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					                                          WHO/MSD/MSB 00.2d




                             Workbook 3




                   Needs
                 Assessment




Workbook 3 · Needs Assessments                           1
WHO/MSD/MSB 00.2d




                    c   World Health Organization, 2000




                                WHO
                                World Health Organization


                                UNDCP
                                United Nations International Drug Control Programme


                                 EMCDDA
                                 European Monitoring Center on Drugs and Drug Addiction




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




2                                                                Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                WHO/MSD/MSB 00.2d




  Acknowledgements

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




Workbook 3 · Needs Assessments                                                                 3
WHO/MSD/MSB 00.2d




4                   Evaluation of Psychoactive Substance Use Disorder Treatment
                                                               WHO/MSD/MSB 00.2d




Table of contents



Overview of workbook series                               6

What is a needs assessment?                                7

Why do a needs assessment?                                 7

How to do a needs assessment?                              8

Question 1                                                10

Question 2                                                14

Question 3                                                16

Question 4                                                23

Comments about case examples                              28

Case example of a needs assessment                        29
     Planning and evaluating outpatient care for drug
     dependent patients in Barcelona (Spain)

Case example of a needs assessment                        42
     A study to determine the welfare service needs
     in the Eastern Transvaal, Republic of South Africa




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WHO/MSD/MSB 00.2d




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



                    Introductory Workbook
                    Framework Workbook

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

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




6                                          Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                      WHO/MSD/MSB 00.2d




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




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

Workbook 3 · Needs Assessments                                                                       7
WHO/MSD/MSB 00.2d




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




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



8                                           Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                     WHO/MSD/MSB 00.2d



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




Workbook 3 · Needs Assessments                                                                      9
WHO/MSD/MSB 00.2d




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




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


10                                               Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                                     WHO/MSD/MSB 00.2d



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

                   Advantages include:                               l   limited utility from prevention or early
                                                                         intervention perspectives because esti-
                   l   The simplicity of the formula, once the           mates are based on the most severe con-
                       necessary statistical data are obtained           sequences of alcohol use

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




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

Workbook 3 · Needs Assessments                                                                                   11
WHO/MSD/MSB 00.2d



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

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




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


12                                                 Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                                       WHO/MSD/MSB 00.2d




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


Workbook 3 · Needs Assessments                                                                                     13
WHO/MSD/MSB 00.2d




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


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


14                                             Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                                   WHO/MSD/MSB 00.2d



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




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


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

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




16                                              Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                                           WHO/MSD/MSB 00.2d



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

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




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




Workbook 3 · Needs Assessments                                                                                         17
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                           l   methadone maintenance                        With your list completed, and appropriate
                                                                            definitions developed, you then examine the
                           l   outpatient counselling                       services in each region or community under
                                                                            investigation and determine whether the ser-
                           l   day/evening treatment                        vice is:

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




Template to assess the availability and accessibility of services
along an ideal continuum of care
                                                         Region #1       Region #2        Region #3         Region #4
                                                        Avail   Acc     Avail   Acc      Avail   Acc       Avail  Acc

  Case identification
                                                                youth
  Comprehensive assessment                                      only

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

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



18                                                        Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                                       WHO/MSD/MSB 00.2d



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

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



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


Workbook 3 · Needs Assessments                                                                                     19
WHO/MSD/MSB 00.2d



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




20                                                Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                                         WHO/MSD/MSB 00.2d




                     Prescriptive approach

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




Workbook 3 · Needs Assessments                                                                                       21
WHO/MSD/MSB 00.2d



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




22                                                Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                                    WHO/MSD/MSB 00.2d




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

Workbook 3 · Needs Assessments                                                                                  23
WHO/MSD/MSB 00.2d




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



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



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



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



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


24                                             Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                                   WHO/MSD/MSB 00.2d




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

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

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




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




Workbook 3 · Needs Assessments                                                                                 25
WHO/MSD/MSB 00.2d




                    Conclusion and
                    a practical
                    recommendation

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


26                                             Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                              WHO/MSD/MSB 00.2d




References

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

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



Workbook 3 · Needs Assessments                                                                            27
WHO/MSD/MSB 00.2d




                    Comments about
                    case examples

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




28                                              Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                                        WHO/MSD/MSB 00.2d




