Needs Assessment




In disasters the most effective efforts to minimize mortality are based on very specific, precisely targeted interventions against demonstrated causes of death. , Historically, however, humanitarian aid was dictated by charity, politics, and well-intentioned assumptions, and not until the introduction of epidemiology to disaster response and the advent of needs assessment did evidence-based humanitarian aid come to the fore. Ideally needs assessment is a rapid, multifocal, cross-sectoral evaluation of the sequelae of disasters that provides accurate data on morbidity, mortality, disease burden, and the impact on medical, transportation, communication, water, electricity, and other lifeline infrastructures. These data, presented in such a way to elucidate the magnitude and geographic densities of need, are meant to alert the relief community and bring about efficient and appropriate humanitarian responses.


By necessity, postdisaster needs assessment must be performed even as emergency services are being provided. To address the conundrum of obtaining accurate data in extremely adverse and time-sensitive conditions, needs assessments must be coordinated across multiple levels, including local, state, federal, and international organizations; utilize various methodologies; and require horizontal processing and ongoing reevaluation. However, while the field has evolved significantly from its origins in epidemiology to a heterogeneous practice that incorporates not only the World Health Organization (WHO) Standardized Protocol but also innovative methods, such as geospatial information systems (GIS), operations research, and even crowd-sourcing, needs assessment continues to face multiple challenges in obtaining accurate, precise, timely, and compelling data. It is the goal of this chapter to introduce the history and rationale behind, components of, and challenges to postdisaster rapid needs assessment.


Historical perspective


Prior to the advent of needs assessment, charity, politics, and well-intentioned assumptions dictated relief efforts regardless of the needs of the disaster-affected community. Consequently, humanitarian aid initiatives were woefully ad hoc, inappropriate, and inefficient.


The first practical application of epidemiology in postdisaster relief may have been on the cusp of the 1960s-1970s in response to the Nigerian Civil War (also known as the Biafran War), wherein the U.S. Centers for Disease Control and Prevention (CDC), in efforts with preventative epidemiologists, piloted new techniques for survey conduction and rapid assessment of nutritional states. , However, widespread implementation lagged behind. Directors of major relief organizations doubled as managers and planners, often lacking sufficient public health foundations to successfully respond to major humanitarian crises.


The need for a more data-driven, epidemiological approach to disaster relief was evident. As agencies faced humanitarian emergencies such as the 1970 cyclone in Bangladesh, the earthquakes in Guatemala and Naples, and the devastating famines in Africa’s Sahel region, quantitative, population-based assessments evolved. While this allowed analysts to describe how mortality and morbidity varied across population groups and demonstrated the dynamic nature of postdisaster needs, significant barriers to standardized epidemiological methods, such as lack of security and the breakdown of surveillance systems, often undermined the accuracy of the assessment. In response to these concerns, the humanitarian aid community created key indicators of mortality and malnutrition that acted as early indicators of crisis and subsequent triggering mechanisms for the relief community. The Standardized Monitoring and Assessment of Relief and Transitions (SMART) method was introduced, and by the 1990s appropriate responses resultant from epidemiological research and targeting strategies led to decreased morbidity and mortality, and interest in the public health of disasters heightened.


This was evidenced in the United States after Hurricane Andrew struck Florida in 1992. In response to the CDC’s request for a rapid needs assessment evaluating the extent of the storm’s effects, cluster sampling of residents took place, identifying population demographics and the number of sick and injured, and accumulating data regarding access to clean water and food, toilet facilities, and infrastructure damage. Similar efforts were made in 1995 following Hurricanes Marilyn in the U.S. Virgin Islands and Hurricane Opal in Pensacola, FL. These data were used to direct aid initiatives and assure the populace that community-driven priorities were addressed. By disseminating information about the availability of health care, food, and water, along with preventive messages regarding food spoilage, water treatment, and vector control, rumors regarding epidemics were controlled and secondary injuries and illnesses were limited.




Current practice


Purpose


Rapid, postdisaster needs assessment, as it operates today, seeks to collect precise and accurate subjective and objective data that measure the damage done to and the critical needs of the affected community. The main purpose of a rapid assessment is, through the evaluation of disease burden and infrastructure fracturing, to identify the magnitude of the crisis; the location, boundaries, and density of the problem; and the immediate humanitarian priorities. Optimally, needs assessments should be largely standardized and efficient, aspire to the humanitarian ethic of neutrality, and provide accurate and precise information. Evaluations should occur during or immediately after the emergency phase, with ongoing reevaluation during the response, rehabilitation, and recovery phases.


