Listening to local voices: adapting rapid appraisal to assess health and social needs in general practiceBMJ 1994; 308 doi: http://dx.doi.org/10.1136/bmj.308.6930.698 (Published 12 March 1994) Cite this as: BMJ 1994;308:698
- S A Murray,
- J Tapson,
- L Turnbull,
- J McCallum,
- A Little
- University of Edinburgh, Edinburgh EH8 9DX Mackenzie Medical Centre, Edinburgh EH8 9DX South Bridge Resource Centre, Edinburgh Victoria Street Social Work Centre, Edinburgh
- Correspondence to: Dr Murray.
- Accepted 3 February 1994
Objectives: To explore the use of rapid appraisal in defining the health and social needs of a community and to formulate joint action plans between the residents and service providers.
Design: Collection of data by an extended primary care team from three sources: existing documents about the neighbourhood, interviews with a range of informants, and direct observations to build a profile of the community.
Setting: Council estate of 670 homes in Edinburgh. Main outcome measures - Perceived problems of the community and suggestions for change.
Results: The interviews and focus groups identified six priorities for change, many of which were not health related. These changes have been or are being implemented.
Conclusions: An expanded primary care team can use rapid appraisal as a first step in identifying and meeting local health needs. It facilitates a multi-disciplinary approach and complements quantitative methods of assessing need.
It is dificult to ind time in general practice to assess the needs of the whole community
Local studies about health status and health care needs are uncommon
This study used rapid appraisal to provide a structure to elicit and learn from local opinions relatively easily
Steps have been taken to meet the perceived needs.
The method offers a practical way of involving local people in decision making about their health services
The World Health Organisation's programme Health for All by the Year 2000 aims at giving everyone equal access to health care.1 As 2000 approaches many inequalities remain, and in the United Kingdom these are most notable in Scotland.2,3 The inequalities are directly related to socioeconomic and cultural factors that are not adequately addressed by the medically dominated model of health.4
The new NHS philosophy encourages patient choice and the tailoring of the process of care to benefit the consumer. But true participation of the public in decision making and evaluation of health care has been more difficult to promote in practice. Particularly in poorer areas, general practitioners need to work with community representatives, teachers, benefit rights workers, counsellors, and the local clergy to establish health education projects.5 The Cumberlege report also emphasised the need for services to be more sensitive to the requirements of individuals, families, and communities.6
At present few populations and communities are involved in planning primary care.7 Practice catchment areas have grown haphazardly so that identification with a defined neighbourhood and collaboration with local services is difficult. Gillam, Hastings, and the NHS Management Executive have called for a structure to involve local people in the purchasing process.*RF 8-10* We describe one method of listening to local voices. The method can be used for local neighbourhood planning and could provide a structured basis for practice sensitive local purchasing.
Rapid participatory appraisal is a research method that has been used in the United Kingdom to provide qualitative information, especially about deprived areas,11 but it is has not been used in planning primary care services. The general framework is based on the “health for all 2000” philosophy, and it has been adapted for use in health care.12 Rapid appraisal can focus on members of urban environments who are relatively deprived. It uses selected people with knowledge of the area (key informants) both to identify problems and to contribute to solutions. The team conducting the investigations and devising a plan of action is derived from various organisations and not just health workers.
The primary aims of rapid appraisal are to gain insight into a community's own perspective on its main needs; to translate these findings into action; and to establish an ongoing relationship between service purchasers, providers, and local communities. It is “rapid” in that the whole exercise can be done in two weeks if external researchers are used.
Information is collected on nine aspects. These are brought together to form an information pyramid (figure). The bottom layer defines the composition of the community, how it is organised, and its capacities to act. The second layer covers the socioecological factors that influence health. The next layer covers data on the existence, coverage, accessibility, and acceptability of services, which allows the effectiveness of present services to be evaluated and identifies what needs to be changed. The final layer is concerned with national, regional, and local policies that indicate whether the political leadership is committed to community participation in health. Data is collected from three main sources: existing written records about the neighbourhood, interviews with a range of informants, and observations made in the neighbourhood or in the homes of interviewees.
The scientific rigour and validity of the approach depends on the concept of triangulation, with data collection from one source being validated or rejected by checking it with data from at least two other sources or methods of collection. Through cross checking findings apparent differences may resolve themselves, and a coherent interpretation can be constructed.13 Instead of randomly selecting informants, people who are thought to be in the best position to understand the issues are chosen.14 People with a wide range of views are interviewed.
