number of people being
organisations. Under treatment start, cared for because of this reason.
we mean:
Mortality related to acute adverse re-
a) first interview made to the centre by action to drugs (overdose)
the person requesting its services;
Information is obtained from the
b) new interview requested by a previous records of autopsies carried out by the
patient after having interrupted treatment Anatomic Forensic Institute. Data are
for a long time and wanting to start treat- collected monthly by the Epidemiology
ment again at the same centre. A patient and Drug Service nursing team. A case
is considered to be new when he/she is registered when the forensic surgeon
hasn’t been to the centre for at least six reports that this death was due to over-
months. dose. The report includes the macro-
scopic pathology, the circumstances of
This information is gathered by means death and eventual tools or objects
of a standardised survey in each first in- found at the scene of death as well as
terview. CFCs collect all data in a sys- any report given by family or friends of
tematic way in order to provide the the deceased person. The toxicological
SIDB as well as the SEIT, with data on findings are not taken into account.

Workbook 3 · Needs Assessments 31


WHO/MSD/MSB 00.2d

Besides this information about the general necessity of assessing social priorities to
population, data from Barcelona’s prison be answered.
files have been collected since 1993.
There has also been an attempt to develop
All these data were processed in such a a unit of analysis for alternative produc-
way that its validity and consistency could tivity, based on product analysis and an
be assured: estimation of time assigned to profession-
als for different care activities. An inter-
a) the data collection was carried out by disciplinary group defined the intermedi-
specially trained health professionals; ate care products accomplished by the
municipal CFCs, and mean time needed
b) a protocol had been developed defin- for every basic product was then calcu-
ing concepts and criteria for inclusion; and lated.
this was a reference protocol for all people
working in the SIDB at any stage of the Coverage evaluation
process;
An estimation of the target population was
c) there was a validated entry of data into needed for evaluating the programmes’
the computer. coverage. Otherwise, it would not be pos-
sible to ascertain if the programme were
After examining the reliability and inter- reaching only a small proportion of the
nal coherence of data gained from differ- population in need. The SIDB provided
ent recorded episodes using the chosen us with the data required to estimate cov-
indicators, it was concluded that there erage using capture/recapture techniques
was a need for an identifying element that (Domingo-Salvany et. al.).
could be used to link different registers
together. The chosen element was the first This kind of information is most useful for
three letters of both surnames (from fa- estimating the need for already existing
ther and mother), birth date and gender. services and for quantifying the volume of
Afterwards, we were able to use an algo- users in need of other care services. Given
rithm for maximising the probability of the chronic and relapsing nature of addic-
unequivocal identification and matching tions and to evaluate coverage properly, it
every individual with episodes protago- was important to differentiate between first
nised by himself. Validity confirmation treatment starts and patients who started
was thus achieved in 97% of pairings, again after drop-out, both among admis-
with sensitivity and specificity both over sions and patients following treatment.
95%.
Assessment of Effectiveness
Measurement of Activity, Productivity
and Cost of Care Various indicators, based on scales
which match several variables in an ac-
For measuring the activity of treatment cumulative way, had been proposed to
centres, standardised measurement units measure the efficacy of care. One indi-
were used for three types of activities: cator could be the percentage of treated
first interview, follow-up visits and patients maintaining abstinence at twelve
methadone dispensation. The assessment months follow-up. Nevertheless, the
of patients in current treatment has evaluation of effectiveness needs to be
proven to be useful, taking into account indirect, using such indicators as reten-
the diversity of drugs involved and the tion in treatment programmes; improve-

32 Evaluation of Psychoactive Substance Use Disorder Treatment


WHO/MSD/MSB 00.2d

ment in delinquency; overdoses and basis. It provides information on


mortality because of acute adverse drug citizens=ð worries by two different ways:
reaction; utilisation of other medical ser- by an open question, with spontaneous
vices; incidence of tuberculosis and answer, and by a list of topics proposed
AIDS. It has been suggested that people to the surveyed so that he/she could rate
maintaining contact with care services his/her level of worry related to each one.
use illegal drugs less, present less delin- The follow-up and comparison of results
quency and are less involved in legal among successive surveys (SabatJð et al.,
problems, even when they are not cured 1997) show interesting changes over the
(Buning, E., 1994). Thus, we elected to considered period of time, probably re-
measure the quality and effectiveness of flecting both the dimension of crime and
care resources by measuring the reten- people’s perception of drug problems.
tion rate in treatment programme. In
recent years, a greater retention in According to the last surveys, there is a
methadone maintenance programmes growing understanding on the part of the
compared to that in drug-free population concerning drug addicts and
programmes had been proven. In our the usefulness of rehabilitation policies.
study we have compared the retention In the spontaneous statement about wor-
capability among four different munici- ries, the drug problem has been dropping
pal CFCs and between both types of steadily (from 10% to approximately 2%).
treatment programmes (methadone Within the list of topics which might be
maintenance and drug-free cause for concern, drugs have also de-
programmes). clined, even for people who continue to
associate youth violence with drug use,
Another approach to the measuring of ef- when specifically confronted to this ques-
fectiveness could be to register the evo- tion. There is a trend towards the reduc-
lution of happenings the avoidance of tion of delinquency registered by the po-
which is one of the treatment goals: petty lice parallel to the starting of methadone
crime and legal offences; utilisation of programmes (unpublished data).
other care services (emergency room,
etc.); AIDS and tuberculosis incidence;
and overdose deaths. Actually, the SIDB
provides us with data concerning over-
dose deaths, emergency room utilisation, What did they find out?
etc., while data on AIDS and tuberculose
incidence are provided by the Epidemio-
logical Service. A deviation in expected
trends concerning those items may be at- Measurement of activity, productivity
tributable to the impact of new policies and cost of care
and programmes.
Table I shows defined intermediate prod-
To measure delinquency one could col- ucts for classifying the activity of four mu-
lect the reporting of criminal actions. nicipal CFCs with concerted manage-
Nevertheless this variable is liable to ment, mean time estimated in each case
swings related to police policy or public and equivalence in care units for drug de-
opinion and attitude. To avoid this prob- pendencies.
lem, surveys of representative samples of
population have been and are still being Table II shows care products and costs
carried out. The survey on victimisation starting from an estimation of direct costs
and urban security is held on a periodical of treatment, without including either in-

