Health_Needs_Assessment

The objective of a Health Needs Assessment, (HNA), as a tool, is to identify the priority health need on which to allocate resources on a population. Then meet the needs of a population through improvement of services and support, enabling professionals to follow the government’s health inequality strategy in narrowing the gap between differing social and economic groups and regions, (Cavanagh & Chadwick 2005). By using a HNA approach Primary Care Trusts, professional agencies and the local communities are able to identify their own needs and can therefore develop services for the identified areas. Need can be interpreted in many different ways, it may be desired as material objects, which can be a requirement but may not considered necessary to sustain life or for survival, Thornbury (2009.) Maslow (1943), described needs placed in a hierarchy, the higher level of needs only being achieved when the lower levels have been fulfilled. (Maslow’s Hierchy of Needs: Appendix 1) Bradshaw in 1972 used taxonomy of Normative, (Appendix 2) shows that needs identified by the professional may be different to those identified by the individual, Thornbury (2009.) The role of the professional is to address the unmet need of the individual or community. This can only be achieved by determining how health is experienced and what influences choice, how health and wellbeing are understood by the population, then finding the best way to engage and facilitate the given population, (Thornbury, 2009) Promoting Health is viewed not only as a National Health Service (NHS) professional’s role but as everyone in societies business, the ‘unhealthy’ policies and practices at local level are challenged by politicians, educators, people in industry, shop keepers, council leisure workers. ‘Healthy’ people are to be empowered within their communities, as they promote healthy outcomes and decisions, (Katz 2000). Sustainable development is important in helping to build healthy public policy and supportive environments for health, to improve equity within health now and in the future through improving living conditions and encouraging healthy lifestyle, WHO (1998b). The social model of health is an outcome of all factors affecting the lives of populations through different routes, to improve a communities health and reduce inequalities, (Dahlgren and Whitehead 1991). The rainbow model (Dahlgren and Whitehead 1991 (Appendix 3)) provides a way of looking at the factors affecting health. This does not show the complex interactions that exist between the factors; it does show types of factor that affect the individual. (Habitat 2010). Historically the Black Report looked at the links between mortality, morbidity rates and social classes. Recommendations were to end child poverty and better a Child’s start in life, (Katz, Peberdy and Douglas 2000). A further report The Health Divide (Whitehead 1988) identified significant differences in death rates between socio-economic groups as cited in Katz, Peberdy and Douglas 2000. The Acheson report (1998) showed Inequalities of health across the country, the gap in health appeared to be increasing, with no dominant factor is given for this although predominantly income, education and adequate housing are cited, (Naidoo and Wills 2000). Brewer and Gregg, (2001) cited in Exworthy, Stuart, Blane, and Marmot, (2003) suggested child poverty is reflected from children’s subsequent earnings, due to their education, even after controlling the child’s ability and aspects of the family background. To make significant improvements in the population’s health and reduce the inequalities this can only be achieved by improving the quality of life through social and economic means and giving support where needed in health and behaviour change. Preventative medicine considered the concept of hygiene and disease, including the importance of nutrition and causes of ill-health focusing on high risk group’s i.e. pregnant women, school children and elderly people. A combination of development in education, housing and economic infrastructure assisted in improving health of these populations, (Thornbury 2009.) School nursing agenda, enables professionals to assess health needs and meet the inequalities of their population. Naidoo and Willis (2005) suggest using answerable questions and finding the best evidence with which to answer them, then critically appraising and applying the results, hence evaluating the practice. The Process is not without problems, time and resources that are readily available. Service intervention would be implemented incorporating the Education Service and Paediatric health services. Ethical constraints of consent and knowledge understanding would also have implications when addressing the populations to be assessed. Within this study the population in question will not be directly interviewed, the data information will be taken from that already in the public domain and that is accessible, due to afore mentioned limitations of time. Step 1: Getting started 1. a What population' The population identified for this report are within an inner city primary school age 8 to 10 years, in a predominantly South Asian population in an industrial city in Northern England. The HNA will identify the priority health need on which to allocate resources services and support, by gathering evidence pertaining to this population. 