                          Case example of a
                          needs assessment

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

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



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

Workbook 3 · Needs Assessments                                                                                      29
WHO/MSD/MSB 00.2d

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

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




30                                             Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                                WHO/MSD/MSB 00.2d




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

Workbook 3 · Needs Assessments                                                                              31
WHO/MSD/MSB 00.2d




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



32                                             Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                                  WHO/MSD/MSB 00.2d



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


Workbook 3 · Needs Assessments                                                                                33
WHO/MSD/MSB 00.2d



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


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

 Product                                      Annual                Meantime           Estimated          Equivalence
                                              activity            (in minutes)          activity            in drug
                                                                                        minutes           dependence
                                                                                                           care units
                                                                                                            (DCUs)

  First visit                                   2,015                    50             100,750               1.00
  Therapeutical (a) follow-up                  15,258                    25             381,450               0.40
  Medical follow-up visit                     18,442                     15            276,630                0.40
  Social follow-up                              7,925                    30             237,750               0.40
  Therapeutical group for families                167                    45               7,515               0.40
  Therapeutical group for patients                549                    45              24,705               0.40
  Nurse interview                               3,507                      7             24,549               0.10
  Drug dispensation                          206,295                       3            618,885               0.05

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

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



34                                                       Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                                              WHO/MSD/MSB 00.2d



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



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

 Product                                 Centre A            Centre B         Centre C          Centre D        Total
                                                                                                               activity


 First interview                           684                 631               353              347          2,015
 Sucessive therapeutical (a)
 follow-up interview                      6,053               3,020             2,429            3,756        15,258
 Sucessive medical
 follow-up interview                      7,057               3,692             2,708            4,985        18,442
 Nurse interview                          1,493               1,129              274              611          3,507
 Social follow-up                          713                4,376             1,422            1,414         7,925
 Therapeutical group for families            65                  37               38                   27         167
 Therapeutical group for patients          312                  90               137               10             549
 Drug dispensation Costs                  57,617              55,986           49,627           43,065       206,295
 Annual Cost (thousands of pts.)          76,460              74,259           48,019           54,205       252,943
 Active users                             1,342               1,314              813              740          4,209
 Cost per user                            56,975              56,514           59,064           73,250        60,096
 Estimated minutes of care activity      513,037             475,286          320,329          363,582      1,672,234
 Cost per care minute (pts)                149                 156               150              149             151
 Drug care units (DCUs)                   9,394               8,029             5,555            6,638        29,617
 Cost per DCU (pts.)                       8,139               9,249             8,644           8,166         8,541

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

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



Workbook 3 · Needs Assessments                                                                                            35
WHO/MSD/MSB 00.2d



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

 Product                                        Starting                              %                       Total
                                                treatment for                                                 starts
                                                the first time




  1991                                              1,099                              44.9                  2,448
  1992                                              1,243                              47.2                  2,633
  1993                                               735                               29.6                  2,483
  1994                                               695                               25.4                  2,736

CFC: care and follow-up centre



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


Table 4: Illegal drug-related emergencies attended by four university hospitals with
permanent emergency ward. Barcelona, 1990-1993.

 Year                Clinic            Sant Paul                 Vall Hebron          Mar                    Total
                                                                                                             starts


  1990                1,099             1,099                        1,099           2,318                   5,065
  1991                1,243             1,243                        1,243           2,010                   5,078
  1992                 735               735                          735            1,832                  4,520
  1993                 695               695                          695            1,541                   3,823


36                                                     Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                                                           WHO/MSD/MSB 00.2d



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

                                          Tuberculosis in IDUs                                    Total Tuberculosis

        Year                      Cases                      Rates                        Cases                          Rates

        1987                       87                            5.1                       854                            50.2
        1988                      155                            9.1                      1,042                           61.2
        1989                      161                            9.5                       923                            54.2
        1990                      213                        12.5                         1,016                           59.7
        1991                      216                        13.1                         1,129                           68.7
        1992                      230                        13.9                         1,101                           66.9
        1993                      177                        10.8                          999                            60.8
        1994                      228                        13.9                          979                            59.6
        1995                      165                        10.0                          899                            54.7
        1996                      1,632                                                   8,942

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




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



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

 Year               AIDS causes               Rates                    Total AIDS            Rates                     AIDS % in
                      in IDUs                                            cases                                          IDUs (a)