Workbook 3 · Needs Assessments 33


WHO/MSD/MSB 00.2d

vestments or indirect costs. Comparison Coverage evaluation


of different products among centres
showed the different way they operated. By means of capture/recapture tech-
It also indicated that cost analysis centred niques applied over six months, both to
in time assigned to care activities as well treatment admissions and to emergency
as that centred on drug dependence care visits and jail entrances, a prevalence of
units (DCUs), dramatically reduced the around 10,000 active opiate addicts
variability in estimation of unitary costs. could be calculated for 1993. From this
information, we could estimate the per-
The mean annual cost per client was 365 centage of those covered by treatment
EDU, within a large range, from 343 to services. Based on the number of pa-
445 ECU among centres, reflecting differ- tients in treatment in our four CFCs, we
ent treatment models and the balance of were also able to estimate the volume
therapeutic activities. The cost of a first of drug addicts attending treatment
interview lay between 49 ECU and 56 programmes in the whole city, thus in-
ECU. Methadone dispensation had a cost cluding the remaining six CFCs of
of 2.59 ECU. Barcelona. Concerning opiate addicts,
5,446 addicts living in Barcelona hap-
Those centres with a lot of patients in low pen to be in treatment, which represents
retention programmes had more clients at a 54% coverage of the target popula-
the expense of a bigger volume of not very tion (4,209 patients in municipal CFCs
active users, generating less mean costs, and 1,237 attending other CFCs).
than those attending centres with more
patients in high retention programmes.

Table 1: Intermediate products defined for classifying the activity of four CFCs belonging
to the City Council with concerted management. Estimated mean time and proposed
equivalence in drug dependence care units.

Product Annual Meantime Estimated Equivalence


activity (in minutes) activity in drug
minutes dependence
care units
(DCUs)

First visit 2,015 50 100,750 1.00


Therapeutical (a) follow-up 15,258 25 381,450 0.40
Medical follow-up visit 18,442 15 276,630 0.40
Social follow-up 7,925 30 237,750 0.40
Therapeutical group for families 167 45 7,515 0.40
Therapeutical group for patients 549 45 24,705 0.40
Nurse interview 3,507 7 24,549 0.10
Drug dispensation 206,295 3 618,885 0.05

a) Therapeutical refers to any care offered within the recovery programme (mainly counselling and psychotherapeutical
approach)

CFC: care and follow-up centre; DCU: drug dependence care unit

34 Evaluation of Psychoactive Substance Use Disorder Treatment


WHO/MSD/MSB 00.2d

Table III (on page 36) presents this infor- those on drug-free programmes. These
mation related to municipal CFSs between results should imply a substantial redefini-
1991-1994. The number of people enter- tion of goals and objectives for the cen-
ing treatment for the first time went down tres, as well as a review of inclusion crite-
during this period to about 25%, what ria for methadone programmes.
could be attributed to a growing number
of drug users getting in contact with the With respect to the general population,
system. there has been a reduction in the percent-
age of people identifying drugs as one of
Assessment of effectiveness the most important social problems (from
9.7% in 1991 to 2.7% in 1993). Coincid-
Clear differences could be observed among ing with a stabilisation in victimisation, citi-
centres concerning their retention rate: af- zens tended to consider drug addicts as
ter 2 year follow-up, retention was 77% patients, demanding more treatment and
for patients on methadone and 6% for care resources.

Table 2: Activity and costs of the CFCs belonging to the City Council with concerted
management. Barcelona 1994.

Product Centre A Centre B Centre C Centre D Total


activity

First interview 684 631 353 347 2,015


Sucessive therapeutical (a)
follow-up interview 6,053 3,020 2,429 3,756 15,258
Sucessive medical
follow-up interview 7,057 3,692 2,708 4,985 18,442
Nurse interview 1,493 1,129 274 611 3,507
Social follow-up 713 4,376 1,422 1,414 7,925
Therapeutical group for families 65 37 38 27 167
Therapeutical group for patients 312 90 137 10 549
Drug dispensation Costs 57,617 55,986 49,627 43,065 206,295
Annual Cost (thousands of pts.) 76,460 74,259 48,019 54,205 252,943
Active users 1,342 1,314 813 740 4,209
Cost per user 56,975 56,514 59,064 73,250 60,096
Estimated minutes of care activity 513,037 475,286 320,329 363,582 1,672,234
Cost per care minute (pts) 149 156 150 149 151
Drug care units (DCUs) 9,394 8,029 5,555 6,638 29,617
Cost per DCU (pts.) 8,139 9,249 8,644 8,166 8,541

a) Therapeutical refers to any care offered within the recovery programme (mainly counselling and psychotherapeutical
approach)

CFC: care and follow-up centre; DCU: drug dependence care unit

Workbook 3 · Needs Assessments 35


WHO/MSD/MSB 00.2d

Table 3: Total treatment starts in four CFCs* belonging to the City Council. Barcelona,
1991-1994.