1. b Methodology used. An Evidence based approach within this community as early intervention through prevention should reduce the costs to society and to health, which in essence will reduce the costs to children’s service in the long term. (DOH 2009). The tool to be used as the methodology for this assessment is the Health needs Assessment Practical Guide, NICE (National Institute for Clinical excellence) [(Cavanagh & Chadwick 2005) (appendix 4)]. Other models are available but this has a simple structure that is easy to follow, all the areas within the steps may not be used if not applicable to this assessment. 1. c Who needs to be involved' A School age population who are able to complete a questionnaire independently and value the use of the research to ascertain improvement in their health and wellbeing. They must be of a standard able to read and understand the Questions. Teaching staff to contribute to and police the completing of the questionnaire. Assist with implementation of relevant services. School nurse will address the concerns of the school age children, and be involved in implementation of the service. 1. d What resources are required' Questionnaire appropriate to age group and understanding. Appropriate place and time, environment to complete the questionnaire. Facilitator for the session. Technical tool to ascertain the received in formation 1. e What are the risks' Commitment to the task by all participants. The ability of the children to understanding the question. Time scale to collect the evidence is minimal. Tasks will be shared out so no-one is overloaded, (could lead to failure of the evidence gathering exercise). Knowledge of what to do with the information gained. Step 2: Identifying the health priorities for the population. 2. a Population Profiling 2. a. 1 Profile of Britain There is an obvious north/south divide when looking at inequalities of deprivation the 3 most Northerly regions have an average 30.9% while the 4 most southerly regions (excluding London) have a 6.8% in comparison to the 19.9% for the national average (DH (Department of Health) 2010a) although the North East on average performs higher in levels of Physically active children and lowest rate of road injuries and deaths. (DH 2010b). To combat these inequalities the Government set up the National Service framework which over 10 years is to improve health and wellbeing of all children, by setting standards for organisations and providers, (DOH 2007a). Cross Governmental initiatives: Every Child Matters aims 2. a. 2 Regional Profiling Regionally there is evidence that inequalities within Yorkshire and Humber are widening although the health of the population in general has improved it remains worse than the England’s average (DH 2010c). The most significant deprivation being that of the population in the cities and large towns. A main Inequality in health within the region is that on average people die at a younger age than in other parts of the country although health has improved this remains below the average within England, (DH 2010c). The NHS Yorkshire and Humber have set out specific areas to improve health and life expectancy across this population within the next 10 years. NHS Yorkshire and Humber (2009) Healthy Ambitions: specific to children and young people 2. a. 3 District Profiling The district health profile states that although early death from heart disease and stroke has decreased over the last ten years, this remains worse than England’s average, life expectancy rate remains lower than England average. Deprivation levels are worse and higher than the England average (DH 2010c). The district is within 10% most deprived local authorities in the country and most deprived in local authority in West Yorkshire (District council & PCT 2009b). This corresponds with the lower than England average in GCSE grades A-C and higher than average unemployment rate and income deprivation, (District council & PCT 2009b). From the district health and lifestyle surveys 49% of adults are in employment. South Asian women were least likely to be employed. (Primary Care Trust (PCT) 2009a). Across the district 70% feel their health is good only 6% consider themselves to have poor health, these figures increase with age and within the city ward. Quality of life in