Social services utilization and need among a community sample .docx

Social services utilization and need among a community sample
of persons living with HIV
in the rural south
Katharine E. Stewart, Martha M. Phillips, Jada F. Walker*,
Sarah A. Harvey and Austin Porter
Fay W. Boozman College of Public Health, University of
Arkansas for Medical Sciences, Little Rock, USA
(Received 7 December 2009; final version received 16 June
2010)
HIV prevalence has increased faster in the southern USA than in
other areas, and persons living with HIV
(PLWHIV) in the south are often rural, impoverished, or
otherwise under-resourced. Studies of urban PLWHIV
and those receiving medical care suggest that use of social
services can enhance quality of life and some medical
outcomes, but little is known about patterns of social service
utilization and need among rural southern
PLWHIV. The AIDS Alabama needs assessment survey,
conducted in 2007, sampled a diverse community cohort
of 476 adult PLWHIV representative of the HIV-positive
population in Alabama (66% male, 76% Black, and
26% less than high school education). We developed service
utilization/need (SUN) scores for each of 14 social
services, and used regression models to determine demographic
predictors of those most likely to need each

service. We then conducted an exploratory factor analysis to
determine whether certain services clustered together
for the sample. Case management, assistance obtaining medical
care, and financial assistance were most
commonly used or needed by respondents. Black respondents
were more likely to have higher SUN scores for
alcohol treatment and for assistance with employment, housing,
food, financial, and pharmacy needs;
respondents without spousal or partner relationships had higher
SUN scores for substance use treatment.
Female respondents were more likely to have higher SUN scores
for childcare assistance. Black respondents and
unemployed respondents were more likely to have SUN scores
in the highest quartile of the overall score
distribution. Factor analysis yielded three main factors: basic
needs, substance use treatment, and legal/medical
needs. These data provide important information about rural
southern PLWHIV and their needs for ancillary
services. They also suggest clusters of service needs that often
occur among PLWHIV, which may help case
managers and other service providers work proactively to
identify important gaps in care.
Keywords: HIV; health services utilization; rural; south; need
Introduction
The prevalence of HIV infection has increased
rapidly in the southern USA compared to the other
areas of the country (Foster, 2007; Reif, Geonnotti,
& Whetten, 2006) and southern states are among
those with the highest AIDS-related death rates in the
country (Reif, Geonnotti, et al., 2006; Whetten &

Reif, 2006). For example, in 2006, Alabama had an
age-adjusted HIV mortality rate of 4.2 per 100,000
persons, compared to 4.0 per 100,000 persons in the
USA (Heron et al., 2009). Several issues in the south
have been considered as possible contributors to the
increased incidence of HIV and AIDS in the region,
including high rates of sexually transmitted infections
(STIs), racial disparities, the conservative culture of
the south, poverty, and lack of access to health
insurance and health care (Krawczyk, Funkhouser,
Kilby, & Vermund, 2006; Luciano, 2002).
These factors create barriers to treatment for
persons living with HIV (PLWHIV), but the major-
ity of this research has been conducted in major
urban areas and these findings are not always
applicable to the southern population (Krawczyk
et al., 2006). For example, the HIV Cost and Service
Utilization Study (HCSUS) estimates that 46% of
PLWHIV in the USA have an annual house-
hold income of less than US$10,000, that 63% are
unemployed and 20% have no health insurance
(McKinney & Marconi, 2002). These estimates
are relatively consistent with observations of clinical
cohorts of PLWHIV, but may underestimate the

significant needs for social services among PLWHIV
in certain areas of the country, including the rural
south, where the proportion of uninsured adults
often approaches or exceeds 25%.
A lack of economic and social resources compro-
mises a person’s ability to access health care services,
and research supports the finding that many southern
PLWHIV are disproportionally underresourced and
thus require considerably more assistance for every-
day activities and basic services, such as housing
assistance, emergency provisions, support groups,
*Corresponding author. Email: [email protected]
AIDS Care
Vol. 23, No. 3, March 2011, 340�347
ISSN 0954-0121 print/ISSN 1360-0451 online
# 2011 Taylor & Francis
DOI: 10.1080/09540121.2010.507743
http://www.informaworld.com
http://www.informaworld.com

mental health-related counseling, legal assistance, and
financial assistance (Reif, Geonnotti, et al., 2006;
Reif, Whetten, Lowe, & Ostermann, 2006; Whetten &
Reif, 2006). Reif and colleagues studied infectious
disease clinics throughout the south, and found that
84.5% of the patients with HIV who were served by
these clinics needed at least one support service, with
47% reporting that at least one need was not met
(Reif, Whetten, et al., 2006).
Given that, in urban samples of PLWHIV, lack
of access to social services is not only related to
general quality of life (Chin, Botsko, Behar, &
Finkelstein, 2009), but is also closely tied to medical
adherence, access to medical treatment, and health
outcomes (Messeri, Abramson, Aidala, Lee, & Lee,
2002; Reif, Whetten, et al., 2006), it is crucial to
understand more about the social service needs of
people living with HIV/AIDS in the south. Since a
sizable proportion of southern PLWHIV is not

engaged with a medical care provider (McKinney
& Marconi, 2002), surveys of social service needs
that are limited to samples of HIV-positive patients
or only urban PLWHIV may provide an incomplete
picture of the experience of PLWHIV in rural or
southern communities.
Community-based surveys may provide a more
comprehensive description of the patterns of social
service utilization and need in this population. One
particularly valuable approach to reaching this com-
munity is through AIDS Service Organizations
(ASOs) which are staffed by individuals who are
well known and trusted by the community of
PLWHIV, and provide social services that are other-
wise limited or unavailable (Tolle, 2009). Under-
standing the patterns of service needs and utilization
among these community populations may be helpful
to providers and case managers in working proac-

tively with their clients.
AIDS Alabama is an ASO located in Birmingham,
Alabama that has been funded since 1988 by HRSA,
CDC, HUD, state, local, and private resources. It
serves a catchment area that includes approximately
16,000 PLWHIV, and coordinates with other ASOs
throughout the state. To understand the priority
needs of its client population, AIDS Alabama con-
ducted statewide surveys of PLWHIV in 1999, 2003,
and 2007.
We examined the 2007 AIDS Alabama Needs
Assessment Survey data to explore patterns of service
utilization and needs, expecting that a high propor-
tion of respondents would report utilization of or
need for services across multiple domains, and that
several services would ‘‘cluster’’ together.
Methods
Participants
AIDS Alabama and partner agencies recruited
PLWHIV to be as representative as possible of the

adult PLWHIV population, in terms of geographical
distribution and racial and gender balance; partici-
pants were recruited from most Alabama counties.
However, in some instances, certain counties re-
mained underrepresented in the sample due to a low
known HIV-positive population. Attempts were
made to include individuals who both were and
were not well-connected to health care, by working
through ASOs, case managers, and other HIV-
positive individuals, who were able to identify and
refer sporadic users of ASO services and those not
receiving medical care.
Measures
This survey was created specifically to assess the
needs and concerns of the adult PLWHIV population
for the use of AIDS Alabama staff in program
planning, and as such was not originally developed
for research purposes. It was jointly developed by
AIDS Alabama and Columbia University School of
Public Health faculty in 1999. The survey content was
slightly edited by consultants at the University of
Alabama at Birmingham for 2003 and again for 2007
but similar collection methods were used in all survey
administrations. In addition to standardized mea-
sures on aspects of living with HIV, the interview
covered demographics; basic needs such as food,
transportation, and housing; and a wide range of
other ancillary services. A total of 14 basic and
ancillary service needs were included: financial,
legal, pharmaceutical, employment, and housing
assistance; substance use, mental health, and alcohol
treatment; medical services, transportation, dental
care, case management, food, and childcare. Respon-
dents were asked to indicate whether they had

received services or had needed assistance in the
past 6 months in each of these areas.
Procedures
Survey questionnaires were administered by trained
interviewers who were HIV-positive Alabamians.
Interviewers traveled to meet and conduct the survey
at a convenient location for the participant, usually at
an ASO or HIV clinic office or meeting room where
privacy could be assured. All information collected
was confidential, assigned a unique identification
number, and free of identifying personal information.
Some interviews were video- or audio-taped with the
AIDS Care 341
participant’s written permission. Each recording was
securely stored without personal information. The
interview took approximately one hour to administer.
Participants did receive US$15 compensation for
their time, travel, and effort.
Results
Data analysis approach
The 2007 survey was administered to 525 community-
dwelling individuals. A total of 29 individuals who
identified with a racial/ethnic group other than Black
or White or had missing data for racial/ethnic group
and 20 individuals who identified themselves as
transgender or had missing gender data were ex-
cluded for comparison purposes, which resulted in