Product Starting % Total


treatment for starts
the first time

1991 1,099 44.9 2,448


1992 1,243 47.2 2,633
1993 735 29.6 2,483
1994 695 25.4 2,736

CFC: care and follow-up centre

The utilisation of hospital emergency rooms in non-IDU population. In 1993, 177 new
depends on several factors, including the cases of tuberculosis were declared in IDUs
kind of answer given by the patient. A ser- (see Table V). Nevertheless, 314 IDU pa-
vice prone to administer or prescribe cer- tients with tuberculosis were registered in
tain drugs will automatically increase its in- Barcelona concerning chemotherapy admin-
flow of drug users. Regardless of the istered to them during the year (part of them
attraction exerted by each centre and the were patients notified the year before and
annual oscillations, Barce- lona’s hospital currently following treatment; others were
emergencies have reduced to around 20% patients who had dropped out of treatment
between 1988 and 1993 (Table IV). and were lost for follow-up). Information
on tuberculosis in different population
Tuberculosis and AIDS are monitored in groups was gathered since 1987.
the surveillance system, both diseases be-
ing strongly related. After an increase from The spread of HIV infection among IDUs
1988, tuberculosis and AIDS had both de- has partly been responsible for the increase
creased. Tuberculosis in intravenous drug in tuberculosis rates. Another consequence
users (IDUs) increased 47% between 1988 of this infection is obviously the rise in
and 1992 (from 155 to 228), descending AIDS cases among IDUs declared in
again the year after. Prevalence of tubercu- Barcelona residents. Between 1988 and
losis remained stable, showing a decrease 1993, while the definition of case by the

Table 4: Illegal drug-related emergencies attended by four university hospitals with


permanent emergency ward. Barcelona, 1990-1993.

Year Clinic Sant Paul Vall Hebron Mar Total


starts

1990 1,099 1,099 1,099 2,318 5,065


1991 1,243 1,243 1,243 2,010 5,078
1992 735 735 735 1,832 4,520
1993 695 695 695 1,541 3,823

36 Evaluation of Psychoactive Substance Use Disorder Treatment


WHO/MSD/MSB 00.2d

Table 5: Tuberculosis incidence in IDUs (a) and main population. Barcelona, 1987-1995.

Tuberculosis in IDUs Total Tuberculosis

Year Cases Rates Cases Rates

1987 87 5.1 854 50.2


1988 155 9.1 1,042 61.2
1989 161 9.5 923 54.2
1990 213 12.5 1,016 59.7
1991 216 13.1 1,129 68.7
1992 230 13.9 1,101 66.9
1993 177 10.8 999 60.8
1994 228 13.9 979 59.6
1995 165 10.0 899 54.7
1996 1,632 8,942

Rates for 100,00 inhabitants; (a) IDU: intravenous drug user

Centres for Disease Control (CDC) was in AIDS definition, which meant the in-
still in force, AIDS cases soared. In 1993, clusion of new TBC cases as AIDS. Af-
229 cases were declared in the city, 47% terwards, there was a drop in incidence
more than in 1988. In 1994, there was a with a trend to stabilisation around levels
top incidence coinciding with the change of 1990 (Table VI).

Table 6: Annual evolution of AIDS cases in drug addicts and of total AIDS cases.
Barcelona 1988 to 1995. Data by 30.06.1996

Year AIDS causes Rates Total AIDS Rates AIDS % in


in IDUs cases IDUs (a)

1988 156 9.1 267 15.7 58.4


1989 192 11.3 358 21.0 53.6
1990 239 14.0 434 25.5 55.1
1991 215 13.1 452 27.5 47.6
1992 249 15.1 505 30.7 49.3
1993 229 13.9 460 27.9 49.8
1994 385 23.4 667 40.6 57.7
1995 287 17.5 558 33.9 51.4
Total 2,051 3,918 52.3
IDU: Intravenus drug user; a) % related to the yearly total AIDS cases.

Workbook 3 · Needs Assessments 37


WHO/MSD/MSB 00.2d

AIDS cases reflect infections received for IDUs in contact with AIDS preven-
several years before. Therefore, it seemed tion programmes in Alicante (Spain) be-
better to analyse infections among cared tween 1987 and 1992. However, there
patients. Recent estimations on HIV in- is a need for critical appraisal when
fection rates among drug dependents in comparing data; indeed, several data
contact with Barcelona’s treatment cen- sources suggest that, in every popula-
tres, provided an incidence of 4.8 in- tion, frequency of HIV infection goes
fection/100 people/year of follow-up. down after a period of high incidence,
There has been a trend towards reduc- even without preventive interventions.
tion: from an incidence rate of 6.24 in
1991 to a rate of 3.46 in 1995. These Deaths because of overdoses increased
are big figures, but similar to those between 1988-1994 and tended to de-
given by the USA in IDUs (4 people a crease afterwards. Compared to mortal-
year). Compared to rates calculated at ity in other cities, Barcelona presented a
an European level, ours are lower than higher frequency of overdose deaths; one
those of Italy (7.4 among IDUs in treat- possible explanation being our higher
ment and lower than the annual HIV in- prevalence in intravenous administration
fection incidence rate (11.7) estimated (see Figure 1).

Figure 1: Three-monthly evolution of mortality due to acute drug


adverse reaction. Total number and mobile mean 4th trimester 1994.