Our project was carried out in Dumbiedykes, a small council estate of 670 homes south of Edinburgh's Royal Mile and next to Holyrood Park. It contains a relatively homogeneous, stable community, and half of the residents are patients of Mackenzie Medical Centre. The investigating team comprised a general practitioner from that practice, the health visitor attached to the practice, the local community education worker, and two local social workers. As the team could not work full time on the project the study was done over three months, with team members giving about four hours each week to the probject. A part time secretary was recruited for this period.
The research team devised a semi-structured interview schedule, which was refined during pilot interviews. We found that the interview training material available from WHO was useful.12
The key informants were identified from various backgrounds (box). They included people with professional knowledge about the community, community leaders of selfhelp groups and voluntary organisations, and people who were centrally placed because of their work (including the local shopkeeper). We also selected 17 residents of Dumbiedykes to represent various age groups, social situations, and health problems. Several group interviews were carried out. During some interviews new informants emerged and these people were also interviewed.
Key informants for rapid appraisal
Voluntary worker, St Ann's community centre
Visiting Sister, St Patrick's Roman Catholic church
Home care organiser, social work department
Project director, South Side care project
Dumbiedykes Social Club convenor
Lothian regional counsellor
Project coordinator, Safer Edinburgh Project
Local community involvement police officer
Receptionist, Mackenzie Medical Centre
Community development worker
Old Town Renewal Trust
Housing department officer, Edinburgh District Council
Local district nurse
Head teacher and deputy head teacher, local primary school
Volunteer, Women's Royal Voluntary Service
Community psychiatric nurse, community drug problems service
Shopkeeper, Dumbiedykes Store
Project coordinator, local youth project
Local health visitor
Public transport unit, planning department, Lothian Regional Council
Coordinator, Dumbiedykes Children's Centre
Recently retired local general practitioner
Group interview - South Side Care Project board of directors
Group interview - Reminiscence Group
Group interview - Dumbiedykes Residents Association
Group discussion - teenage girls at youth project
17 residents selected to represent various age groups, social situations, and health problems
Participants were visited by two team members in their homes or at work. One interviewer talked to the respondent and the other took notes. The doctor and health visitor did not interview together in case such interviews would concentrate too narrowly on a medical definition of health.
Data from written documents, interviews, and observations was allotted to appropriate blocks of the planning pyramid by opening a box file for each block. Data from each interview was split into the 10 separate areas and allocated to each file. The data from all interviews were collated with other sources of information such as the 1991 census.
We held a feedback meeting to present the findings to all informants. After this two focus groups were set up to discuss and allot priority to the problems identified and to explore potential interventions. These groups also discussed how to improve the uptake of existing services and suggested new ways to meet gaps in services. Two researchers sat in each group to facilitate and record the findings. A report was circulated by the research team, and the local newpaper reported the study in detail and invited comments on the findings and proposals.
The community had a large number of elderly people and single people. Newcomers to the area often had medical or social problems and tended to be younger. There was little sense of community identity. There were fewer services in Dumbiedykes than before the second world war. Most informants identified one volunteer worker and her community centre colleagues as the main community activists. A local counsellor commented on the lack of a heart or centre in the estate. Three house groups run by a nearby church gave social and spiritual support to some residents.
Common complaints about the physical environment included the hills in and out of the estate, the difficult steps, and generally poor access. Lack of play areas for toddlers and young children was also often mentioned. Dog fouling was a greater issue than vandalism or violence.
Many people found it hard to manage financially, especially elderly people, who often turned on an extra electric bar on their fire to keep the interviewers warm. Twenty six per cent of men and 11% of women were recorded as unemployed in the 1991 census. Nineteen per cent of houses were owner occupied compared with 60% in Lothian generally.
Perceived causes of ill health included unemployment, stress, dampness, poor diet and eating habits, and smoking. Drug misuse among the younger people and social isolation among elderly people were also felt to be problems. The main disease centred health problems in the estate were thought to be asthma, bronchitis, heart problems, and arthritis.
Some people, unaware of recent developments, wanted an increase in local educational services such as after school care, youth provision, and adult education classes or groups. Most people with children spoke favourably about a nearby youth project.