476 individuals included in subsequent analyses.
Descriptive analyses were completed to obtain the
characteristics of this sample.
Binary service utilization/need (SUN) variables
were created for each of the services included in the
survey. If the respondent indicated either that s/he was
receiving services of a specific type or had needed that
service then a value of 1 was assigned to the service/
utilization variable; if the respondent indicated that
they had not received the service and had not needed
it, then a value of 0 was assigned. This combined SUN
variable approach reflected the overall demand for
each service by including those who have already
gained access to the service as well as those who
needed the service but were not able to obtain it.
Descriptive univariate analyses were completed to
determine the number and percentage of respondents
who reported using or needing each service, and
demographic characteristics were compared for those
who had an individual SUN variable score and those
who had missing data for that variable. No significant
differences were noted for any of these comparative
analyses. Subsequently, multivariate linear regression
analyses described the characteristics of individuals
most likely to need or use each service. Logistic
regression models included each SUN as the outcome
variable. Predictor variables in each model included:
race, gender, age, relationship status, education,
having children in the home, and employment status.
Next, values for the individual SUN variables
were summed to create an overall SUN score for each
respondent. A total of 367 respondents had complete
data for each of the SUN variables and thus a

calculated overall SUN score. Descriptive univariate
analyses were completed to characterize the pattern
of overall SUN scores; again, demographic character-
istics were compared for those with and without an
overall score. No substantial differences between
groups were identified. Multivariate linear regression
analyses described the characteristics of individuals
who were evidenced the highest and lowest SUN
scores (defined as those respondents in the highest
and lowest quartiles of overall SUN scores, respec-
tively). The outcome variable was the overall SUN
score and predictor variables were included as
described above.
Then SUN variables were subjected to an explora-
tory factor analysis using squared multiple correla-
tions as prior communality estimates. The principal
factor method was used to extract the factors. We used
both oblique and orthogonal rotation of factors;
because the results were essentially identical, the
orthogonal rotation results are reported. A three-
factor solution was hypothesized; factor selection was
based on eigenvalues (]1.0), scree plot, and inter-
pretability were considered in confirming factors.
Items were considered to load on a factor if the
rotated factor loading was greater than or equal to
0.35 on one factor and less than 0.35 on other factors.
Demographics of the sample
The characteristics of the analysis sample are sum-
marized in Table 1. The majority of survey respon-
dents were black males between the ages of 40 and
64 years. The average age was 42.5 years (standard
deviation (SD), 9.84). The youngest was 18 years and

the oldest 76 years of age. A majority were single or
never married. Approximately, one in four respon-
dents had children in the home, one in three had some
college education, and one in four reported having less
than a high school diploma. Just fewer than 70%
reported being employed either full or part time.
Frequency of service utilization/need (SUN)
Services used or needed by the survey respondents
are summarized in Table 2. The most commonly
used or needed services included case management,
medical assistance, and financial counseling. The
least needed or used services were childcare, legal
assistance, alcohol treatment, and employment assis-
tance. Approximately, half of the respondents in-
dicated that they either needed or were receiving
mental health services, transportation assistance, and
housing assistance.
Demographic group associations with service
utilization/need (SUN)
Table 3 summarizes findings regarding the demo-
graphic subgroups most likely to report using or
needing services, by type of service. Regression
342 K.E. Stewart et al.
analyses indicated no significant differences among
groups in their likelihood of needing or using medical
or legal assistance. Black respondents were more

likely to be users of alcohol treatment, employment,
financial, food, housing, and pharmacy assistance
than were their white counterparts. Individuals not
living with a partner or a spouse were more likely to
be using or need substance use treatment services
than respondents in partnered relationships. Women
were more likely than men to be users of childcare
assistance, as were individuals with children in the
home, compared to individuals without children in
the home. Furthermore, compared to respondents
who were employed, respondents who were not
working were more likely to be users of a number
of services, including: case management, mental
Table 1. Demographic characteristics of analysis sample, AIDS
Alabama 2007 analysis sample (n�476).
Characteristic n %
Gender
Male 314 66.0
Female 162 34.0

Racial/ethnic group
White 112 23.5
Black 364 76.5
Age
18�39 years 165 34.8
40 years and older 309 65.1
Education
Less than high diploma 121 26.3
High school diploma or higher 339 73.7
Children in home 116 25.4
Relationship
Living with life partner or spouse 83 17.5
Not living with partner (widowed, married but
separated, divorced, never married)
391 94.0
Employed 139 69.8
Income
Less than US$800 a month 334 70.2
US$800 a month or more 142 29.8
Unemployed and receiving
SSI, SSDI or disability income 206 60.6
Table 2. Types of services needed and/or used by survey
respondents, AIDS Alabama 2007 (n�476).

Services needed or used n %
Alcohol treatment 107 23.2
Case management 426 93.8
Child care 21 4.5
Dental care 302 64.9
Drug treatment 164 34.9
Employment 115 24.5
Financial counseling 389 83.1
Food 338 71.9
Housing 272 58.0
Legal assistance 74 16.3
Medical assistance 428 90.3
Pharmacy assistance 310 71.6
Mental health counseling 242 52.0
Transportation 262 55.3
AIDS Care 343
Table 3. Results of regression analyses to identify high-risk
groups by assistance type, AIDS Alabama 2007.
Risk group
Adjusted odds ratio
a
95% confidence interval
p-Value

Assistance type Black Female Older age
Less
education
Children in
home
Not
partnered
Not
working
Alcohol treatment 1.9 1.4 1.1 0.7 0.6 1.9 0.7
1.0, 3.5 0.9, 2.4 0.6, 1.8 0.4, 1.2 0.3, 1.1 0.09, 3.9 0.4, 1.2
0.0499 0.1558 0.8141 0.1697 0.1046 0.0953 0.2091
Case management 1.6 1.2 0.9 1.2 1.7 0.8 4.2
0.7, 3.9 0.5, 3.2 0.4, 2.2 0.5, 2.9 0.5, 5.6 0.3, 2.6 1.8, 9.8
0.2794 0.6506 0.8585 0.6232 0.3695 0.7717 0.0008
Child care 0.9 4.1 0.5 1.6 4.6 1.4 2.2
0.2, 3.6 1.4, 12.4 0.2, 1.4 0.6, 4.5 1.5, 13.6 0.4, 5.1 0.7, 7.5
0.9187 0.0125 0.1840 0.3921 0.0068 0.6519 0.1747
Dental care 1.6 1.2 1.0 0.7 1.0 1.0 1.7
1.0, 2.5 0.7, 1.9 0.6, 1.6 0.5, 1.1 0.6, 1.7 0.6, 1.8 1.1, 2.7
0.0656 0.4837 0.9842 0.1531 0.8830 0.9504 0.0177
Drug treatment 1.0 1.0 0.9 0.9 0.7 2.4 1.0
0.6, 1.5 0.7, 1.6 0.6, 1.4 0.6, 1.3 0.4, 1.3 1.3, 4.6 0.6, 1.5
0.8910 0.8778 0.6595 0.5538 0.2650 0.0053 0.8734