Source: Institut Anatomic Forense de Barcelona


(*) Mobile mean: arithmetical average between number of deaths in the previous and following
trimester

38 Evaluation of Psychoactive Substance Use Disorder Treatment


WHO/MSD/MSB 00.2d

How were the results patients to be cared. The various compa-


nies and NGOs based in Barcelona which
used? are capable of offering treatment
programmes for drug dependencies may
After analysing results, it was concluded opt for our contract by means of present-
that several changes had to be introduced. ing their technical project to a public com-
For example, it was seen as necessary to petition. This project has to be in agree-
potentiate methadone programmes (num- ment with the protocols established for
ber and availability: low threshold each CFCs in the bases of the competition
programmes, methadone bus, as well as (specifications). Each treatment centre in
every resource devoted to harm reduction the city has to take care of patients be-
(syringe exchanges, etc.) There was a need longing to its area of influence, which has
for potentiating medical care (vaccination, to be previously designated. According to
chemoprophylaxis, early treatment and fol- the analysis made by means of the SIDB
low-up) and social awareness had to be pro- in those areas, each centre gets assigned
moted so that patients and programmes (es- its priorities on types of programmes and
pecially harm-reduction approaches) could on the number of patients to be cared. The
be better accepted. Since 1995, unit for the calculation of the budget in
programmes have been launched tailored every single centre is established through
for each urban district to answer their own the drug dependence care units (DCUs).
and differentiated needs. The Pla d’Acción This is a unit of productivity, calculated
sobre Drogues de Barcelona cares for the through the assignment of times for every
further development of this territorial therapeutical intervention according to the
project promoting the direct involvement allotted programme and to the technical
of district authorities and neighbouring as- protocol which has been agreed upon
sociations so that everybody is able to feel (number of visits and recommended typol-
a personal participation and to make every ogy). On the other hand, the technical
step together. specifications lay down some quantity and
quality standards (retention, coverage,
A further change to be introduced was the etc.). Companies overcoming these stan-
model of contract, this time according to dards may apply for a reward in the form
the delivered care services. This was of a greater payment every three months.
placed under management of the Plan
d’Acción sobre Drogues de Barcelona. A Only the high degree of development of
protocol was established devoted to the the SIDB information system has allowed
follow-up of the contract. This considers the working out of these technical con-
the different types of treatment tracts and their adjustment to the prob-
programmes and the minimal capacity for lems of each area of the city.

Workbook 3 · Needs Assessments 39


WHO/MSD/MSB 00.2d

It’s your turn


What are the strengths and the weaknesses of the presented case example? List three
positive aspect and three negative aspects:

Strengths of the case study

Weaknesses of the case study

40 Evaluation of Psychoactive Substance Use Disorder Treatment


WHO/MSD/MSB 00.2d

References for case example

Aviño-Rico, MJ., Hernández-Aguado, I., Institut Municipal de Salut. Servei


Pérez-Hoyos, S., García de la Hera, M., d’Epidemiologia. Plan Municipal d’Acción
Bolúmar-Montrull, F. Incidencia de la sobre Drogodependències. Evolució
infección por VIH-1 en usuarios de drogas Indicadors SIDB. Sistema d’Informació
por vía parenteral. Med. Clín. sobre Drogodependències a Barcelona, 2on
(Barc.),1994, 102: 369-73. trimestre 1996. Ajuntament de Barcelona.
Área de Salut Pública, Juliol 1996.
Brugal, MT., Torralba, L., Ricart, A.,
Queralt, A., Graugés, D., Caylà, JA. Lönnqvist, J. Evaluation of psychosocial
Evaluación de los programas de treatments. Acta Psychiatrica Scandinavica,
tratamiento por toxicomanías. Contri- 1985, 71 (Suppl. 319): 141-150.
bución del análisis de supervivencia. Gac.
Sanit., 1994, 44 (suppl.): 30. Manzanera, R., VillalbRð, JR., Torralba,
L., Solanes, P. Planificación y evaluación
Brugal, MT., Caylà, JA., García de Olalla, de la atención ambulatoria a las
P., Jansá, JM. Disminuye la infección por el drogodependencias. Med. ClRðn. (Barc.),
virus de la inmunodeficiencia humana en 1996, 107: 135-142.
los drogadictos intravenosos de Barcelona?
Med. ClRðn. (Barc.),1995, 405: 234. Nicolosi, A., Musicco, M., Saracco, A.,
Molinari, S., Zikiani, N.: Lazzarin, A. In-
Brugal, MT., VillalbRo,Torralba, L., cidence and riskfactors of HIV-infection:
Valverde, JL., Tortosa, MT. a prospective study of seronegative drug
Epidemiologia de la reacción aguda users from Milan and Northern Italy,
adversa a drogas. Barcelona, 1983-92: 1987-89. Epidemiology,1990,1: 457-459.
análisis de la mortalidad. Med. Clon.
(Barc.), 1995, 105: 441-445. Sabaté, J.; Aragay, J.M., Torrelles, E. La
delinqüència a Barcelona: realitat I por.
Brugal, MT., Graugés, D., Queralt, A., Catorze anys d’enquestes de victimitzacio
Ricart, I., Caylà, J.A. Sistema (1984-1997). Barcelona, Inst. Estudis Met-
d’Informatión de Drogodependències de ropolitans de Barcelona. Area Metropolitana
Barcelona (SIDB). Informe 1994. Servei de Barcelona. Mancomu-nitat de Municipis.
d’Epidemologia. Institut Municipal de la Ajuntament de Barcelona,1997.
Salut. Pla Municipal d’Acción sobre
Drogodependències. barcelona, 1996. Sánchez-Carbonell, J.: Camí, J.
Recuperación de heroinómanos: defini-
Domingo-Salvany, A.; Hartnoll, R.L.; ción, criterios y problemas de los estudios
Maguire, A.; Brugal, MT; Albertin, P. And de evaluación y seguimiento. Med. Clín.
the prevalence study group (Caylà, J.A.; (Barc.), 1986, 87: 377-382.
Casabona, J.): Analytical considerations
with capture-recapture prevalence estima- Vlahov, D. The ALIVE study. HIV
tion: case studies of estimating opiate use seroconversion and progression to AIDS
in Barcelona metropolitan area. Ameri- among intravenous drug users in Balti-
can Journal of Epidemiology, (in press). more. In: Nicolosi, A. (de). HIV epidemi-
ology. Models and methods. New York:
Raven Press, 1994, 31-50.