Initial comments about the primary care services were favourable. Complaints were made about long waiting lists for occupational therapy and chiropody and about a shortage of district nurses and auxiliaries to help with personal hygiene. It was sometimes hard to get an appointment with the local general practitioners. Queues at the accident and emergency department were thought to have got worse, as had arrangements for discharge from hospital.
The local social services were well known, well used, and appreciated. However, the non-local services were not well known, and many people expressed a wish for more information.
Informants had little knowledge about the patient's charter and the community care plan. Recent health policy interventions were thought by many to be cost cutting exercises.
We asked each informant for suggestions for change. The commonly recurring ideas were discussed in the two focus groups and a consensus list was drawn up (box).
Suggestions for change mentioned during interviews and requested at focus groups
Arrange for a bus to come into the estate
Create multiple small play areas and dog free zones
Plan activities in the community rooms: Regular citizen's advice Housing advice A course about alternative therapies Individual or group based counselling An information day
Improve the running of the local general practices
Ask the local chemist to help more - for example, with collecting and delivering prescriptions
Inform all residents about Dial-a-bus, taxi cards, and other initiatives which help deal with the dificult physical environment
In contrast to the quantitative methods used by epidemiologists rapid appraisal offers very specific insights, helping to define what the problems are rather than how many people are affected by them. It helps identify the strength of feeling within the community on key issues.
We did not identify any previously unknown medical problems, but the team got a deeper understanding of the health and social problems in the neighbourhood. We were dismayed at the lack of knowledge about and uptake of some services while other services were overstretched. We plan to compare the needs identified in this study with the needs found by a postal survey instrument and by analysing primary care and hospital medical records.
Future plans for dumbiedykes
The following improvements in services have been implemented, are imminent, or are under discussion. Lothian transport intends to route a bus through the estate, and the city architect is considering creating dog- free zones in the estate. The social work department has arranged for the mental health development worker to run a mental health group in a community room. The home help supervisor now runs information courses for home helps in the community room in Dumbiedykes so that they can inform clients of relevant local services such as the nearby community centre, special transport schemes for elderly and disabled people, and allowances. The Community education department has held introductory sessions in the community room to assess interest in complementary therapies. The local practice has responded to feedback from the community by getting toys for the waiting area, addressing older patients more formally, and by encouraging local pharmacists to collect prescriptions for repeat medications. An extra telephone line has been installed in the practice. The local district and regional counsellors and a citizens' advice worker now hold regular surgeries in the community room, and an information day has been held.
Within general practice, lack of planning time and the pressure to respond to the immediate needs of patients means that studies of local health status and needs are given low priority. Rapid appraisal provides a structure to elicit and learn from local opinions relatively easily.
One attraction of such appraisal methods is their flexibility. In Dumbiedykes we had 12 meetings of the development team and interviewed 45 people. Most of the information was gathered from the first interviews, and in retrospect the first 25 interviews (10 residence, 15 local workers) would have been sufficient. Using local workers to do the research had many advantages. They knew about available services, and when residents expressed a need which could be quickly met they could inform them. A local directory of agencies in the community which contribute to health was quickly established and is increasingly used by the practice team. Local ownership of the research process means that the actions are more likely to be implemented.
Listening to and understanding people does take a considerable time, effort, and emotional input, even using a relatively simple method. Because a local team was used it is not surprising that solutions were identified along with the problems. This community development approach in primary care may be more successful than community development projects that are more distant from the resources.
We have used the opportunities that arose to work jointly with the community to develop services and to faciliate team work between statutory and voluntary agencies. Some Dumbiedykes residents now perceive their doctors as “community general practitioners” and have commented positively on the doctors' public advocacy of “healthy” policies.
Many of the findings had little medical content. Yet those responsible for other sectors have responded enthusiastically to suggestions from the community vocalised by this project. As general practitioners our responsibilities start with individual patients but finish far from the consulting room.
All major definitions of good general practice refer to the need to consider the physical, psychological, and social wellbeing of patients. This method encourages a broad perspective on the health needs of individuals and also helps doctors identify a wider professional responsibility to the community.16 Stott states that the jury is still out on what is professionally realistic for the new general practitioner of the '90s and beyond.17 How realistic is assessment of health needs based in primary care?
We thank the many informants, the social work department, and the community education department for their support. We also thank Lothian Health for facilitating this research and the advisory group which met to overview the research process.