Employment 2.7 0.9 0.7 1.5 1.1 1.2 1.0
1.4, 5.4 0.5, 1.5 0.5, 1.2 0.9, 2.4 0.6, 1.8 0.6, 2.3 0.6, 1.8
0.0043 0.6671 0.2379 0.1425 0.6534 0.5648 0.8624
Financial counseling 3.2 1.5 1.0 0.9 1.0 1.2 11.9
1.7, 6.2 0.8, 3.0 0.6, 1.9 0.5, 1.7 0.5, 2.2 0.6, 2.4 6.4, 22.2
0.0003 0.2446 0.9131 0.8470 0.9477 0.6737 B0.0001
Food assistance 3.1 0.8 1.2 1.2 0.9 0.9 2.0
1.9, 5.1 0.5, 1.3 0.7, 1.9 0.8, 2.0 0.5, 1.5 0.5, 1.7 1.3, 3.2
B0.0001 0.3266 0.5172 0.3487 0.5844 0.8153 0.0036
Housing assistance 1.6 1.5 0.8 1.1 1.2 1.1 2.2
1.0, 2.5 1.0, 2.3 0.5, 1.3 0.7, 1.6 0.7, 1.9 0.7, 1.9 1.4, 3.4
0.0643 0.0758 0.3419 0.7698 0.5057 0.7107 0.0004
Legal assistance 1.2 0.7 1.5 0.9 1.1 1.3 1.4
0.6, 2.2 0.4, 1.4 0.8, 2.8 0.5, 1.6 0.6, 2.2 0.6, 2.8 0.7, 2.7
0.6797 0.3373 0.1816 0.6998 0.7343 0.4881 0.2892
Medical assistance 1.3 0.9 1.7 1.4 1.8 1.0 1.1
0.6, 2.6 0.5, 1.9 0.9, 3.3 0.8, 2.7 0.7, 4.3 0.4, 2.3 0.5, 2.2
0.5383 0.8133 0.1184 0.2784 0.1962 0.9510 0.8088
Pharmacy assistance 1.8 0.8 0.8 0.9 0.8 0.7 1.3
1.1, 3.0 0.5, 1.3 0.5, 1.3 0.6, 1.5 0.5, 1.4 0.4, 1.3 0.8, 2.2
0.0187 0.4399 0.3169 0.8139 0.5036 0.2791 0.2303
Mental health 0.6 1.3 0.9 1.2 1.3 0.9 1.6
counseling 0.4, 1.0 0.8, 1.9 0.6, 1.4 0.8, 1.8 0.8, 2.1 0.5, 1.5

1.1, 2.5
0.0738 0.2941 0.7388 0.3265 0.3320 0.5849 0.0252
Transportation 1.2 1.3 0.9 1.1 1.1 1.4 4.2
assistance 0.7, 1.9 0.8, 2.0 0.6, 1.4 0.7, 1.6 0.7, 1.8 0.8, 2.4 2.7,
6.7
0.5649 0.3320 0.5363 0.7811 0.7552 0.2563 B0.0001
a
Adjusted for all other variables in the table.
Note: Statistically significant values (p 50.05) are indicated in
bold text.
health, and dental services; and, financial, food,
housing, and transportation assistance.
Given a possible range of 0�14 services being used
or needed, the maximum number of services for an
individual respondent was 13 and the minimum was 1.
No respondents indicated that they did not use or
need any services. The mean number of services
received or needed was 7.5 (SD, 2.46), and the median
was 8.0. The highest quartile of users reported 9 or
more services and the lowest quartile reported 6 or
fewer. Black respondents were more than twice as
likely to be in the highest quartile of the sample in
terms of numbers of services used or needed (OR, 2.3;
95% CI, 1.2�4.3) than white respondents. Respon-

dents who were not employed were 2.5 times as likely
to have high numbers of services used or needed than
unemployed respondents (OR, 0.4; 95% CI, 0.2�0.7).
Factor analysis of service utilization/need (SUN)
patterns
The results of the exploratory factor analysis are
presented in Table 4, showing three distinct factors:
Basic needs � case management, dental, employment,
financial, food, housing, and transportation assis-
tance; Substance abuse � drug and alcohol treatment;
and Legal/Medical care � legal and medical services.
Employment assistance showed some association
with all factors but loaded onto basic needs. Mental
health services loaded with both substance abuse and
legal/medical care. Child care assistance did not load
strongly on any factor but was most closely asso-
ciated with basic needs. All other items were distinctly
associated with a single factor.
Discussion
The results of this analysis affirm prior findings that
many PLWHIV require extensive support services
beyond medical care. Although HIV-specific medical
care, pharmacy support, and case management
are among the highest priority needs, other services
are very important to the health of this population
and tend to cluster together in predictable patterns.
A large proportion of our sample reported use or

need for basic needs services, including housing,
meals, and transportation. This need illustrates the
circumstances of PLWHIV who are severely resource-
limited. Importantly, there is a strong link between
access to these services and engagement in medical
care as well as adherence to antiretroviral medications
(Messeri et al., 2002). Thus, provision of basic
services is a crucial aspect of care for social well-
being and improvement of medical outcomes.
An important portion of our sample required
mental health, alcohol, or substance abuse treatment.
The link between mental health, substance use, and
clinical progression of HIV disease is also well-
established (Hoang et al., 2009). Thus, provision of
these services should not be considered an adjunct to
medical care but a necessary component of care for
those who need these services. Community agencies,
ASOs, physicians, and clinics must coordinate so that
needs for basic services and mental health are
routinely assessed in clients, even if not engaged in
medical care. This can be challenging in environ-
ments where there are multiple agencies and organi-
zations serving the HIV-affected community. In rural
areas, where resources may be more widely scattered
and the number of PLWHIV may be relatively
Table 4. Rotated factor loadings of the individual services used

or needed scores.
Factor loadings
Basic needs Substance abuse treatment Medical/legal services
Service Eigenvalue � 2.53 Eigenvalue � 1.59 Eigenvalue �
1.09
Financial assistance 0.68 �0.01 0.0
Food assistance 0.64 0.08 0.14
Housing assistance 0.59 0.02 0.21
Transportation assistance 0.58 �0.01 0.21
Dental services 0.46 0.15 �0.07
Case management 0.44 0.09 �0.14
Employment assistance 0.37 0.24 0.29
Alcohol treatment 0.03 0.82 �0.08
Drug treatment 0.03 0.82 0.10
Legal services 0.09 0.23 0.67
Medical services �0.01 �0.31 0.65
Child care services 0.26 �0.10 0.0
Mental health counseling 0.06 0.40 0.39
Note: Statistically significant values (p 50.05) are indicated in
bold text.
AIDS Care 345
smaller, the coordination challenges may be even
more extensive. Primary care and community clinic
nurses, social workers, case managers, and physi-
cians, may facilitate coordination by proactively
identifying resources in these major areas of need
and routinely assessing HIV-positive clients’ needs in
these domains.

This project is among the first to examine
patterns of service utilization and need among a
rural, southern community sample of PLWHIV, an
increasing proportion of the HIV epidemic. As
such, the findings contribute to the growing evidence
regarding the importance of social services, espe-
cially because previous studies have been largely
limited to urban samples or clinical populations.
Because a significant proportion of PLWHIV is not
engaged in clinical care and rural PLWHIV may
be particularly likely to lack access to professi-
onal services such as expert medical and legal care
(Krawczyk et al., 2006; Reif, Whetten, et al., 2006),
understanding the patterns of need and utilization of
social services in rural, underserved communities is
important.
The clustering of services in predictable groupings
may provide guidance for case managers, social
workers, and others who are the primary support for
rural PLWHIV who are not in care. Even though
clients may be focusing on a single service to meet an
immediate, specific need, case managers, and social
workers can explore the client’s need for additional
services in the various domains to assure comprehen-
sive, coordinated support services. For example,
clients who present requesting food assistance may
require additional basic needs that would go undis-
covered without more in-depth assessment.
Limitations of the study and suggestions for future
investigation
The sample described in this paper was comprised of
adult PLWHIV in Alabama and thus do not ade-

quately document the needs of PLWHIV under the
age of 18. Needs assessment surveys that are specific
to the concerns of children and adolescents with HIV
may identify very different patterns of social service
utilization and need. Although the survey’s sponsor-
ing agency created a sampling strategy that specifi-
cally attempted to ensure that the sample would be
representative of the entire adult PLWHIV popula-
tion in the state, some generalizability questions
remain. The study sample included slightly more
African-Americans and slightly more women com-
pared to state surveillance reports of the HIV-positive
population in the state and in the southern region
overall (The Kaiser Family Foundation, 2010). How-
ever, since rates of HIV are increasing rapidly in
African-Americans and women in the south (US
DHHS, CDC, NCHSTP, & APIDS, 2002), this
overestimation may provide insight into patterns of
service utilization and demand in the area among the
subgroups that are disproportionately affected by
HIV at this time in the epidemic.
This analysis was intended to document the
patterns of and overall demand for social services
among PLWHIV in Alabama, as represented by the
combination of those survey participants who re-

ported receiving services and those who reported
needing services. This is a crucial first step in assisting
service providers in clustering their services and in
predicting which of their clients will likely require
specific services. However, additional research should
be conducted to further support agency leaders and
policy-makers in determining next steps in the provi-
sion of care. For example, this investigation was not
adequately powered to determine what differences, if
any, exist among those who have received services
and those who need the service but have not received
it. Future studies of larger samples should examine
the extent to which the population of those who
report a need for a specific service fall into one of
three categories: (1) those who need the service and
cannot obtain it because the service is not available in
the community; (2) those who need the service and
cannot obtain it because the service does exist but