comparison to other areas is considered low. (PCT 2009a). Evidence suggests that health issues related to housing problems are of concern in some parts of the district. The city area reports conditions of damp and heating problems, (PCT 2009a). one-in-five adults are obese predominantly women, poor diet and nutrition is seen as a key factors when considering obesity, therefore improving dietary intake and knowledge has been high on the public health agenda in recent years (PCT 2009a). Younger people were less likely to eat breakfast and more likely to eat from takeaways than meals prepared at home. Eating 5 fruit and vegetable a day had increased from 31% in 2005 to 40% 2008. The recommended level of exercise of 5 times 30 minutes moderate exercise a week is only 10% achieved of those surveyed achieved this regularly, suggesting no Improvement of exercise levels since 2005 survey. Different motivational factors for stopping smoking were found among sub-groups of those who considered stopping. The survey found one in five people smoke, (PCT 2009a). Local Health Needs 2. a. 4 Ward Profiling The ward in which the school is located has a larger population of younger people nearly 1/3 are aged under 15 years old and 1/2 are under 24 years old. Against district average there is a lower amount of over 45 years old (District Observatory 2007b) this has an effect on the employment with in the households and dependency of children (22% of households) and school populations. 60.1% of the ward’s population describe themselves as being of Pakistani ethnic origin, 14.5% in the district. 21% of the population describe themselves as White, 78% in the District, 7.5% as Bangladeshi and 4.6% as Indian, and there are also significant numbers from other ethnic groups, (District Council 2007). There is a lower than district average of lone parent families, housing conditions are generally poor, with over 1/4 are overcrowding, which is much higher than the district average, nearly 1/2 the households do not have central heating or sole use of inside toilet. (District Observatory 2007b). In the ward only 43.2% of all people are either working or seeking work. This is considerably lower than the district average of 63.4%, (District Observatory 2007b). Over half the adults have below average Qualifications therefore a correlation of the amount of people available to seek and sustain work. 13.3% of the population in this ward described their health as ‘not good’. The average for the district is 10.1%. A greater number than average households have a least on person with long term illness. On all measures this ward is considered more deprived when compared to the District average; in fact much of the ward would be considered to be in the 2% most deprived for Income and Education for the country. The Housing Domain score is nearest to that of the District average score for this ward. This indicates that for Housing, this ward is only slightly above that of the district average. However, all other indices for this ward, except crime and Housing fall well within the 10% most deprived. (District Council 2007) 2. a. 5 School Profiling Ethnicity The respondents of this survey classified themselves as 89% Pakistani, 9% Bangladeshi and 2% Indian (SHEU (school Health Education Unit) 2009); this is consistent with the Ward population. Nutrition The school children completed the SHEU survey which indicates similar finding to the Ward and district previous surveys. It will be used to analyse the perception of need within the school population. 4% had nothing for Breakfast, only 9% had drink, just 2% had a cooked breakfast (SHEU 2009) comparatively within the district 23% of young teenagers do not eat breakfast (District Observatory 2007a), showing emergence of a trend. As is customary within the culture of this schools population, over 72% ate a home cooked meal after school but a significant number also consumed ready made meals from shops and equally Take Aways, (SHEU 2009) 70% of boys had milk as most days, whether this just a drink is not clarified, but questions which type of milk and how much at this age. Guidelines suggest full cream milk only up to age 2 years, (Food Standards Agency 2010.) 