Workbook 3 · Needs Assessments 41


WHO/MSD/MSB 00.2d

Case example of a
needs assessment
A study to determine the welfare
service needs in the Eastern
Transvaal, Republic of South Africa

By
The authors alone M. K. Christian
are responsible for Director: Professional Services
the views expressed National Deputy Executive Director
in this case example.
SANCA National

Who was asking the a investigate the social problems which oc-
cur in its region and consider, plan and
question(s) and what propose measures for the solution thereof;
did they want to know?
b determine of its own accord or on request
the existing or future welfare needs of the
The Eastern Transvaal region (now named inhabitants of the region or any part
Mpumalanga - one of the nine Provinces thereof;
of the Republic of South Africa) is a very
big and largely underdeveloped area. Out- c plan and prepare a welfare programme
side of a few developed urban and indus- with a view to future development or
trial areas, there is a farming community provision of welfare services/facilities
and a tourist industry as this Province in- which would be likely to be necessary
cludes the famous Kruger National Park to satisfy such
and a number of other scenic areas. So- (i) identified needs,
cial Welfare Services and facilities were (ii) and to recommend the or
almost non-existent for the majority of the der of priority in which such ser
black population. vices should be accorded;

The responsibility for the area concerned d up to 1990, the local government, the
fell under the Regional Welfare Board Transvaal Provincial Administration
Eastern-Transvaal who according to the (TPA) was the main role-player render-
National Welfare Act (Act 100 of 1978) ing only social welfare services at grass
had to:

42 Evaluation of Psychoactive Substance Use Disorder Treatment


WHO/MSD/MSB 00.2d

roots level. Specific Services in the 4 act as a link between communities and
fields of: specialist services;

1) physical disability: blind, deaf, 5 co-ordinate welfare services locally.


cripple;
2) care for the aged; In order to carry out the above mission,
3) mental illness/health; the TPA Social Work Services decided to
4) substance abuse; draw in the NGO’s initiative in the follow-
5) child and family welfare; ing manner:
6) offender rehabilitation
1 Thirty one (31) additional social work posts
were almost non-existent because these would be made available. These social
were usually rendered by the Non-Govern- workers would be appointed by the TPA
ment Organizations (NGOs/registered wel- and would be employed by them;
fare agencies), who had neither the money
or subsidised social work posts to carry out 2 The NGOs would then be allocated a
such services in the small widely separated certain number of posts and would be
communities, over such a large area. involved in the recruiting, training, su-
pervision and evaluation of the social
In 1991, the Regional Welfare Board and workers concerned;
the TPA invited the leading National
Councils NGOs specialist-agencies pro- 3 It was envisioned that after 2 to 3 years,
viding specialist services, to participate the social worker posts would be taken
in a think-tank and workshop, as to how over by the agency concerned.
to move away from grass roots social
work, towards enabling and assisting The Regional Welfare Board of the East-
NGO/specialist agencies to develop com- ern Transvaal initiated the need assessment
munity structures and render much involving the TPA and the SA National
needed services. Following this historic Council on Alcoholism and Drug Depen-
meeting, the outline for a unique 5 year dence (SANCA). This was conducted
social welfare development programme among the communities of the rural and
was established. In this programme, vari- underdeveloped areas of the Eastern
ous specialist NGO agencies would be as- Transvaal in order to assess, the role of
sisted by the Regional Welfare Board and alcohol and drug use within the broader
TPA to: issue of social problems identified. This in-
formation was not to be used in isolation
1 investigate social problems and determine of other problems but to become an inte-
local welfare needs. Listen to the com- gral part the planning of a 5 year welfare
munity members and involve them in wel- programme for the communities con-
fare activities; cerned. It was anticipated that the
programme would move patiently through
2 act as facilitators to bring people or groups the following three phases:
of people together, to address local wel-
fare problems; Phase 1 - social planning phase: Com-
munity profile and needs assessment;
3 inform communities regarding welfare
policy and other matters (e.g., registra- Phase 2 - the community development
tion and subsidisation of child welfare phase;
facilities);
Phase 3 - the service development
phase.

Workbook 3 · Needs Assessments 43


WHO/MSD/MSB 00.2d

Time frame The Community profile and needs assess-


ment was to be given priority and carried out
Although it was planned that by 1996 so- during the normal hours of employment and
cial welfare programmes would be estab- while social workers were visiting communi-
lished according to the needs expressed, ties concerned. Therefore, cost were mini-
the phases could not be neatly boxed in mal and limited to training, where travel and
time. The Social Planning phase would accommodation were paid by the TPA.
probably be ongoing while Community
Development was being initiated. In the Planning
same way, the Service Development phase
may begin during the continuation of the Phase I: The social work section of the
Community Development phase. TPA Eastern Transvaal drew up the con-
cept document of agreement between the
TPA and the agencies - this was to be dis-
What resources where tributed before July 1991.

required? 1 a concept service contract for the social


workers was to be drawn up by the TPA
During the Social Planning phase each of the regional office and distributed to the
8 agencies and 2 Government Departments agencies concerned before July 1991;
participating, allocated official representatives
who formed the core group together with the 2 all documents were to receive approval
existing social work staff of the TPA com- and clearance before commencing the
munity services - in all some 30 persons. needs assessment. The remaining posts
Each group agreed to bear their own costs would be filled at a later stage in the
and provide specialist input. The TPA in programme.
Witbank agreed to provide the secretariat
and co-ordinate the planning and follow-up Training: A training programme was de-
meetings. Twelve social work staff were al- veloped to provide specialist input from
ready doing community work, 10 more were the various agencies. The group of 22 so-
selected and employed. Care was taken to cial workers met at a venue in
employ workers who were familiar with the Johannesburg for 6 days, additional train-
region and the various cultural groups and ing in community development was also
languages represented. given.