they experience problems of access (e.g., transporta-
tion, funding); or (3) those who need the service and
could get it, because the service is available and
accessible. Each of these possibilities has distinctly
different implications for community intervention
and action.
Similarly, although this investigation was limited
to an examination of cross-sectional data, there is
some evidence that provision of some of these social
services is associated with subsequent engagement in
medical care (Lo, MacGovern, & Bradford, 2002).
Additional research should examine the efficacy of
social service provision as an intervention to increase
engagement in medical care and adherence to medical
recommendations.
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AIDS Care 347
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V_Care_on_Patient.9.aspx
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Needs Assessments
Leslie M. Tutty and Michael A. Rothery
N
eeds assessmen ts a re a for m of resea rch conduclcd to gather
information
about the needs of a population o r group in a co mmunity. One
of the
more practical types of research, needs assessments are used to
develop
new services or to evaluate the relevance of exist ing programs.
They may
also be used to establish a need to rev ise or create policy.
Th is chapter begins with a definition o[ needs assessment, how
we define " needs:' and
how we determine who to ask abou t needs. Common
methodological approaches to
n eeds assessments are described and evaluated using examples
p rim arily from the social
work literature. The benefits of triangulation, or using more
than one source or method
of gathering information, are presented, followed by a
discussion of who shou ld digest
and weigh info rm at i.on about ne eds once the information is
ga thered. Finally, we conside r
th e importance of developing a plan to implemen t
recommendat ions so that th e work of

assessing needs is used to clients' benefits, not relegated to the
shelves occupied by other
dusty and neglected reports.
What Is a Needs Assessment?
Needs assessments have not changed much over the years. In
1982, Kuh (cited in Stabb,
1995) listed five general purposes commo nly served by needs
assessment research that
remain relevant today:
l. Monitoring stakeholders' perceptions of various issues, which
can guide the devel-
opment of new programs or policies
2. Justifying existin g policies o r programs
3. Assessing client sa tisfacti on with services
4. Selecting the most desirable program or policy from several
alternatives
5. Determining if needs have been met, a purpose closely akin
to program eva luation
Two key q uestions are addressed when needs <1ssessments are
undertaken: "Wh o?" and
" IIow?" The "who" questio n requires the researcher to be dear
abo ut the membersh ip of
the group whose needs are to be assessed. Often, a study entails
gathering information
from a variety of respondents, from individuals who may never
have been clients to those
149

150 PART II • QUAII.TITATIVE APPROACHES: TYPES OF
STUDIES
receiving multiple services. In almost every case, however, at
least one set of respondents
will be the individuals who are most immediately affected by
gaps in services or supports,
rather than relying so lely on the opinions of service providers,
academics, or funde rs .
The "how" question addresses th e methods used to gathe r
informa tion from the group
whose needs are of interest. These are not unique; rather, needs
assessments borrow
familiar techniques such as surveys, interviews, and focus
groups, all of which are high-
lighted in other chapters in this book. Quant itative methods
such as surveys or standard-
ized m easures may be used, as may q ualitative m ethods such
as in-depth individ ual
interviews or focus groups. Combinations of both arc
increasingly popular since each
method has its advantages and limitations.
Defining Need
When we invoke the concept of needs, we may easily assume
that we share with others a
common understa nding of what it is we are talking about.
However, it is worthwhile look-
ing more closely at the defini tion of the te rm since usefu l
characteristics and di stinctions
are highlighted when we do so.

The concept of need is not new: Researchers have been defining
and red efining the
term for decades. Stabb (1995) distinguishes between met and
zmmet needs. "Met
needs are necessary or desirable co nditions that alrea dy exist
in act ua li ty. Unmet needs
arise when there is a discrepancy between desirable conditions
and current actuality"
(p. 52). Both met and unmet needs could conceivably become
the focus of needs assess-
m ent research, although unm et needs will be the main concern
in the vast majority of
cases.
A different distinction (perhaps m ore usefu l for our purposes)
is provided by Witkin
and Altschuld (1995), who define a need as "a discrepancy or
gap between 'what is,' or the
present state of affairs and vhat should be; o r a desi red state
of affairs" (p. 4). In this
an alysis, needs equate with unmet needs, the most common fo
cus fo r needs assessment
research. Revere, Berkow itz, Carter, an d Ferguson (1996) add
the sugges tion that need is
defined by "community values, [a nd is) amenable to change"
(p. 5).
From these perspectives (and wi th reference to considerations
introd uced earlier), a
needs assessment gathers informatio n about gaps between real
and ideal conditions, the
reasons that these gaps ex ist, and what can be done about them
, all wi thin the con text of
t.he beliefs of the community and available resources for
change.

Another distinction introduces the question of degree. Some
needs are stronger or
more important than others. f undamental needs with relevance
to people's sur vival,
safety, or basic comforts are not the same as "wants" or less
compell ing needs. A social
work professor's desire for a week in Mexico as a break from
winter is qualitatively very
different from a homeless person's need for food and shelter in
the face of the same cold
conditions. While it is often d ifficult to draw the line between
rela tively impor ta nt needs
and less important wants, it is still important to do so. Needs
assessments are focused on
needs that affect ind ividuals' abilities to function well in
important areas of their lives.
Wants associated with perceived quality of life (b ut not to the
same extent with life's real
essentials) are more lhe purview of market research.
Social workers generally find Maslow's (1970) hierarchy of
needs useful when consid-
ering the needs and priorities of their clients. It is also a
framework that can inform needs
assessments. Maslow's five levels of need are physical and life-
sustaining needs (such as
air, water, food, warmth, and elimination of bodily wastes),
physical safety (e.g., protec-
tion from physical attack and disease), love and support, self-
esteem an d self-wo rth, and
self- realizat ion (e.g., needs to be productive and creative) .
Maslow con tended that these
CH APTER 9 • N EEOS A SSESSMENTS 151

basic needs must be attended to before attempting to address
higher level needs (or
"wants"). Needs assessments can gather information relevant to
any one or more of these
five levels, b u t the hierarchy of priorities prov ides useful cr
iteria fo r deci d ing on what to
focus first in data collection and recorn mending changes.
Finally, some authors argue that once an "expressed need" is
verbalized, it becomes a
want or a demand (Stabb, 1995) . This is not the same as
differentia ting needs from wants
o n the basis of the strength of the potential impact on
someone's well -being and is prob-
ably less useful for our purposes. However, a related point is
noteworthy: Verbal demands
are not always the d irec t expression of need. Just beca use
someone exp resses a want d oes
not mean that it represen ts a need. Thus, in needs assessments,
it is important to gather
information from members of a population beyond those
publicly advocating for specific
d emands.
Who Do We Ask About Needs?
The term stakeholders is often used to refer to clients or
potential clients or the people who
actually n-perience the need thal is being studied. However,
Revere and colleagues (1996)
suggest broaden ing th e d efinition to refer to "service
providers and m a nagem ent, com-
munity members, certain politicians, the funding source,
business/trade associations and
the actual research •..vorkers" (p. 7) since each of these has a
vested inte rest in the study and

its o utcomes. Th is flex [ble use of the term is helpful,
suggestin g a range of potential
sources of data and recognizing that needs assessments have
ramifications for people
beyond those normally surveyed .
Needs assessmen ts tra ditiona lly look to three groups as
sources of data: the target group
(i.e., clients or potential clients), key informants such as
community leaders or service
providers, or a sample of aJI members of the relevan t comm
unity. Each is described in more
detail below.
The target group or populatio11 comprises the very individuals
about whom we arc con-
cerned and whose needs we w ish to assess. Common sense
suggests that these are the
voices we most wish to listen to in o ur q uest t o gather the best
an d most current infor-
mation. However, engaging with individuals to encourage them
to share their needs and
op inions is not always easy. Highly d isadvantaged, socially m
arginalized individuals and
grou ps, the typ ical focus of social workers' interventions, are
nol always accustomed to
being asked their opinions and may not easily articulate their
needs to a researcher when
inv ited to d o so. Furthermore, they may have understandable
reasons fo r n ot trusting
members of those who have mo re powe r in soc iety, a group to
which researchers belong.
Consider the homeless as an example, especially the
subpopulation that has been diag-
nosed with psychiatric disorders. With any such group, the
researcher ca n not simply