79% eat three meals a day, 89% help with cooking meals, and 77% ate with the Family. Children predominantly ate a higher than district average of Crisps, sweets and chocolates. (Appendix 5) Dental All the children responded that they brush their teeth at least 2 times a day, girls being slightly better than boys. 50% had seen a dentist about problem teeth, only 45% go for a check up, although 94% say they have at some time visited a dentist, (SHEU 2009). This compounds the evidence that within this ward there is a significantly higher than district average of Dental carries in the over 5 year olds, and manifested in the evidence of higher levels of dental disease than in other regions of the city. Added to by the inequalities in dental provision across the city and evidence that inequalities in oral health can be marked by socio-economic status and ethnicity. (District Council & PCT 2009a) Exercise A higher than district average enjoy physical activities, more boys responded to being out of breath more often than the girls. Boys on a par with the district average, but girls well below. The boys and girls do PE separately and each gender liked different sporting activities, (SHEU 2009). Most responses were to school based activities. Obesity A predominately higher than average number of children are overweight and obese within this ward, and School this remained static over the two years of National child measurement Programme. The city figures are 1% above Yorkshire and Humber and 2% above England at year 6. (District Council and PCT 2009b) School statistics are comparable with the ward that few are under weight in reception, progressively more overweight with a rise in percentage of overweight and obese in year 6, (SHEU 2009) Smoking The City has a higher than national average of 43% who start to smoke under 16 years old.(District Council & PCT 2009b) There is more relevance to, parents smoking and in the home. 25% say that parents smoke, 20% smoke outside, 5% in certain rooms and 13% anywhere, 16 % smoke with children in the car, (SHEU 2009) owing to a higher incidence of second hand and passive smoking for children. Under 5’s in this locality have high admission rate of Acute upper/lower respiratory infections and diseases of the middle ear (District council & PCT 2009a) which have causal link to secondary smoking (Thornton & Lee 1999). Alcohol Customary this population do not partake of Alcohol and this is reflected in the respondent answers. At this age they have never tried alcohol. Some of the children did not respond to the Question. (SHEU 2009). Drug Misuse Pupils had an awareness of Drugs clarified in their Knowledge of who to talk to, over ¾ would talk to parents. Over a ¼ were aware of someone in the locality who took non–prescription Drugs, (SHEU 2009) Mental Health/behaviours The majority concern for this population was moving to secondary school, and end of year tests, and war and terrorists. Most were happy within school over 3/4 of the girls wished to change things about themselves and often fell out with friends. Girls also responded to being bullied more than boys 33% to 14%, (SHEU 2009). Road Safety /Accident/ Admissions 6% of children travelling in a car never wear a seatbelt, 36% only sometimes. 67% didn’t use a booster seat and according to height 15 % should use one, (SHEU 2009). City wide young people are 20% more likely to be admitted due to serious injury than nationally and 80% more likely to die, the majority of serious injuries are from falls or Vehicle related. Statistically within the city the greatest cause of death in 0-19 year old is injury or poisoning, (District Council & PCT 2009a). Children from more deprived backgrounds are more likely to be admitted to hospital in this city, (District council & PCT 2009a) could be argued due to disparity of Primary care services, lack of understanding in a second language for parents, neglect of children or over protectiveness of carers, and a illness’s due to deprivation factors. 2 . b Perception of Need 2. b. 1: A summary of the local population 2. b. 2 Priority Health determinants Ranking 2. c Identifying and assessing health conditions and factors The Triangulation of health determinants (Appendix 7) has thrown up areas of concern. The main areas of • Obesity – relevant to all population for this purpose school age children, although action being taken through public health, impact on health outcomes and lifestyles. • Infant mortality - hugely important although under the remit of midwifery and health visiting. • Physical Activity - relevant across age groups and predominantly in school age population. Will contribute to obesity and healthy lifestyles of population. • Road/home Accidents safety - high on public health agenda are those services to combat are evident. Step 3: Assessing Health Priority for action The health priority determined from all factors for this HNA is Obesity which will incorporate Physical Activity and lifestyle changes. 