1 the social workers appointed were to be Except for the specialist input, all social
employees of the TPA and would receive welfare staff were employed to become an
their salaries from the TPA; the Commu- integral part of the entire social welfare
nity profile and needs assessment would programme, beginning with the commu-
be undertaken as a priority and as part of nity profile and needs assessment.
official duties;
Further on in the programme and ac-
2 the TPA would supply offices and ve- cording to the needs/priorities identified
hicles; a number of social work posts were ac-
tually allocated to the agencies - who
3 the specialist agencies would be respon- then proceeded to provide special train-
sible for professional supervision and in- ing to enable the workers to address the
service training of the social workers. problems with the community. One so-
cial work post per 20 000 people was
decided upon.

44 Evaluation of Psychoactive Substance Use Disorder Treatment


WHO/MSD/MSB 00.2d

How were the data key community members, professional and


collected? lay people who could provide information,
kept the workers occupied for several
months. Trust had to be built up as well. A
The community profile and needs assessment
community profile and needs assessment
questionnaire was drawn up, keeping in mind
was to be completed for each community.
that unlike urban areas, official data was un-
likely to be available and facts and opinions
In all 15 communities that were surveyed
(quantitative/qualitative) would have to be
over 3 years, more than 2000 structured
combined with the questionnaires. All pro-
interviews took place - finalising into 1
files, and completed questionnaires and re-
community profile with a detailed report
ports would be in English. Group and indi-
and recommendations for each area.
vidual interviews would be conducted in the
language of choice: Zulu, Swazi, Ndebele,
Sotho and Xhosa. Some information and statistics was ob-
tained from visiting Town or Village coun-
The region was divided up and various cils, police stations, churches, clinics,
communities/townships were assigned to schools and consulting records.
the 22 social workers. Accessing the com-
munity, identifying existing infrastructure and Other information had to be obtained through
interviews with key people involved such as:

Actual community Townships surveyed N=15


Magisterial Community/ Population
District Township

Piet Retief e-Thandukuyklamya 20000

Witbank Thubelihle 6510


Kwaguqua 158994

Bethal e-Mzinoni 23286

Standerton Sakhile 47744


Thuthukani 9318

Wakkerstroom e-Sizameleni 4600

Volksrust Vukuzakhe 17000


Morgenzon 4068

Perdekop Siyazenzela 2670

Evander Lebolanc 57840


e-Mbalenhle 130048

Sabie Simile 8000

Lydenberg Mashishina 27300

Barberton c-Mjindini 24504

Workbook 3 · Needs Assessments 45


WHO/MSD/MSB 00.2d

the local shopkeeper, shebeen owner (indig- preparation of the standard community pro-
enous tavern), Induna (minor chieftain). file, needs assessment and substance abuse
questionnaire proved invaluable in being
Community group meetings were held and able to organise the final reports. Very of-
discussions initiated - not only did a valu- ten it was not possible to get statistics or
able community profile emerge, but facts concrete facts - only general perceptions
and opinions were sought on a number of and informed opinions. What was most im-
issues. Group meetings were popular - portant was that there was seldom any con-
providing an opportunity for Community tradictions - opinions were firmly held.
to get together and enjoy refreshments
(this was minor but a most important cost Sophisticated computer analysis was not
in the programme). available and in many cases would not
have been meaningful because of the na-
The questionnaire on alcohol and drug use ture of the data gathering. Individual com-
was very comprehensive, target groups of pleted profiles and reports were analysed
respondents came from clinics, health care as available by the core group and the rec-
workers, nurses and doctors and other so- ommendations of various community
cial workers, traffic departments, police, members and social worker concerned
magistrate courts, teachers, ministers of re- were taken into consideration for Phase
ligion and members of the community and 2 and prior to Phase 3.
youth. Sometimes the workers left a ques-
tionnaire to be completed - in most cases What did they find out?
because of language and literacy difficul-
ties, these were completed by the social The Community Profile and needs assess-
workers. Availability and willingness of re- ment was able to pinpoint very specifically:
spondents to participate were the only cri-
teria used. No resistance was experienced. 1 the number of people involved and the
requirements concerning the needs of
The social workers received regular super- the blind, deaf and physically disabled
vision and encouragement’s. Reports and and mentally handicapped. This varied
completed work was finally co-ordinated only according to the size of popula-
by the TPA officials had core group. tion.

How were the data 2 In general however, no matter the size


analysed? of the population, it became very clear
that all communities share and identi-
fied the same social problems and that
A monitoring group was established and the underlying theme expressed over
meetings were held every 6 months, to and over again was that of “unemploy-
evaluate progress. Each worker was as- ment, poverty and alcohol abuse were
sisted to collate all documents pertaining the social problems which go hand in
to the Community profile. Gaps were hand”.
identified for workers to proceed with
gaining additional information. Substance use/ abuse

Each worker was responsible for the fi- There were two main substances used -
nal profile and report back on each com- alcohol and dagga (cannabis satavia). Glue
munity. In this regard the value of pre- and petrol sniffing were very minor.
training and the joint effort made in the