approach and invite them to en umerate Lheir needs. Strategies
(and time) for building
trust, rapport, and for encouraging engagement in the research
process are prerequisites
for successful data gather in g.
McKi ll ip (1998) defines another gro up serving as a common
source of data, key infor-
mants, as "opportunistically connected individuals with the
knowledge and ability to
repor t on communi ty needs. Key in fo rmants arc lawyers,
judges, physicians, min isters,
minority group leaders, and service providers who are aware of
the need and services per-
ceived as important by a community" (pp. 272- 273). An
advantage of gathering data
from key informa nts is that they may have a broad er
knowledge of serv ices available in
the community than the target population, and they may be
better at articulating what
needs must be effectively addressed. One disadvantage is that
key informants sometimes
have a vested interes t in developin g new services or preserving
esta blished resou rces even
152 PART II • Q UANTITA IIVE A PPROACHES: T YPES OF
STUOIES
though they arc less than adequate (we all develop loyalties, and
these can affect our judg-
ment). McKfllip (1998) also notes that key informants may
underesti1nate the willingness
of m embers of the target population to participate in programs
while overestimating the

extent of the problems.
The third group, community members, comprises th e entire
citizen ry of a comm unity.
This group encompasses members of the target population but
also includes those not
directly affected by these needs. App roaching community
members for information has
the advantage of identifying how broadly based the needs are,
rather than assuming that
they are restricted to the ta rget population. lt also offers the
opportunities to lea rn about
how needs (and the strategies Lo ameliorate them) are perceived
in the commu ni ty at
large and to think about how that v.rill affect efforts to
implement changes. A disadvan-
tage, though, is that community members m ay be relatively
t111awarc of the needs of its
more marginalized citizens.
In summary, each of th ese groups may b e the focus of the
needs assessmen t methods
documented in the next several sections. The choice of whom to
engage may be based on
access to the group or limitatio ns of tin1e and resources. If
possible, representation from
each of the target population, key commu ni ty stakeh olders,
and members of the general
public is worth considering as each provides valuable but
somewhat different information.
Methods of Needs Assessment
As mentioned prev iously, one ca n co nduct needs ass essm
ents u sing a variety of strategies.
We will d£scuss methods in lwo broad catego ries, quantitative

and qualitative.
Quantitative m ethods gather data th at are tran slated in to
numerical form and described
using statistics. Using such methods, it is possible, for example,
to conclude that in a sam-
ple of 102 shelter residents, 70.5% of these women abused by
intimate partners were
abused themselves as childre n and described 73.7% of their pa
r tners as also having been
abused (Tutty & Rothery, 2002). Such high proportions may be
interpreted as suggesting
the need for early in tervention with children in sh elters in the
hope of preventing the
cycle of violence from affecting a new generation.
Providing statistics about the extent of a need can be a powerful
method of raising
awareness of the severity of gaps in services. The section on
quantilative needs assessment
will describe three such methods: surveys, s tandardized needs
assessment measures, and
using existing statistica l databases.
In cont rast, qualitative needs assessments ask questions that are
more op en-ended and
allow the research in fo rma nt to describe in detail the
complexities o f the issues at hand.
for example, a qualital ive needs assessment conducting in
terviews with another group of
,63 abused women residing in a shelter noted that providing for
their basic needs such as
safety and food was of great impo rtance (Tutty, Weaver, & Ro
thery, 1999) . However, some
women expressed concerns about the fact that a few residents
were difficult to live with,
and some mothers did not m anage lhcir children's aggressive

behavior or ignored them.
These results suggest a somewhat different focus for
intervention by crisis counselors and
th e need to p rovide parenting progra ms for some residents.
Results from qualitative needs assessments often lack s ta
tistical dat a that could convey
the extent of the problem, but they tend to be rich in detail that
conveys the complexities
and uniqueness of the experiences of different individuals. T he
quali ta tive needs assess-
ments methods described in the chapter include interviews
(either face-to-face or by tele-
~!1~ll~h f8EU~ KrGUp~. nomtm1 groupg, ~nd t CMh halt
meetings.
CHAPTER 9 • NEEDS ASSESSMENTS 153
Quantitative Methods of Needs Assessment Surveys
Allhough surveys may ask open-ended qualitative questions, the
great majority are devel-
oped for quantitative data analysis. Quantitatively oriented
surveys, particularly those
employing questionnaires, are the most freq uent method of
assessing needs. The tasks
involved in developing a survey to assess needs are ident ical to
those undertaken when
surveys arc developed for other purposes, so they will not be
detailed here. The major
steps involve
1. D eciding who Lo survey (e.g., target groups, key info
rmants)

2. Selecting a method of sampling (e.g., random or systematic
sample)
3. Determining the content of items (through reviewing the
literature or holding
focus groups with key informants, as only two examples)
4. Ch oosing what type of question to use (e.g., open-ended,
multiple choice, or scaled
with respect to the extent of agreement)
5. Selecting a method of distribution (e.g., the Internet, mail, or
telephone)
The advantages of surveys include the ease and flexibility with
which they can be
administered compared to other methods and th e relative lack
of expense to collect a con-
siderable amount of data. Disadvantages include the extent to
which a set questionnaire
can predetermine the issues that respondents address and the
consequent danger of not
hearing about needs that would emerge in a more open-ended
process.
With such risks in mind, Witkin and Altschuld (1995)
recommend being cautious about
assuming that a written questionnaire is the most app ropriate
tool wh en considering con-
ducting a needs assessmen t. While a questionnaire can be an
important tool, they suggest
that it should not be used until after more exploratory methods
have been employed to
ensure that the factors measured by questionnaire items are as
well chosen as possible.

Furthermore, some cultural groups find surveys strange or
difficult (especially if
English is not one's first language) and respond negatively to
them. Weaver (1997), for
example, described a questionnaire developed to assess the
needs of an off-reservation
Native American community in an urban area. A large numb er
of qu estionnaires were
mailed out, with virtually no returns. The alternative of a
qualitative approach including
focus groups and individual interviews was adop ted with
considerably greater success.
An example of a needs assessment that employed survey
methods more appropriately
is Brennan Homiak and Singletary's (2007) study that surveyed
Christian clergy members
from 15 denomina tions in central Texas with respect Lo their
perceptions of the number
in their congregation experiencing intimate partner violence and
what clergy needed to
better address this serious concern. Of the 100 surveys mailed,
44 were returned, a some-
what low but not unusual return rate for mailed surveys.
The clergy members estimated that less than IOo/o of thei r
congregation members
experienced partner violence--low when compared to incidence
studies in Texas that
cited lifetime rates of 47%. Only about one third of the clergy
had received domestic
violence-specific training; they were more likely to have
resource materials in their
churches and were familiar with local agencies and shelters for
abused women. While a

small proportion of the clergy considered themselves very
equipped to counsel victims of
domestic violence or make referrals, the majority did not. The
authors recommend th at
social workers take the lead in offering trai ning to assist the cl
ergy in promoting violence-
free congregations.
154 PART II • Q uANTilATIVE A PPROACHES: TYPES OF
STUDIE~
As mentioned prev iously, surveys may usc both ch eck-lis t
type, predetermined
resp onses and open -ended questions that allow for m ore
context ual detai led responses
and arc analyzed using qualitat ivc m ethods. A recent exa mple
of using open-ended ques-
tions is a survey with 206 agency-based social work field
instructors, querying their initial
awareness, personal and professional needs, and field issues
that arose in response to th e
World Trade Ce nter disaster of Septem ber lith, 2001. The field
instructors had clearly
been weary but retained sensitivity to studen t and client n eeds.
The res ults suggest th e
imp orta nce of develop ing an integrated crisis p lan to better
lin k the school, students, and
field instructors in the event of future disasters.
Standardized Needs Assessment Measures
A relatively n ew needs assessme11t methodology entails
developin g stand ardized measu res
to assess th e needs of a specific popu lat ion group. For exampl
e, Wancata and colleagues