Integral components of needs assessments are as follows: (1) confirm the emergency; (2) describe the type, impact, and possible evolution of the disaster; (3) measure the present and potential health impacts; (4) alert the international community to the gravity of the situation; (5) assess the adequacy of the current response capacity; and (6) recommend immediate humanitarian actions. , Although each particular disaster necessitates a unique needs assessment, the WHO has designed a standardized rapid health assessment protocol for common emergencies. In general, the major steps of this protocol include description of purpose, preparedness, planning, conducting the assessment, analysis of data, and presentation of results. While the purpose and priorities of a needs assessment were addressed above, the other steps will be described below.


Preparedness


Successful disaster response hinges on disaster preparedness. Thus, it is imperative that governments, health systems, and international organizations have at least a basic infrastructure in place to be able to immediately implement an appropriate rapid assessment and response. According to the WHO rapid health assessments protocol, preparedness requires (1) establishing baseline data, (2) emergency planning, (3) training of staff, and (4) monitoring and evaluation. A system to establish baseline data, including population demographics, vulnerability assessment, and preexisting burden of disease, facilitates the anticipation of needs after disasters and allows for a preliminary response system that can be deployed quickly when emergencies arise. The WHO protocol recommends creating a “preparedness checklist,” including the following questions that evaluate preexisting disaster response infrastructure, essential information to have when considering postdisaster resources:




  • Does a national health policy exist regarding emergency preparedness, response, and recovery?



  • Who is the person in the health ministry in charge of emergency preparedness?



  • What type of coordination exists between the health sector, civil defense, and other key government ministries?



  • What type of coordination exists between ministries of health, the UN, and nongovernmental organizations (NGOs)?



  • What operational plans exist for disasters?



  • Do national and local health plans exist for disaster management?



  • Are surveillance measures in place that can detect early signs of disasters?



  • Have environmental health services taken preparedness steps?



  • Have facilities and areas been identified to serve as shelter sites?



  • What training activities exist for disaster preparedness? Who is involved? Have disaster drills been administered?



  • What resources exist to facilitate rapid response to disaster (e.g., emergency budget, supplies)?



  • Does a system exist for updating information on key human and material resources needed in a disaster?



By acknowledging and anticipating humanitarian emergencies through preparedness programs and establishing databases of baseline demographics, infrastructure, and resources, not only will needs assessments be improved but so too will the majority of postdisaster humanitarian responses. It must be stressed that any databases established must be regularly revisited and updated.


Planning


Preparation for conducting needs assessment requires addressing crucial logistical and ideological issues, including determining who is to perform the surveillance, who receives the data, and what data are collected; creating appropriate time lines; establishing quality assurance protocols; and determining task delegation and predeployment logistics.


Ideally, rapid needs assessment is performed by an interdisciplinary team garnered from local NGOs, governmental organizations, and international agencies that includes epidemiologists, public health professionals, engineers, and statisticians. As is feasible, authority and responsibility should be shared among members of the affected community and country as well as international personnel. Teams should include members and leaders that have familiarity not only with the type of disaster but also with the region and population, possess epidemiological and technical skills, and have decision-making capacity in the face of sparse data. While there is quite the polemic regarding the need for neutrality in humanitarian responses, sociopolitical affiliations should be carefully considered when selecting needs assessment personnel. Identification of the agency to perform or lead the rapid surveillance is crucial, and the coordination of multiple organizations intending to work within the same fora is paramount.


A critical aspect of performing needs assessment is directing the data to the appropriate audience. The main recipient, of course, will be the agency that sponsors the survey. However, it is imperative to acknowledge that such information should be dispersed as widely as possible. Such a diverse audience that includes survivors, NGOs, United Nation agencies, donor governments, and the media will require the ability to cater to differing informational needs, lexicons, and presentation styles.


The specific information gathered during the immediate emergency phase of the disaster should include (1) baseline data, including information on demographics, lifeline services, and sociopolitical conflict; (2) data intrinsic to the crisis; (3) logistical data; and (4) information about surviving resources. The following are examples of what should be included :



  • 1.