46 Evaluation of Psychoactive Substance Use Disorder Treatment


WHO/MSD/MSB 00.2d

Alcohol 6 there were very few cases of drunken


driving, as there was little opportunity
Commercial products were very expensive and few cars to drive.
and usually purchased from Bottle Stores or
drunk in Taverns. Because of unemployment 7 drunken pedestrians caused accidents -
and poverty, cheap alcohol concoctions or high incidence in rural and country areas.
home-made brews called SPION or 8 schools report drinking among the high
MBAMBA were available at Shebeens. school groups where alcohol use is a
These are informal backyard type taverns, source of entertainment and bought in
usually not registered. Shebeens are the the afternoons from the shebeens.
most important adult recreational facility 9 little or no drinking or drugging was ob-
and a source of income for the owner. served in the schools, only 1 case was
Youth also obtain their liquor from the reported in all reports.
shebeens in the afternoons after school, but 10teachers however see neglect, malnutrition
do not drink on the premises. Women visit and signs of physical abuse, they hear about
the shebeens in the late morning and early conditions at home and they are convinced
afternoon, while the men dominate the that drinking is a serious.
evening and night sessions. It was esti- 11the opinion most often expressed was that
mated that more than 60% of the popula- children from these families end up drink-
tion in all 15 townships were abusing al- ing themselves and not fit for the labour
cohol and of this number, 40% were drinking market.
at alcoholism levels. 12most epileptics and tuberculosis patients
neglected their medication because of the
Problems of alcohol abuse in the effort and distance to hospitals in urban
community areas and drank as a form of self medi-
cation.
Alcohol was abused over weekends and
after working hours by youth, men and Dagga or Cannabis
women between the ages of 20 and 50.
The confirmed opinion is that more men The dagga plant is indigenous to South
drink than women, but that women are Africa and easily grown for private use.
now drinking more than they used to, a In the communities surveyed, it was not
home brew of soured milk or sorghum was grown commercially (but is elsewhere in
considered an important part of the meal. South Africa). People were aware of the
Poverty prevented the woman from pro- legal consequences. Informed commu-
ducing this, thus malnutrition was high. nity members and leaders spoke out in
unison against legalising dagga as it was
1 wife battering and physical assaults were observed and an importantly held opin-
high ion that dagga use promoted the “dete-
2 families kept impoverished through drink- rioration of society”. School children
ing and unemployment dropped out and led useless lives or
landed in prison. Prison statistics clearly
3 most women do not recognise that a hus- indicated that arrests and convictions
band may have a problem. They live within due to dagga were significantly higher
the circumstance and accept the alcohol than those of alcohol and usually linked
use/abuse as a way of life. to crime. It was also noted that the so-
4 hospitals and clinics report high incidents phisticated use of dagga and crushed
of assaults. mandrax (white pipe) as smoked in ur-
ban areas was virtually unknown in these
5 most arrests are for assault, drunk and communities.
disorderly and theft.

Workbook 3 · Needs Assessments 47


WHO/MSD/MSB 00.2d

Dagga is used more by youth as it is cheap was unemployed and that the population had
(free) and exciting but is often continued into more than doubled the 1985 figures.
adulthood. Youth however, did not see dagga
smoking as serious, starting fairly early between The political climate in communities and
10 and 20 years with most users between the townships was as uncertain as the politi-
ages of 20 and 30, mainly male. cal development in South Africa. Where the
traditional Induna systems were still in op-
Generally, people were unaware of services eration, there was strong willpower to
or programmes that could help reduce the organise themselves.
use of alcohol and dagga and prevent the
social and health problems occurring. When Schools were overpopulated and grossly
health and social functioning deteriorated, the under served - influencing future educa-
community managed this within their ranks. tion and employment opportunities. Pri-
In some of the communities, help was avail- mary schools outnumbered high schools
able and alcoholics/dagga addicts could be 6 to 1. In 4 areas there were no high
referred to Themba Centre or dealt with schools. School was also very basic offer-
through local health clinics where some ing no additional skills or training.
knowledge was beginning to filter through,
TPA social workers throughout the region Alcohol use was obviously an important
had a case load of less that 30. part of entertainment, used by youth and
adult members of the communities. This
is seen in the extra-ordinary high number
Community problems evaluated
of shebeens (340), taverns (32) and
beerhalls (6) around compared to shops
The most serious problems identified were:
(22) and churches (46). The community
leaders, however, did view the drinking as
1 Unemployment
a serious set back to development and re-
2 Poverty quested awareness and education
programmes as urgent.
3 Lack of Infrastructure

4 Alcohol and Dagga Abuse Very limited sports (4) and recreation fa-
cilities (2) were found - usually only in the
family and community being negatively mining villages. Cinema and TV almost
influence by these. non-existent due to weak power supply
and poverty.
In communities, a greater percentage of
the children were in the care of grand- Religion played a big role in keeping the
parents who could not always provide community together and was very accept-
control or for their financial needs. Child ing of all conditions of life. Religious lead-
neglect and abandoned children were a ers still had the respect of the communi-
further indication of poverty as parents ties and even \political bodies and they
left to go to the cities to look for work. were usually the backbone of those in-
volved in problem solving.
The lifting of the influx control legislation
a few years earlier had a tremendous effect The needs for adequate shelter, water,
on the population in these communities, roads, electricity were expressed more
placing tremendous strain on the few exist- urgently that the needs for services for
ing resources, as people tried to get nearer physically disabled, etc. There was how-
to work opportunities. By 1994, it was esti- ever, an expectation that there should be
mated that 60% of the working population provision for these.