(2006) initially used focus groups and in depth individ ual
interviews to develop a mea-
sure comprising 18 common p roblems exp erienced by
caregivers o f adults diagnosed
with schizophrenia. The difficulties were translated into items
such as "not enough infor-
mation on the illness, its symptom s and course," " fear of
stigmatization and discrimina -
t io n ," and " burnout or illness of the carer."
Using such a measure in other needs assessment research has
the advantage of building
on the work that has gone into identifying and conceptualizing
potentially impo rtan t
n eeds and of using a meas ure for whi ch reliabil ity and validi
ty will often have been estab-
lished. A poss ible disadvan tage is that needs proven relevan t
to caregivers of adults diag-
nosed 'l'ith schizophrenia in one location may not ha ve the
same importance in others.
Conversely, items about other needs tha t are important in a new
loca le may be m issing
from the standardized measure.
Using Existing Statistical Information
Another quantitative method of con du cting needs assessments
is using da ta that h ave been
previously collected. Existing data may be available in agency
fi les or governmen t data
banks, for example. Such secondary analyses have the
advantage of sparing researchers the
tim e and expense of gathering new data. A d isadvantage is that
one is lim ited to data th at
som eone else considered worth gath ering, and potentially
important variables may be
absent or may need to be inferred indirectly from the data that

were recorded.
Review ing case fil es can be challenging. As a follow-up to a
previousl y completed study
on the o utcomes of a specialized domestic violence court
(Tutty, McNichol, & Christe nsen,
2008), we are using district attorney files to collect a number of
variables, including the
demographic cha racteristics of tbe accused and the victim, whe
ther the victims testifi ed or
provided a victims impact statement to the court, and hov,, the
trial was resolved.
In contested cases, the files can b e very large, literally inches
thick! The fi les are created
for the crimina l justice system, not researche rs, so there is no
consistent organi zation. As
such, collecting data from one file can take several hours.
Considerable information may
not be recorded. Lawyers are not necessari ly as interested in
demographic cha racteristics
such as ethni city or age as most researchers are, and so lit tle
of th is can be found in the
files. Desp ite these challenges, if we are to evaluate the
specialized courts, paper flle
reviews are our only option to assess whether the courts are m
eeting Lhe needs of both the
victim s and th e accused.
The followi ng needs assessment used case records to assess wh
ether the needs of abused
and neglected children were adequately addressed by the child
welfare int ervention . Tracy,

CHAPTER 9 • N EFDS A SSLSSMENTS 155
Green, and Bremseth (1 993) revi ewed case records of
supportive services for abused and
neglected children in one U.S. state. Five hundred child welfare
cases were sampled to
explore facto rs associated wit h decisions to offer one of two
services, family preservation if
children at risk were still at horne, or reunification fo r families
with children who had been
placed. The authors collected information on demographic
variables, presenting problems,
service history, service needs, services planned and provided,
service characteristics, and
serv ice outcomes. This en terprise, the aLlthors noted,
consumed thousand s of hours.
The analysis uncovered significant stresses affect ing the chi
ldren sampled, parental
substance abuse, economic difficulties, and poor liv ing
conditions, which were infre-
qu en tly addressed in case plans, whi ch emphasized
indications of child abuse. The
authors conclutled that "there was little one-to -one d irect
corresponden ce between the
service need and the service offered" (Tracy e L al., L993, p.
26), raising serious questions
about the quality of service pla nning (and the training of child
welfare workers).
Qualitative Methods of Needs Assessment
Qualitative needs assessment research may be conducted via
individual interviews, small
group discuss ions, or even large town hall meetings, each of
which allow for more open
exploration of issues than the q uantitative m ethods previously

outl ined. Such studies
tend to involve a greater t im e commitment from respondents
but offer much more
opportunity to identify and discuss issues in depth.
Individual Interviews
Face- to -face a nd telephone interviews are one method of
gathering in-depth information
about the needs of particular groups. Preparation involves thi nk
ing through the purpose
of th e interview, constru cti ng an in terview schedule, and
train ing in terviewers (Vitkin &
Ahsch uld, J 995 ) . When a goo d rapport develops between
interviewer and respondent, the
result can be disclosure of informatio n and ideas about
sensitive issues that would not
emerge when more formal, structured approaches are used.
Also, in a more open-ended
process, respond ents may identify needs that no one had
anticipated.
The disadvantages of this approach inclu de the fact that it is
notoriously la bor intensive.
Interviews arc tim e-consuming to conduct, often lasting one to
two hours, especially if
asking individuals to reveal their personal stories. As a result,
often only a relatively small
sample of individuals may o r can realistica lly be interviewed.
Training the interviewers also
takes time, and the job of transcribing and analyzing interviews
is normally a lengthy, com-
plex task. The following needs assessment is an example of
using face-to -face intervie ws.
In the past 30 years, intimate partner violence has become an

issue of significant soci-
etal concern, resulting in specialized justice and physical and m
ental health sh ifts to more
ad equately safeguard the women and children wh o are the
primary vict ims. Yet certain
ethnocultural groups, including immigrants and refugees, are
underrepresented among
those seeking assistance from formal supports such as the police
and emergency shelters.
With respect to the question of what would constitute culturally
appr opriate responses
t o domestic violence, Pan ct al. (2006) conducted 120 face- to-
face inte rviews with
members of three ethnic communities in San Diego: Somali,
Vielnamese, and Latino. The
interv iews were provided in the appropri ate language, and
within each cu ltural group,
10 women, 10 men, 10 boys, and 10 girls participated.
Beca use of tl1 e sensitive na ture of the issue, the topic of dom
estic v iolence was intro-
duced usi ng vignettes, rather than asking interviewees whether
they had personally been
abused. This allowed the respondents to speak about abuse in
their culture in more gen-
eral terms and to sugges t possible resolutions to the problem.
156 PART II • QUANTITITIVE APPROACHES: TYPES OF
STUDIES
The analysis of the interviews highlighted six core issues,
including "varying defmi-
tions of violence, specific definitions of family harmony, strict

gender rol es, varying con-
flict resolution strateg ies, cultural ide ntity a nd spirituality"
(Pan et al., 2006, p. 42) . The
differing perspectives from the three ethnic communities
suggested the need to develop
diverse culture-specific services.
Foc u s Groups
Focus groups are rel a ti vely unstructured small group
experiences, typically with about 8
to 12 participants. The group composition is usually
homogeneous in that members share
a particular experience or interest, like the members of what we
described earlier as the
target population. Focus group interviews typically take from
one and a half to two and a
half hours, and a number may be conducted for a given study.
Witkin and Altschuld ( 1995) summarize the process of a typical
focus group. Initially,
members hear a general statement of the purpose of the session
and are given a question
related to this purpose designed to elicit perceptions about
important needs. Often, par-
ticipants are asked to write down the ideas that the question
stimulates and then to share
them wi th the group. The leader typically writes ideas as they
are shared, summarizing
them and making sure th at there is agreement among members
wi th what is bein g
recorded. This process is then repeated with other
predetermined questions.
Leadership is important to a focu s group's success, espec iall y
since the re is no highly

stru ctured agenda (except for the pos ing and answering
questions aspect ). According to
Witkin and Altschuld (1995), "The leader must be
nonjudgmental, create a supportive
group atmosphere, be able to keep the interview process going,
be a good listener,
and be alert to sense when a group is deviati ng from the
prescribed question route in
meaningful and non-meaningful directions" (pp. 172-173).
These are by no m eans easy
demands.
One advantage of group approaches over individual interviews
can also be a disadvan-
tage. Whi le participants do not have the same opportunity to
explo re their own perceptions
or experiences in depth as in individual interviews, a group
approach can elicit information
that would not emerge without the stimulus of i nterC~cting
with others and rea cting to their
ideas. When group discussions detour in innovative ways, th is
may lead to original and cre-
ative ideas. Brainstorming, or encouraging members to present
any solution to a problem
without prejudging it, is one way to encourage such innovation.
Alternatively, withou t effec-
tive facilitation , the groups may pmsue unproductive tan gents,
and there is a heightened
risk of interpersonal conflict detracting from the effectiveness
with which research goals are
p ursued. The fo ll owing study used focus group methodology.
A relatively new role for sociaJ wo rk graduates is working with
senio rs and their
ram ilies to assist these clients in a number of ways. Yet, how
readily are social worke rs per-

ceived as resources to this population? Naito-Chan, Damron-
Rodriguez, and Simmons
(2004) used focus groups to explore what skills social work
practitioners need to ade-
q uately address the Heeds of older persons and their families.
The four focus groups
included older adults and caregivers of older adults (consumers
) as well as providers of
care and recent social work grad uates, both wo rking in
gerontology settings.
Notably, the analysis highlighted that a numb er of the
consumers had little under-
sta ndin g of how social workers could assist them. Key among
the consumer needs was
resource finding, which th e consumers did understt~nd as a
social worker role. However,
other social work competencies such as assessments and case
management were not men-
tioned by the consumers. The results suggested the need for
public education abo ut the
roles of social wo rkers in the field of aging.
CHAPTER 9 • NEEDS AsSESSMENTS 157
Nom i nal Groups
An al ternate group approach to needs assessment has been
developed (McKill ip, 1998).
Nominal groups are more structu red than focus groups: The
agenda allows group discus -
sion but with a more consistent attention to the goal of
achieving consensus about needs.
Fewer needs assessments that use a nominal group approach can