    Intrinsic to the crisis




    • Boundaries of the affected area and the density of impact



    • Time line of the crisis



    • Major threats to survival



    • Information regarding severely affected or isolated populations and disaggregated data based on sex and age



    • Prioritized search and rescue areas



    • Assessment of lifeline services; that is, access to water, power, sewage, etc.



  • 2.

    Logistical




    • Damage to transportation infrastructure or other mobility issues en route to affected areas



    • Damage to broadcasting systems



    • Need for establishing or restoring communication infrastructure



    • Assessment of the damage to air traffic centers



  • 3.

    Surviving resources




    • Assessment of health care facility damage and capacity



    • Review and itemization of government stockpiles of in-kind resources



    • Information regarding existing NGOs, governmental organizations (GOs), international organizations (IOs), and community service organizations (CSOs) that are currently operating and characterization of the recipient population and capacity




In humanitarian emergencies, there are differing time lines corresponding to different crises. Generally, four main phases of humanitarian crises and corresponding roles for needs assessment have been identified, with Phase 0 being reserved for coordinated preparedness assessment :




  • Phase 1 (72 hours): Initial assessment aimed at estimating the scale and severity of the impact, locating affected populations, and informing initial response decisions and Phase-2 rapid assessments



  • Phase 2 (weeks 1 to 2): Multicluster or sector initial rapid assessment (MIRA) intended to inform initial planning of the humanitarian response, highlight priority actions, define the focus for follow-up in-depth assessments, and establish the baseline for monitoring



  • Phase 3 (weeks 3 to 4): Single-cluster or sector coordinated in-depth assessments, harmonized across clusters or sectors to analyze the situation and trends, adjust the ongoing response, inform detailed planning for humanitarian relief or early recovery, and establish baselines for operational and strategic performance monitoring



  • Phase 4 (weeks 5 +): Continued single-cluster or sector coordinated in-depth assessments with early recovery consideration, harmonized across clusters or sectors in order to analyze the situation and trends, inform the phasing out of life-sustaining activities and detailed planning for humanitarian relief and recovery, and feed into performance monitoring.



This can be juxtaposed to a time line of needs assessment after sudden-impact disasters :




  • Phase 1 (24 hours): Local response usually occurs with simultaneous assessment and response, and medical measures are often implemented with incomplete information. Preliminary morbidity and mortality data are difficult to obtain but needed within the 24 hours following impact to guide requests for assistance.



  • Phase 2 (48 hours): Assessments should focus on needs for medical response in the less accessible areas, shortages in primary health care resources, and secondary needs (i.e., shelter, food, and water). At this stage, the need for additional national and international resources should be evaluated.



  • Phase 3 (days 3 to 5): Surveillance data should be collected regarding environmental health, food, special protection and shelter for vulnerable groups, and information key to reestablishing primary health care systems and facilities.



  • Phase 4 (days 5 +): Evaluation should focus on those data that inform response and recovery operations, assessing preexisting surveillance systems and health care infrastructure and health trends.



After the large questions of who, what, and when have been answered, final preparation includes establishing a quality assurance system, which allows gaps in data to be identified and information to be validated and creates time lines for reassessment. Intraorganizational and interorganizational roles should be confirmed and deliverables defined, and administrative assignments should be delegated. Logistics, such as travel clearance, transportation, safety protocols, and developing communications systems, must also be addressed before conducting the assessment.


Conducting the Assessment


In order to improve the likelihood of obtaining accurate data, rapid needs assessment must be systematic, despite having to conduct such surveillance during the chaos of a disaster. Generally accepted types of data collection include (1) review of existing data, (2) inspection of the affected area, (3) key informant interviews, and (4) rapid surveys.


While inspection of the area can be done by air or ground, aerial assessments are most helpful in determining the boundaries of the affected area and the conditions of the infrastructure and environment. Aerial surveillance provides geospatial and infrastructure data, but group assessments can provide a better sense of shelter and food availability and potential hazards and a gross sense of the type of population affected. Vital to needs assessment is the establishment of a reliable denominator, since rates depend on a moderately accurate estimate of the population at risk. Aerial inspection (e.g., house counts), along with group assessments (e.g., average family size), can augment any preexisting baseline data to create an initial denominator.