3. a Existing Services in the Local Area 3. a. 1 Service provision within school from Health Professional. School nurses offer drop-in services within schools for parents or children with weight issue of concern, this may be by arrangement by the school or direct from the parent. Across the city this can be an unequal service and some Drop-in are better accessed than others. Parents are given appropriate information and signposting, referral to weight management services may be appropriate, (DH 2009). Throughout the school year Nurses offer health promotion to all age groups intertwined with their curriculum and educate on healthy eating and making healthy choices. The National Child Measurement Programme (NCMP) (NOO 2009a) has enveloped school nurses to weigh and measure children in Reception and Year 6. With parents consent the results are shared with NCMP, who then receive a letter detailing where their child’s measurement fall along a spectrum of underweight to very over weight. Parents are invited to ask the school nurse service for advice but the nurses do not outwardly sort those who hit a target level, of unhealthy weight. 3. a .2 Provision within School The school follows the National Curriculum and Public Service Agreement indicator in providing 2 hours of Physical Education per week pupils. (Her Majesties Treasury 2007). The school achieved Healthy school status and is working towards the Enhanced Model. The sometimes run sports after school clubs a have input from the city Rugby team, football team and cricket teams. School meals are Halal or vegetarian and provided by an outside catering service. 3. a. 3 Provision within the community Health centres offer assistance for weight management but these are sporadic, GP’s offer advice and will refer to Paediatrician, Dietician and Option team ‘MEND’ project. Families feel embarrassment to attend added to the accessibility of service and travel. The Healthy life-style Project, jointly PCT and charity funds offers healthy eating sessions away from school. The B-active teams offer sporting activities during term and school holidays which can be accessed at the local sport complex and swimming pool, within walking distance of the school. City Community Environment project locally encourages interaction with growing food , learning about fruit and vegetables and some activities for children to attend. Encompassed in a mainly built up area, there is local access to nearby park and play activities. Step 4 Action Plan for Change 4. a Identifying a service Although there are service provisions for overweight management and an increasing number of physical actives to entice children and families to lead healthier lives, they are spread across the district. This population would benefit from a service on their doorstep which could bring the relevant services to them when required. This will be advertised through the children centres and the school newsletter. It would be accessible to parents and children during the daytime, and within walking distance of their homes. The target clients would initially be identified by the NCMP letters, encouraging the family to look for assistance. Creating supportive environments for people to lead healthy lives, who will then to make healthy choices, thus making it possible and easier for people is to make social and physical environments also health enhancing, WHO (1998a). 4. b Service Aims The Aim of the service will be to encourage and support families to achieve optimum weight and management through arrange of healthy lifestyle alterations. This can only be achieved if the family see the need for change and wish to make happen. The structure referral route for the service is outlined in the diagram Appendix 9. The population to be addressed will be gathered through data from the NCMP each year, also parental and school concerns. GP’s and Community Paediatrician can also refer. The intervention will be a whole family approach. The need for early intervention within Families plays a role in breaking the cycle of inequalities, school based programmes have been effective to reduce obesity prevalence in young girls and adolescents, as it becomes a crucial time in their development therefore reducing their risk to ill health. (DOH 2009) This is emphasised by the importance to educate children about eating healthy foods, making the right choices, and being physically active. A healthy adult diet should be modelled to children, emphasising a lesser quantity. The importance is to make sure children do not develop the health related problems (Robertson 2010). 4. c Service Objectives. • To be collaboratively working with other professional to enhance the maintenance and management of the client families to active their goal. • Full health and lifestyle screening for the whole family to facilitate change in behaviour patterns. • Motivate and encourage the family to assess their eating and lifestyle habits using Diaries. • To continue to promote the changes made and encourage maintenance of the lifestyle. (NICE 2006) • To halt ‘passive Obesity’ by kerbing the year on year rise in obesity and promote cost effectiveness. (Foresight 2007) (DOH 2009) (National Obesity Observatory (NOO) 2009b) 4. d Collaborative Involvement. Although a school based initiative the involvement of a wider multidisciplinary team would be need. The School Nurse, a