48 Evaluation of Psychoactive Substance Use Disorder Treatment


WHO/MSD/MSB 00.2d

The youth, not affected by alcohol and dagga trained to assist at various levels in the
use, demonstrate a willingness to get involved community.
with community issues as well as to organise
their own entertainment. They appear to be 3 awareness campaigns were planned for the
impatient with older members of the commu- youth between the ages of 12 and 25 to
nity who demonstrate apathy to get involved capture their interest. In a very short while,
with health and welfare issues, especially when they formed into SANCA youth groups
there is no financial gain. In spite of this com- where attention was given to a comprehen-
mon trend, there are community members who sive life skills programme aimed at their own
do involve themselves, but require motivation stated needs.
and financial and practical support.
The youth quickly cottoned onto the
How did they use the fact that a life of alcohol and drug use
would only continue the misery for
information? many other youth. Strategies now in-
cluded training selected youth as peer
For the first time in South Africa, the role counsellors who could work among the
of alcohol and dagga in keeping people young people themselves, who could
and communities underdeveloped was promote a different lifestyle, give talks
demonstrated, both contributing to cause and workshops at schools, churches but
and effect of poverty, unemployment, etc. more importantly in places where
Large scale community development was young people congregated.
required before the development of spe-
cialist services. However, community Further training provided helping skills
work intervention was urgently required and early identification of substance
and could be implemented. TPA social abuse and a referral system of resources
workers already involved in the needs as- available elsewhere. Positive minded
sessment were allocated to specialist NGO youth were targeted and the peer coun-
agencies. SANCA was given 5 posts and selling movement had its origin in the
one supervisor. These were now given Eastern Transvaal.
specific training in substance abuse, prod-
uct knowledge and prevention models and 4 Where existing infrastructures such as clin-
public speaking. The Community profiles ics, hospitals were identified, the social
and their own involvement with the com- workers visited to created awareness and
munities concerned, already indicated suit- offer a training package suited to their
able target groups. needs, or those of their clients, a com-
mon example was the pre-natal clinics
It was felt that the most effective strate- visited by mothers-to-be.
gies to combat alcohol and drug abuse
would be: 5 Conditions were most often very
simple and lacking any refinements,
1 to establish an action committee of con- the social workers ‘ having to go
cerned people. Such a committee would well prepared to get the message
be informed and made aware of the over to a target group that largely
findings of the community project and lacked previous formal education
would be motivated to become part of and could not read.
the solution.
6 Social workers had to be careful not to
2 training in helping skills and early identifi- create unrealistic expectations in the
cation of users and people in need of help community — but to work with what was
would follow. A core group would be possible with maximum utilisation of com-

Workbook 3 · Needs Assessments 49


WHO/MSD/MSB 00.2d

munity members, but at the same time ar- In the final analysis, it was the community
ranging meetings and putting them in touch members themselves who outlined and un-
with prospective or available resources. derlined and named their problems. All re-
source persons gave their names willingly and
7 The youth to youth movement had opened only a few respondents asked not to be
up many more opportunities to combat named in person - this was respected. So-
alcohol and drugs and had assisted the cial workers were well received as persons
social workers beyond the initial planned who were trying to help make a difference.
intervention. No problems regarding the need assessment
were encountered, only those of distance,
a) on-going training and motivation long hours and the continual evidence of many
was required and the development needs to be met. Monitoring and support for
of a training curriculum; the social workers were never neglected
throughout the years.
b) when funds were available, identi-
The Eastern Transvaal Region has now
fying badges, caps and T-shirts were
become an official Province of the Repub-
provided;
lic of South Africa with its own Depart-
ments of Health and Welfare. All strate-
c) the slogan “say YES to life and NO gies and welfare programmes mentioned
to drugs” was adopted with the have been adopted and programmes con-
SANCA lo o. tinued in co-operation with the agencies
concerned.
At the present time and because of the flex-
ible time-frame mentioned previously, all The model used for the community
of the above steps have been taken and profiles and needs assessment will be car-
are being met at various levels in seven of ried over to other communities in
the 15 communities. Mpumalanga.

Given time, the social workers will give 1 primary and secondary prevention strate-
less time to the established programmes gies were recognised as a priority;
and move into the next areas. There is now
a waiting list of sorts, as more and more 2 institutional treatment/rehabilitation re-
requests for similar programs to be estab- garding substance abuse already existed
lished are being received in respect of Al- in the province. Awareness of the need
cohol and Drug strategies already in op- for treatment and accessibility to the fa-
eration. Other information generated by cilities however formed an important part
the community profile has led to Social of the strategy:
Welfare programmes being developed to
move, into Phase 3 in some of the com- 3 Reconstruction and Development
munities concerned. Programme (the RDP) of the new Gov-
ernment structures has been assisting
There was sensitivity to the fact that all in the upliftment of these communities,
the Community/Townships surveyed were but still has far to go.
underdeveloped, plagued by poverty and
unemployment. Care had to be exercised,
to avoid labelling the community in any
manner.

50 Evaluation of Psychoactive Substance Use Disorder Treatment


WHO/MSD/MSB 00.2d

It’s your turn


What are the strengths and the weaknesses of the presented case example? List three
positive aspect and three negative aspects:

Strengths of the case study

Weaknesses of the case study

Workbook 3 · Needs Assessments 51


WHO/MSD/MSB 00.2d

References for case example

1 Concept Document: 1991 All documents are the property of SA Na-


tional Council on Alcoholism and Drug De-
2 Minutes of Meetings: 1991 - 1994 pendence but may be utilised for scientific
and academic purposes. Any further infor-
3 SANCA files on the 15 communities/ mation can be obtained on request.
townships surveyed
This case example is broader than a typical
4 Community Profiles and Reports: 1992 - needs assessment. It also includes elements
1994 of process evaluations, cost evaluations, and
outcome evaluations.
5 Progress and Evaluations of Welfare
Programmes initiated as intervention strat-
egies (Alcohol and Drugs)

6 Model for Service Development (avail-


able on request)

52 Evaluation of Psychoactive Substance Use Disorder Treatment