Key informant interviews should include members from each sector of the affected community, including community leaders, local government officials, health workers, and personnel from community service organizations and other emergency response groups. These interviews can shed light on variables such as the following:




  • Perception of the event



  • Previous condition of the area



  • Size of the affected community



  • Estimated morbidity and mortality rates



  • Existing food supplies and needs (e.g., approximately 1900 to 2100 kcal per person per day)



  • Supply and quality of water (e.g., generally 15 L of clean water per person per day)



  • Adequacy of sanitation (e.g., 1 latrine per 20 people)



  • Existing fuel and communication links



  • Existing resources in the community



  • Adequacy of security and/or the prevalence of violence



  • Impression of any existing conflict, specific contentious issues, tensions between community factions, etc.



  • Cultural norms and mores that might affect relief efforts



Although key informant interviews can rapidly provide information, surveyors should always be cognizant that such data are likely to be exaggerated and/or biased. ,


Aside from inspection of the area and key information interviews, surveys are central to accurate situational assessments and should be utilized when information cannot be obtained from alternate sources. A few of the common rapid surveillance methods after disasters include sentinel surveillance, surveys by specialist teams, and detailed critical sector assessments.


Sentinel Surveillance


Sentinel surveillance involves creating a reporting system that detects early signs of preidentified problems at certain sites. This method allows for a triggering mechanism to alert humanitarian responders during early warning phases.


Surveys by Specialist Teams (Sampling Methods)


Well-designed surveys from reliable samples allow surveyors to confidently generalize findings and apply them to a larger population. A few of the multiple methods for sampling follow:




  • Simple random sampling: when every member of the population at risk is equally likely to be selected and such selection has no effect on other selections



  • Systematic random sampling: choosing every 20th subject, for example, on a list. This is potentially inaccurate if the list is nonrandom or incomplete.



  • Stratified random sampling: dividing the population into strata, randomly selecting subjects, and then combining them to give an overall sample



  • Cluster sampling: Samples are restricted to a limited number of geographical areas, called clusters. For each geographic area selected, samples are random and then combined to give an overall sample.



SMART, as an example, is a rapid cluster sampling method that is now widely used. The population is divided into groups, and a sample is randomly selected for assessment to provide statistically adequate estimates. Whereas these methods are more easily implementable and provide real-time estimation in unsecure and inaccessible settings, cluster sampling has a lower level of precision than random sampling and subsequently constrains the external generalizability of key variables such as mortality.


Detailed Critical Sector Assessments by Specialists


Critical sector surveillance is appropriately named, necessary not only for health and health infrastructure evaluation but also for assessing critical resources such as water and electricity, and it often can be performed by staff from within or outside of these systems.


The impact of a disaster on the health of a population entails assessing injuries, illnesses, death rates, and missing persons. Rapid assessment of primary injuries should estimate the number of persons injured and the severity, types, and sites of injury. Primary injuries are those that are the result of the disaster itself, whereas secondary injuries occur during the postimpact phase of a disaster, such as injuries related to the cleanup. Identifying where survivors seek care for such injuries not only is valuable data in itself but also provides one major source of information.


Although communicable diseases are relatively rare in the acute phase following a disaster, surveyors should identify pathogens already present and that are likely to spread in the context of poor sanitation and the population massing that occurs at shelters and evacuation centers. A preliminary disease control plan should be derived from these data.


In crises, mortality is usually limited to reports of bodies recovered, but such passive information can be supplemented by designating burial sites and maintaining burial counts. Data should include age- and sex-specific death rates, causes, and risk factors. In humanitarian crises, crude mortality rates (CMRs) should be reported as per 10,000 per day, with death rates approximately 0.4 to 0.6 per 10,000. Rates exceeding 1.0 are considered elevated, and rates over 2.0 are deemed critical. When evaluating CMRs, one must take into account the unique crisis time line; rapid-onset disasters will have more front-end mortality.


The severity of a disaster is also closely associated with the number of persons missing. Though it can be difficult to obtain precise numbers, preliminary data can be derived from families and search and rescue teams.


Perhaps as crucial as characterizing the impact of the disaster on health is defining its effect on the health care infrastructure. Surveillance efforts should collect any data that help determine which facilities are still functioning and which resources are needed to restore and/or supplement existent services. Questions should address the type and location of facilities, post-event structural integrity, capacity, injuries and death of staff and personnel, and any resource limitations. If possible, data collected should include patient injury types, any need to evacuate patients for specialized care, and the types of medicines and other supplies most urgently needed.