tier one health professional, would offer a service and advice the family (District Council and PCT 2009a). After initial assessment of the clients within a family, a plan agreeable with the family will be drawn up; this will involve the clients accessing other services available, such as leisure centre, gyms, clubs and workshops, within the local vicinity. Service level agreements would need to be drawn up with providers and managers. Appendix 8 illustrates the contributors to the successful health needs assessment and provision. Service commissioners would need to be involved in the decision making of service provision (NOO 2009b). The families within the school need to also be involved in the process. A pilot Questionnaire would be sent all children in the school, too ascertain parent wishes and expectations of the service. Parental opinion will be sort at parents evening, coffee morning, sports events within school. Those hard to reach will be asked to school for their opinion. At strategic level the referral directive would be agreed, involvement of other service providers and a care pathway agreed upon, following national guidance (NICE 2006). See Appendix 9. 4. e The Family Health Programme. The Family health programme, would involve school staff being aware of their role in child health and wellbeing through a PowerPoint presentation, enabling staff have the knowledge of who and how to refer clients. The presentation would be delivered to relevant GP practices and Health Visiting teams as to how the present service will be added to and their role within the service requested. The Options Team and MEND will play a role as this will be a two way generation of referral and their advice will be sort. The Options Team also hold an up to date data base of all activities within the locality, which will be of use when care planning for activities. Families would be encouraged to use the Change4life, website and incorporate these ideals into their plan. The families would hold a copy of their individual plan and family plan. 4. f Room Provision. The idea of this service is that it is moveable to meet the need of the client. Initially a parent may be seen in school where a room is provided. Alternatively in the Clients home, following PCT (2009b), Health and Safety Policy, risk assessment would be completed. Review of care plans may take place in the home, considering the quantity of family members also. One or two professionals are more portable than a family of six, hence reducing the risk of non compliance trough non attendance. A private clinic room would be appropriate to facilitate appointments, do record keeping, source research, continue further work, and for private consultation. Ideally the local health centre with a reception area which would also have w.c provision and waiting area. 4. g Costs of Service. Initial cost would be the purchasing of PCT approved Height measure and weighing scales. Printing cost of Questionnaire, appointment letter, information leaflets from resource library or website. One qualified school nurse to asses and plan the care required and a nursery nurse to support and encourage child and family. Training would be required in the delivery of assisting clients maintain healthy lifestyle, and this may be sort, through Dietetics and Physiotherapist and Gym specialists. One of costs being the production of a power point presentation and delivery of this to other professionals. Ongoing cost would be a clinic room, and clerical costs. 4.h Time Scale (NOO 2009b) suggest time scale of a year before relevance to the service is concluded. Families will be seen regularly to keep a professional but consistent track on their success. The time scale will be individual to the families. Weight management is a long term prescription, so families may be on the books for considerable number of years. Subsequently different professionals will have different remits and alter throughout the course of the plan. 4. I Evaluation As PCT guidelines evaluation tool will be used at each appointment, which will assist to enhance the services quality. The evaluation and audit would be ongoing against the aims and objectives of the service provision. Audit of referrals to and from the service and attendance at appointments, Anonymity of BMI statistics would be correlated to produce evidence of sustenance of weight management. As more families become involved the added value would be evident in the programmes success and audit process. Foresight (2007) predicted that weight related issues will cost £50 billion within the wider economy by 2050 if no improvement through service delivery to the relevant populations is made, therefore the provision of Patient–led services enables spending to move from services to investment in health and well being (DH 2007b) for the greater good. 