be found in the litera-
ture. Although more than a decade old, the following study
provides a model of nominal
groups with respect to issu es that remain current.
It is com m on ly acknowledged that inter perso n al and so cial
pro blems, whether at
home, in the neighborhood, o r on school grounds, can seriously
affect students' abi lity to
learn. Gerdes and Benson ( 1995) used a nominal group process
Lo assess problems expe-
rienced by inner-city African American schoolchildren. The
goal was to identify the most
serious problems faced by students from their own perspectives.
The authors used a strat-
ified random sample of students from Grades 1 to 9 who were
assigned to groups based
on whether they were from pr imary grades (l-3), middle grades
(4-6), or junior high
grades (7-9). Ninth-gra de st udents who had experienced the no
min al group process
acted as facil itators .
The group members were first asked to list the problems that
they faced at school on a
sheet of paper. Using a round-robin format, every student
identified one problem, adding
a new item to a list on a flip chart, until it was agreed that the
list was complete. From this
list, each student identifi ed th e seven most serious problems
and rated their severity. The
facilita to r then calculated the group ranking of the items.
The 1·a nkings of concerns varied across the d iffe rent age
groups. Figh ting and prob-
lems with teachers were priority issues for Grades 1 to 3,

fighting and drugs were the most
serious to Grade 4 to 6 students, and pregnancy, drugs, and drug
deals were the strongest
concerns for the junior high students.
Teachers from the stu den ts' schools also participated in
nominal groups, registerin g
additional concerns about stu dent issues such as low parental
support, parental probl ems,
and lac.k of mot ivation. Both students and teache rs expressed
a sense of powerlessness in
addressing the pro blems that th ey were identifying. While the
nominal group iden tified
needs very effectively and in a way that encouraged partnership,
it was but the first step in
the process of change.
Community Forum Approach
Large open public hearings or community forums may be used
to g<1th er information fro m
the diverse individuals comprising a community whose needs
are being assessed (McKillip,
1998). Similar to a town ha ll meeting lasting for several hours
with large numbers of par-
ticipants (sometimes 50 or more), this method aims to ensure
thaL the b roadest possible
sampling of opinions results in a data set reAecting a
community consensus regarding the
issues being scrutinized. Clearly, this approach aims to give a
vo ice to all community
memhers, including many who are immediately affected by th e
problems of interest.
Witkin and Al tschuld (1995) note tha t special leadership skiJJs
are vi tal to the success

of this approach. No t eve ryon e has the skills to facilitate large
meetings that encourage
group members to participate actively and trust that they can
openly share ideas that may
be different from the majority view.
The advantages of community forums include the fact that they
arc a relatively inex-
pensive way to hear from large numbers of interested individu
als. Another advantage is
that pubHc meetings serve to sensitize lhc gen eral public to the
problems or to hi ghl igh t
potential resistance to proposed solutions. Also, engaging a
cross section of community
158 PART I I • QUAN TITATIVt APP ROAC HES: TYPFS or
SIUDIES
members may have valuable secondary benefits. For example,
when the time co mes to
implement recommendations, important people may have bought
into the changes bein g
suggested.
A pr imary disadvantage to this method is th at there is no
means of ensu rin g rhat the
participants are a representative sample of their community.
lndeed, this will normally
not be the case: The ideas and perceptions collected will be
those of people who, for some
reason, are motivated to infl uence what happens. Citizens who
are less interested will not
attend and will not be heard, even though they may have
reactions to the needs being

assessed and th e eventual recommendations for dealing with
them.
reeds assessments using a community forum approach were
rarely described in the
literature. The followi ng study is an in triguing model of usin g
the forum t·o both present
the results of a previously conducted needs assessment to the
research respondents, which
subsequently used th e forum to further refine and develop
action plans arising from the
initial study.
The author included a community fo rum as one aspect of a
study of th e relative con-
trib ution of social cl ass and ethn icity Lo the differential
functioning of Puerto Rican
elders in Springfield, Massachusells. The first phase of the
study consisted of ind ividual
interviews with 591 elders. The purpose of the co mmunity
forum was both to present a
number of the research respondents with the interview resu lts
and to ask subsequent
questions. A total of 41 elders parti ci pated in the fo rum.
The forum discussion questions grew from the quantitative
survey findings. Two of the
five forum questions were, "Why are cultural support systems
not playing a mo re active
role in helping elders with their needs?" and "Why are churches
not playing a more active
role?" The author highlighted the extent to which the forum
participants assisted in inter-
preting the prev ious quantitative needs assessmen t findings,
resulting in rccom menda
tions that fit closely with this unique and previously

marginalized community.
Triangulation of Needs Assessment Information
To obviate risks of bias from usin g limited so urces of
information, Yegidis, Weinbach, and
Morrison-Rodriguez (1999) recommend "triangulatin g" or
"collecting data from three
(or more) sources, each having different perspectives!' Witkin
and Altschuld ( 1995) argue
for this step more strongly, suggesting that studi es using only o
ne method sho uld be con-
sidered seriously flawed .
'lo illustrate, suppose one is resea rching the need in a
community for a shelter for
women. One could co ndu ct a survey of key informants (social
workers, the police,
women's organizaLions, self-help group lea ders, etc.), host a
community forum, and per
form a secondary analysis of existing data in police and social
service agency files abo u t
the incidence of women requiring shelter. Congruence in the
perceptions obtained from
each study aspect would clearly represent a stronger case than if
o nly one source was
accessed. rr th e res ults contradict each other, however, the
resea rcher has th e difficult task
of assessing which set of perceptions enjoys Lhe grea test
credibil ity.
A number of the examples provided in this chapter illustrate the
use of more than one
m ethod of data collection. An assessment of the health needs of
transgendered individu-
als in Philadelphia (Kenagy, 2005) is a case in point.

Transgendered individuals have or are in the process of
undergoing medical proce-
dures to change their gender. Wbile this process entails
considerable involvemen t with
the medical system, it is not clear what health needs
transgendered people experience
C HAPTER 9 • NEEDS A SSESSMENTS 159
afterwards. Kenagy (2005 ) used face- to-face interviews or self
administered mail surveys
with 182 indivi duals (1 13 male-to -female and 69 female-to -
male in dividuals) .
The responses to queries abo ut hea lth needs were p ri marily
concerns with respect to
HIV/AIDS status {6% were HIV positive), risk ofHIV infection
or rein fection (60% had
engaged in unprotected sex within the past year), suicide (30%
had attempted), their
experiences of violence (54% had b een forced to have sex; 52%
had been physically
ab used), and access to health care (about two thirds had a do
cto r or primary care p hysi -
cian). Importantly, though, more than one quarter of the
informants had been refused
medical care because they were transgendcred. The results were
used to argue the need for
p revention services specific to the transgendered population.
It is n ot uncommon for va rious const ituents to h ave different
views about needs. As
noted by Revere et al. ( 1996),

It is relatively easy to decide tha t a starving man needs food or
a homeless person
n eeds sh elter. But what if an assessme nt points to areas of
need tha t are n ot
acknowledged by the individuals themselves, who may believe
they need so mething
else altogether? What if the target population and the service
providers in the com-
munity recognize different areas of need or d isagree as to what
will best meet that
need? (p. 4)
For example, a needs assessment standardized instrument was
developed by M. Carter,
Crosby, Geertshuis, and Startup ( 1996) to assess the needs of
people with a chronic
mental illness. Thiny- two q uestions m eas ured perception s as
to whether clie nts needed
assistance with a va riety of tasks and issues, such as shopping
and cooking, famil y
relationships, making use of spare time, and motivation.
Two forms were developed, one for clients and one for staff
members, so that the
perceptions of the clients and the key informants could be tr
iangulated. The results
showed poor agreement between workers and clients on many
items, suggesting critical
differences in perceptions. The issue in such a case is not who
to believe but how to
address the discrepancies so that they do not negatively affect
services.
Ano ther sense in which discrepan cies can b e problematic has
lo do wi th w ho priori-
tizes needs once they are identified. How and whether research