As aforementioned, surveyors should also examine the integrity of the postimpact environmental situation. Analysis of the water supply, sanitation, shelter, transportation, communication, and electricity is crucial. An adequate supply of water is of paramount importance, so particular attention should be made to estimate the size of communities without water, potentially contaminated resources, and the magnitude of the damage to supplies.


New Innovations


With the evolution of information technologies and the Internet and the explosion in mobile device availability and usage, humanitarian response and needs assessment has at its fingertips new, powerful, real-time tools to track populations and postdisaster needs. Crisis mapping, which utilizes mobile platforms, computational and statistical models, geospatial technologies, and subsequent analytics, not only provides a wealth of data but also conveys agency to those most affected by the disaster.


Mobile communications have the potential to radically affect needs assessments. Crowdsourcing, the practice of obtaining services, ideas, or content by soliciting populations through an online or mobile community, has been used to identify developing conflicts, disease outbreaks, and densities of need throughout health and lifeline sectors. Open-source platforms, such as Ushahidi, provide software for information collection, visualization, and interactive mapping. These technologies have been utilized most recently in the crises in Sudan and after the 2010 Haitian earthquake. , Initiatives that implement SMS reporting by crisis-affected populations have been shown to provide incredible volume, speed, and accuracy of information that has later been incorporated into GIS to inform humanitarian organizations regarding needs, ongoing responses, gaps in resources, and redundancies of initiatives. SIM card positioning has provided accurate geospatial data that have yielded information about crisis variables ranging from population outflows to cholera outbreaks. Utilizing this model, efforts of agencies have been redistributed to those most affected by the disaster, with surveyors on the ground along with public health officials verifying data. Whereas these technologies are rife with potential, their widespread integration into needs assessment is hindered by the challenges of information bottlenecks; delays; inaccuracies; difficulties with technological dissemination, standardization, and organizational buy-in; and the need for powerful integrative programs.


In so implementing any of these survey methodologies, it is imperative to collect sex- and age-disaggregated data (SADD), even in the initial phases of assessment and response. Almost all of the major humanitarian standards, handbooks, and guidelines require the inclusion of SADD into assessments, and all organizations operating under WHO Health Clusters are mandated to ensure gender equality in their humanitarian response. However, in practice, there is a lack of understanding of and conviction in the merits of SADD and a skepticism regarding what can realistically be collected during the first phases of response, and thus employment of disaggregation is unfortunately rather limited and delayed until later stages.


Analyzing and Presenting Data


Throughout all phases of disaster response, it is critical to have the right data, at the right time, displayed in a fitting manner that compels the relief community to respond with appropriate action. Data should be as specific as possible, with SADD emphasized to facilitate the design of appropriate interventions. Data analysis should thus be performed with standardized techniques that allow for interdisaster comparisons.


The complexity of data collection and analysis that are to culminate in efficient disaster management has highlighted the need to introduce innovative tools, such as GIS and operations research that assist in decision-making processes. Operational research (OR) is a burgeoning scientific field that offers decision support by identifying the optimum design and operations of a system under specific constraints, such as scarce and dynamic resources. Through diverse techniques, including mathematical programming, probability and statistics, simulation, decision theory, and multiattribute utility theory, OR can utilize needs assessment data to comment upon the ideal location of emergency facilities, distribution schema, evacuation routes, inventory planning, infrastructure assessment, and postrecovery reconstruction. GIS able to spatially portray not only predisaster baseline data but also real-time early warning data, disaggregated needs data, and the evolving humanitarian response, is now integral to the analysis and presentation of needs assessments and is a significant part of crisis mapping.


Presenting needs assessment data, postanalysis, should emphasize fidelity to the evidence but cater to the varying informational requirements and lexicons of diverse audiences, for example, implementing agencies versus donors. Per the WHO Standardized Protocol, a basic outline for a standardized presentation is as follows :



  • 1.

    Reason for the emergency


  • 2.

    Area affected


  • 3.

    Description of the affected community at baseline


  • 4.

    Impact of the disaster (mortality, injuries, financial losses, and disaggregation of these data)


  • 5.

    Existing resources and infrastructure


  • 6.

    Additional requirements, longitudinally


  • 7.

    Clearly stated priorities for the response organization.



Results should be widely distributed so that information can be verified and/or complemented and organizations without needs assessment programs or initiatives can utilize the data to design appropriate interventions.

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Aug 25, 2019 | Posted by in EMERGENCY MEDICINE | Comments Off on Needs Assessment
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