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Indoor and Built Environment Jan 1999 8:21-39 accessed online on 24/08/2010 @ http://ibe.sagepub.com/content/8/1/21.abstract WHO 1998a (World Health Organization, 1986). Healthy Public Policy, Health Promotion Glossary, accessed online 31/05/10 @ http://whqlibdoc.who.int/hq/1998/WHO_HPR_HEP_98.1.pdf WHO 1998b (World Health Organisation 1998) Sustainable Development, Health Promotion Glossary, Switzerland. accessed online 31/05/10 @ http://whqlibdoc.who.int/hq/1998/WHO_HPR_HEP_98.1.pdf Whitehead (1988) The Health Divide Health Education Council cited in Katz, J. Peberdy, A & Douglas, J. (2000) Promoting Health Knowledge and Practice. London. Palgrave, Macmillan Press LTD. Wright, J. Williams, R. and Wilkinson, J. R. (British Medical Jounal) BMJ 1998; 316(7140):1310 (25 April), Accessed on line 21/07/2010 @ http://www.bmj.com.ezproxy.leedsmet.ac.uk/cgi/content/full/316/7140/1310 Appendices Appendix 1 Maslow’s Hierchy of Needs Appendix 2 Bradshaw’s Taxonomy of need Appendix 3 THE RAINBOW MODEL Appendix 4 Health Needs Assessment a Practical Guide Appendix 5 How often do you eat these foods “on most days” Appendix 6 BMI Classification 91st/98th Centile 2008/2009/ NMCP Appendix 7 Priority Health Determinants Ranking Appendix 8 Health Needs Appendix 9 Family Health Programme Pathway Appendix 1 Maslow’s Hierchy of Needs: His first element was physiological, the need for food, water and shelter, once addressed, the individual would progress to requiring safety, once satisfied, the individual would progress to the next stage and so forth until achieving actualisation. Appendix 2 Bradshaws Taxonomy of need (1972) Bradshaw in 1972 used a taxonomy of Normative, (professional preventing injury), Felt, (parent feeling they need more help with child problems), Expressed (the felt need becomes a desire), and Comparative needs, (not shown in the table) (disparity of services/care), these show that needs identified by the professional may be different to those identified by the individual. (Thornbury 2009) Services may not exist to alleviate the demand (Naidoo & Wills 2000) Appendix 3 THE RAINBOW MODEL (The factors influencing health) Individuals are at the centre, with factors affecting their behaviour radiating out to the other factors which affect them. Source: G Dahlgren and M Whitehead, Policies and strategies to promote social equity in health, Institute of Futures Studies, Stockholm, 1991 Appendix 4 Health Needs Assessment a Practical guide The five Steps of Health Needs Assessment Step 1 Getting started What population' What are you trying to achieve' Who needs to be involved' What resources are required' What are the risks' Step 2 Identifying health priorities Population profiling Gathering data Perceptions of needs Identifying and assessing health conditions and determinant factors Step 3 Assessing a health priority for action Choosing health conditions and determinant factors with the most significant size and severity impact Determining effective and acceptable interventions and actions Step 4 Planning for change Clarifying aims of intervention Action planning Monitoring and evaluation strategy Risk-management strategy Step 5 Moving on/review Learning from the project Measuring impact Choosing the next priority Appendix 5 (SHEU 2009) Appendix 6 Show Classification for children 2008/2009 Appendix 7 Priority Health Determinants Ranking Priorities National Regional District Local Priority Rating Smoking yes yes yes 3 Obesity yes yes yes yes 4 Infant Mortality yes yes yes yes 4 Physical Activity yes yes yes yes 4 Teenage pregnancy yes yes yes 3 Road /Home Accidents yes yes yes yes 4 Tooth decay yes yes yes 3 Appendix 8 Contributors to Needs Assessment; a picture of all persons involved in the Health Needs Assessment Process. Appendix 9 Family Health Programme Pathway NCMP Referal of Family GP/Professional screening Concern Concern Concern Assessment Phase Identify Child/ family to be GP for Assessed initial Assessment 1st Appointment : Discuss Programme : assess readiness for change. Negative : give support Literature : arrange measurement, care planning to commence : Involve the whole family Treatment Phase 2nd Appointment : Measurement and care plan : commence Lifestyle diary (Food + Exercise) Positive: : reassess readiness for change Refer to Secondary 3rd Appointment : modify lifestyle from diaries : plan small manageable steps : Support readiness to change Continue support, modifying appointments Nurse or Nursery Nurse. : Establish progressive weight management Established Phase : Appointment as required/phone contact And Audit : Modify plan to meet needs, : Appointment/group work as required 3 month follow up To continue as support Reassess if weight increase or lack motivation (based on NICE (2006) guidelines and Department of Health Obesity care pathway 2006)