results get used is often a
political decision, and different social issues are given
importance al different times.
For example, child abuse has existed throughout recorded
history, but its perceived
importance as a problem varies considerably over time and
place, and the reso urces avail-
ab le to reduce it a nd ameliorate its effects fl uctuate as well.
Over the past several decades, we have come to recognize the
surp risingly large number
of children who have been sexually abused. Identifying this
problem entailed measuring its
prevalence and also clarifying Lhe needs of child victims, for
child welfare intervention and
psych otherapeutic help and so on . As these efforts absorbed
scarce research resources, some
have argued that o ur push to assist sexual abuse victims has
been given such a strong prior-
ity that we have not attended sufficiently well to the needs of
other mistreated children,
those who are negl ec ted or who witness violence between their
paren ts, fo r example.
Implementing the Results of Needs Assessments
Although needs assessments are, by d efini tion, research with
practical impli cati ons,
e nsur ing that the results are imple mented is freque ntly chall
enging. Several issues are part
160 PAin II • QuANTITATi v~ API'ROACHES: TvPes Ol·
STuDIES

of this general problem. First, the results must be presented in a
form in which the sug-
gestions and how to implement them are clearly outlined. Th is
has been problematic in
the past, as C. Carter ( 1996) noted in her review of needs
assessments from the late 1970s
through 1989. She found that, while authors usuaHy detailed the
research process, they
offered few s uggestions about how to carry out the required
changes. Second, Carter
observes that researchers often write for other academics.
Important as the academ ic
a udience is, with needs assessments, the people we want to
i.nlluence with our work
include service providers, policy makers, and th e target pop
ulation. T hese groups may
require a report different from professors and their students.
The organization of mater-
ial and the style of presenting findings and recommendations
should be sensitive lo the
likely interests and priorities of nonacademic readers.
Researchers might even co nsider
writing more than one repo rt, in the in terests of effec tive
comm unica tion with diverse
audiences.
Amodeo and Gal (1997) recommend another strategy for
facilitating utilization of needs
assessment research, which is to involve the sponsor
organi7.ations in all steps of the study.
T his ensures that the sponsor is knowledgeable about the
research and committed to fol-
lowing it up effectively. In their discussion of this theme,
Amodeo and Gal p ropose that
researchers should allot a generous amount of time after data
collection to help the spon-

sor agency digest the findings and plan a response Lo them.
Conclusions
The examples we have offered illustrate that needs assessments
are a practical research
method with vast potential usefulness to social work. The
results can be especially mean-
ingful in our work because they document the needs of people
experiencing problems,
rather than addressing the more esoteric interests of social
scientists bent on testing or
developing theory. Needs assessme n t ca n raise important
questions, identify what aspects
of services or policies are useful, indicate what n eeds to be
improved, and highlight gaps
or misappli ca tions of servi ces. The results ca n challenge us
in the same ways that all good
J"escarch does, inviting us to test our assumptio ns against
evidence gathered from the
clients and wmmunities we serve, changing our beliefs and
interventions in beneficial
ways as a result.
References
Amodeo, M., & Gal, C. (1997) . Strategies for ensuring use of n
eeds assessmen t findings:
Experiences of a community substa nce abuse preven tion
program. journal of Primary
Prevention, 18, 227-242.
Brem1an Homiak, K. , & Singleta ry, J. E. (2007) . Famil y
violence in congregalions: An exp loralory
study of clergy's needs. Social Work and Christia11ity, 31, 18-
46.

Carter, C. (1996) . Using and comm unicating findings. In K.
Revere, S. Berkowitz, C. Carter, &
C. Ferguson (Eds.), Needs assessment: A creative and practical
guide for social scientists (pp. 185- 20 l ).
WashinglOn, DC: Taylor & Fran cis.
Carter, M., Crosby, C., Ge('rtshuis, S. , & Startup, M. (1996) .
Developing reliabili ty in clienL-ccntered
me ntal health needs assessment. Journal of Mental Health, 5,
233-243.
CHAPTER 9 • NEEDS ASSESSMENTS 161
Gerdes, K. E., & Benson, R. A. (1 995). Problems of inner-city
schoolchildren: Needs assessment by
nominal group process. Social Work in Education, 17, 139-147.
Kenagy, G. P. (2005) . Transgender health: Findings from two
needs assessment studies in
Philadelphia. Health artd Social Work, 30( 1 ), 19- 26.
Maslow, A. ( J 970) . Motivation and personality. New York :
llarper & Row.
McKillip, J. (1998) . Needs analys is: Process and techniques.
fn L. Sickman & D. Rag (Eds.),
Handbook of applied social research methods (pp. 261 284).
Thousand Oaks, CA: Sage.
Naito-Chan, E., Damron- Rodriguez,}., & Simmons, W. (2004).
Identi fying competencies for geri-
atric social work practice. journal of Gerontological Social
Work, 43( 4 ), 59- 78.

Pan, A., Daley, S., Rivera, L. M., Williams, K., Lingle, D., &
Reznik, V. (2006). Understanding the role
of culture in dom estic vio lence: T he Ahimsa Project fo r Safe
Families. Journal for Immigrant
and Minority Health, 8(1 ), 35-43.
Revere, R., Berkowitz, S., Carter, C., & Ferguson, C. (
l996).lntroduction. Iu R. Revere, S. Berkowit7.,
C. C. Carter, & C. F. Ferguson (Eds.), Needs assessment: A
creative and practical guide for social
scie11t-ists (pp. 1-12) . Washington , DC: Taylor & Francis.
Stabb, S. (1995). Needs assessment methodologies. In S. D.
Stabb, S. M . H arris, & ). E. Talley (Eds.),
Multicultural needs assessment for college and university
student populations (pp. 51-115 ) .
Spri11gfield, IL: Charles C Thomas.
' tracy, E. M., Green, R. K., & Bremseth, M.D. {1993 ). Meeting
the environmental needs of abused
and neglected children: implications from a statewide survey of
supportive services. Social
Work Research & Abstracts, 29(2), 21 - 26.
Tutty, L., & Rothery, M. (2002) . How well do emergency s
helters assist women an d their children?
In L. TuLly & C. Goard (Eds.), Reclaiming self Issues and
resources for women abused by intimate
partners (pp. 25-42). Halifax, NS: Fernwood and Resolve.
Tutty, L M., McNichol, K. , & Christensen,}. (2008) . Calgary's
Homefront specialized domestic vio-
lence co urt. In J. Ursel, L. Tutty, & }. LeMaistrc (Eds.), What's
law got to do with it? The la"~ spe-
cialized courts and domestic violence in Canada. Toron to, ON:

Cor morant Press.
Tutty, L. M ., Weaver, G., & Rothery, M. A. ( 1999). Residents'
views of the efficacy of shelter services
for abused women. Violence Against Women, 5, 869- 925.
Wancata, }., Krautgartncr, M., Berner,}., Scumaci, S., Freid!,
M., Alexandrowic7., It, et al. (2006). The
"Carer's r eeds Assessment for Schizophrenia": An instrument to
assess the needs of relatiYes
caring for sch izophrenia patients. Social Psychiatry &
Psychiatric Epidemiology, 41, 221-229.
Weave r, H. W. ( 1997). The ch allenges of research in Native
American commun it ies: Incorporating
princip les of cultural compete nce. Journal of Social Service
Research, 23, l - 15.
Wilkin, B. R., & Al tschuld, 1. W. ( 1995). Planning and
conducting needs assessments: A practical
guide. Thousand Oaks, CA: Sage.
Yegidis, B. 1.., Weinbach, R. W., & Morrison -Rodriguez, B.
(1999). Research melhodsfor social work-
ers (3rd eel.). Boston: All yn & Bacon.
http:/ /www.extension.iastate.edu/communitics/tools/assess/
This Web site by the Iowa State University Extension Division
provid es a primer on five types of needs
assessments: existing data sources, attitude survey approaches,
key informant approaches, com munity
forums, and focus groups.
http:/ /ctb.k u.edu/tools/scctio n_l 042.htm
The Com munity Tool Box is a se rvice of the Work Groups for
Comm unity Health and Developm ent at

the University of Kansas. Th is compre hensive Web site prese
nts information on numerous evaluation
methods for use in the community, with needs assessments be
ing only one.
162 PART 11 • Q uANTITATIVE A PPROACH ES: TYPES Of
STUD I ES
DISCUSSION QUESTIONS -
1. Whal are the disadvantages and advantages of quantitative as
compared to qualitative needs
assessment methods?
1. What are the advantages and disadvantages of asking key
informants about the needs of an iden-
tified population versus speaking to those affected by the
problem them selves?
3. Compare community forums and focus groups. For what pu
rposes might one be preferred over the
other?
4. Discuss the concepts of "needs" and "wants." How can those
developing needs assessment ensure
that the needs that are bei ng identified are necessa ry and
important?
5. What are the best strategies to ensure that needs assessment
recommendations are implemented?

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