 1988                   156                    9.1                        267                 15.7                       58.4
 1989                   192                   11.3                        358                 21.0                       53.6
 1990                   239                   14.0                       434                  25.5                       55.1
 1991                   215                   13.1                       452                  27.5                       47.6
 1992                   249                   15.1                        505                 30.7                       49.3
 1993                   229                   13.9                        460                 27.9                       49.8
 1994                   385                   23.4                       667                  40.6                       57.7
 1995                   287                   17.5                       558                  33.9                       51.4
 Total                 2,051                                            3,918                                            52.3
IDU: Intravenus drug user; a) % related to the yearly total AIDS cases.


Workbook 3 · Needs Assessments                                                                                                         37
WHO/MSD/MSB 00.2d



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




                    Figure 1: Three-monthly evolution of mortality due to acute drug
                    adverse reaction. Total number and mobile mean 4th trimester 1994.




                                                                                   *

                    Source: Institut Anatomic Forense de Barcelona
                    (*) Mobile mean: arithmetical average between number of deaths in the previous and following
                    trimester




38                                              Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                              WHO/MSD/MSB 00.2d




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




Workbook 3 · Needs Assessments                                                                            39
WHO/MSD/MSB 00.2d




                    It’s your turn
                    What are the strengths and the weaknesses of the presented case example? List three
                    positive aspect and three negative aspects:

Strengths of the case study

1




2




3




Weaknesses of the case study

1




2




3




40                                           Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                             WHO/MSD/MSB 00.2d




References for case example

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




Workbook 3 · Needs Assessments                                                                           41
WHO/MSD/MSB 00.2d




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


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




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

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


42                                                Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                                   WHO/MSD/MSB 00.2d



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

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

Workbook 3 · Needs Assessments                                                                                 43
WHO/MSD/MSB 00.2d



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

                    required?                                           1 a concept service contract for the social
                                                                          workers was to be drawn up by the TPA
                    During the Social Planning phase each of the          regional office and distributed to the
                    8 agencies and 2 Government Departments               agencies concerned before July 1991;
                    participating, allocated official representatives
                    who formed the core group together with the         2 all documents were to receive approval
                    existing social work staff of the TPA com-            and clearance before commencing the
                    munity services - in all some 30 persons.             needs assessment. The remaining posts
                    Each group agreed to bear their own costs             would be filled at a later stage in the
                    and provide specialist input. The TPA in              programme.
                    Witbank agreed to provide the secretariat
                    and co-ordinate the planning and follow-up          Training: A training programme was de-
                    meetings. Twelve social work staff were al-         veloped to provide specialist input from
                    ready doing community work, 10 more were            the various agencies. The group of 22 so-
                    selected and employed. Care was taken to            cial workers met at a venue in
                    employ workers who were familiar with the           Johannesburg for 6 days, additional train-
                    region and the various cultural groups and          ing in community development was also
                    languages represented.                              given.

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


44                                                Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                                           WHO/MSD/MSB 00.2d




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


Actual community Townships surveyed N=15
           Magisterial                                  Community/                            Population
            District                                     Township


           Piet Retief                           e-Thandukuyklamya                             20000

            Witbank                                    Thubelihle                              6510
                                                       Kwaguqua                               158994

             Bethal                                    e-Mzinoni                               23286

           Standerton                                  Sakhile                                 47744
                                                      Thuthukani                                9318

         Wakkerstroom                                 e-Sizameleni                             4600

           Volksrust                                  Vukuzakhe                                17000
                                                      Morgenzon                                 4068

           Perdekop                                   Siyazenzela                              2670

            Evander                                     Lebolanc                               57840
                                                      e-Mbalenhle                             130048

             Sabie                                       Simile                                8000

           Lydenberg                                  Mashishina                               27300

           Barberton                                   c-Mjindini                              24504


Workbook 3 · Needs Assessments                                                                                         45
WHO/MSD/MSB 00.2d



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

                    How were the data                               2 In general however, no matter the size
                    analysed?                                         of the population, it became very clear
                                                                      that all communities share and identi-
                                                                      fied the same social problems and that
                    A monitoring group was established and            the underlying theme expressed over
                    meetings were held every 6 months, to             and over again was that of “unemploy-
                    evaluate progress. Each worker was as-            ment, poverty and alcohol abuse were
                    sisted to collate all documents pertaining        the social problems which go hand in
                    to the Community profile. Gaps were               hand”.
                    identified for workers to proceed with
                    gaining additional information.                 Substance use/ abuse

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




46                                              Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                                 WHO/MSD/MSB 00.2d



Alcohol                                         6 there were very few cases of drunken
                                                  driving, as there was little opportunity
Commercial products were very expensive           and few cars to drive.
and usually purchased from Bottle Stores or
drunk in Taverns. Because of unemployment       7 drunken pedestrians caused accidents -
and poverty, cheap alcohol concoctions or         high incidence in rural and country areas.
home-made brews called SPION or                 8 schools report drinking among the high
MBAMBA were available at Shebeens.                school groups where alcohol use is a
These are informal backyard type taverns,         source of entertainment and bought in
usually not registered. Shebeens are the          the afternoons from the shebeens.
most important adult recreational facility      9 little or no drinking or drugging was ob-
and a source of income for the owner.             served in the schools, only 1 case was
Youth also obtain their liquor from the           reported in all reports.
shebeens in the afternoons after school, but    10teachers however see neglect, malnutrition
do not drink on the premises. Women visit         and signs of physical abuse, they hear about
the shebeens in the late morning and early        conditions at home and they are convinced
afternoon, while the men dominate the             that drinking is a serious.
evening and night sessions. It was esti-        11the opinion most often expressed was that
mated that more than 60% of the popula-           children from these families end up drink-
tion in all 15 townships were abusing al-         ing themselves and not fit for the labour
cohol and of this number, 40% were drinking       market.
at alcoholism levels.                           12most epileptics and tuberculosis patients
                                                  neglected their medication because of the
Problems of alcohol abuse in the                  effort and distance to hospitals in urban
community                                         areas and drank as a form of self medi-
                                                  cation.
Alcohol was abused over weekends and
after working hours by youth, men and           Dagga or Cannabis
women between the ages of 20 and 50.
The confirmed opinion is that more men          The dagga plant is indigenous to South
drink than women, but that women are            Africa and easily grown for private use.
now drinking more than they used to, a          In the communities surveyed, it was not
home brew of soured milk or sorghum was         grown commercially (but is elsewhere in
considered an important part of the meal.       South Africa). People were aware of the
Poverty prevented the woman from pro-           legal consequences. Informed commu-
ducing this, thus malnutrition was high.        nity members and leaders spoke out in
                                                unison against legalising dagga as it was
1 wife battering and physical assaults were     observed and an importantly held opin-
  high                                          ion that dagga use promoted the “dete-
2 families kept impoverished through drink-     rioration of society”. School children
  ing and unemployment                          dropped out and led useless lives or
                                                landed in prison. Prison statistics clearly
3 most women do not recognise that a hus-       indicated that arrests and convictions
  band may have a problem. They live within     due to dagga were significantly higher
  the circumstance and accept the alcohol       than those of alcohol and usually linked
  use/abuse as a way of life.                   to crime. It was also noted that the so-
4 hospitals and clinics report high incidents   phisticated use of dagga and crushed
  of assaults.                                  mandrax (white pipe) as smoked in ur-
                                                ban areas was virtually unknown in these
5 most arrests are for assault, drunk and       communities.
  disorderly and theft.

Workbook 3 · Needs Assessments                                                                               47
WHO/MSD/MSB 00.2d



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

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


48                                                Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                                       WHO/MSD/MSB 00.2d



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

Workbook 3 · Needs Assessments                                                                                     49
WHO/MSD/MSB 00.2d



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

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




50                                              Evaluation of Psychoactive Substance Use Disorder Treatment
                                                                                             WHO/MSD/MSB 00.2d




                    It’s your turn
                    What are the strengths and the weaknesses of the presented case example? List three
                    positive aspect and three negative aspects:

Strengths of the case study

1




2




3




Weaknesses of the case study

1




2




3




Workbook 3 · Needs Assessments                                                                           51
WHO/MSD/MSB 00.2d




                    References for case example

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

                    6 Model for Service Development (avail-
                      able on request)




52                                              Evaluation of Psychoactive Substance Use Disorder Treatment

				
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