Health Needs Assessment For Hepatitis
The systematic approach to ensure that the health services utilizes all their resources to improve the health and wellbeing of the population is called Health needs assessment (Grant et al., 2015) or it is the methodology that usually review the health issues of population in regard to establish and apply such actions which improve the health conditions (Sakellarie, 2012). Health needs assessment is process which is commonly used in Public Health settings. According to Elkan and Robinson (2002), a need could be describes as desire for something by the population or quest for something lacking in comparison to others. Furthermore health needs assessment is not only a process of solving health problems by listening to sufferers or relying on the personal experiences but it is to provide information which helps in the delivery of services (Stevens et al., 2004). Therefore health needs assessment is required to plan services and address the inequalities based on the evidence available. So health needs assessment benefits working together by engaging a specific population. Moreover health needs assessment can be differentiated in to needs supply and demand (Stevens et al., 2004). Every three years the hospitals and health care agencies are required to conduct health needs assessment in order to gain information regarding the health needs and concerns of the population (Alfano et al., 2014).
Hepatitis C Virus (HCV), which was only identified in 1989 (Cheent and Khakoo, 2011) is RNA virus (Verma et al., 2014) and incubation period of hepatitis C is commonly between 2 weeks to 6 months (WHO, 2015). It is blood borne virus which is transmitted through sharing injected equipment like syringes and needles, unscreened blood transfusion, unsafe sexual contact and from infected mother to baby (WHO, 2015). Moreover poverty, less than 12 years of education and been divorced or separated are also linked with the increase risk of HCV infection (Laver et al., 2001). According to the World Health Organization (WHO, 2015) there is no vaccine for HCV. Hepatitis C virus infection is a global public health issue and has come to the top of the virus induced liver diseases in many regions of the world. Foster (2005), further argue that around 8 out of 10 hepatitis C patients is thought to be unaware of the disease. According to World Health Organization (WHO, 2015), about 130 to 150 million individual are infected by the virus all over the world and nearby 500000 patients die across the globe. 80 percent of people who are anti HCV positive may continue to carry the virus for years (Damani and Emmerson, 2003). According to the report published by World Health Organisation (WHO, 2015) most affected regions are Africa, central and south East Asia. Study reveals that chances of getting screened for HCV are more in developed countries as compared to developing and non-developing countries. Moreover in most of the South East Asian countries like Bangladesh, India and Pakistan the health systems are not as developed as to test most of the population but in spite of limitations to screening still the number of infected people from HCV are higher in South Asia. Geographically Pakistan is situated in the western part of Indian subcontinent with five provinces namely Punjab, Sindh, Baluchistan, Khebar Pukhtoon Khuwa (KPK) and Gilgitistan. On west side of Pakistan Iran and Afghanistan, on east side India while on north side China is located. Moreover the research study reveals that the prevalence of HCV epidemic is much higher than the surrounding countries (Attaullah, 2011).
According to a research study more than 10 million people are living with hepatitis C with high morbidity and mortality in Pakistan (Shah et al., 2015). Therefore the country is facing huge burden of HCV epidemic. The frequency of HCV infection ranges from 8% to 15% in general population and it’s high in age between 21 and 40 years (Fatima et al., 2015). There are about six HCV genotypes. However the research study shows that the most common genotype in Pakistan is type 3a with the rate of 68.94% in Punjab, 76.88% in Sindh, 58% in KPK and 60.7% in Baluchistan (Attaullah, 2011). Furthermore, the study argues that more than 86% of patients infected by HCV genotype 3a received multiple injections (Idress and Riazuddin, 2008). The reason for this epidemic could be the practice of single syringe vaccination by health professionals before 1990 in Pakistan. Punjab which is the most populated province of Pakistan with approximately 56% of country’s total population (Chakshazad, 2003), the male patients infected by this virus are more than the female at ratio of 66% male and 23% female (Ali et al., 2015).
Factors responsible for spread are still not under controlled in Pakistan. Many barbers still don’t change the blades even don’t think of sterilizing. Study shows that about 79% of the barbers in Pakistan are rubbing same Potash alum stone on facial shaving cuts of customers (Waheed et al., 2011). Studies done by Janjua and Nizamy (2004) in Pakistan on barber’s state that level or awareness of HCV among barbers is limited and their practise of reusing razors is a high risk of spreading disease. Likewise needle exchange process for injecting drug users is another factor involved in hepatitis virus spread (Vickerman et al., 2009). Another study in Pakistan reveals that awareness level of public regarding hepatitis C virus is very low as compared to HIV Aids or other common diseases.
Attention is required to the issue in order to control the spread of silent life threatening disease in Pakistan. Inadequate knowledge about the disease may lead to a major health risk for population and economy of Pakistan. William Osler (1849-1919) states “It is much more important to know what sort of a patient has a disease, than what sort of disease a patient has” (Norris and Nissenson, 2008). Health needs assessment involves number of models available to examine this health problem.
According to Bradshaw’s model (1972), there are four different types of needs namely normative needs, felt needs, expressed needs and comparative needs (Bradshaw et al., 1994). Normative needs are usually defined by the professional’s observation and opinion deviated from the health problem such. Felt needs are related to the desire, want or subjective views of need which may or may not expressed whereas expressed needs are demand or in other words we can say felt need turned in to action. Comparative needs are the need of population individual or groups as well as equity and comparison between the services available in different areas. Another most known model is the three layers of rainbow model by Dahlgren and Whitehead. Dahlgren and Whitehead (1991) argue about the complex multi-layered influencing factors on health (Graham, 2009). Furthermore the model aimed to map the relationship between the individual, their environment and disease.
Health needs assessment involves mainly three approaches which are epidemiological approach, comparative approach and corporate approach (Wright et al., 1998). Comparative approach in health needs assessment is the comparison and contrast between the health services available for people in one area with those somewhere else (Bradshaw et al., 1994) but it could be difficult to ensure a like for like comparison between identified groups within those areas (Stevens et al., 1994). However comparative approach could be the powerful tool for investigating the health services in different parts. Whereas corporate approach to health needs assessment is usually based on systematic collection of knowledge, the wishes, demands and alternative views of internal parties including professionals, public, service users, community health councils and voluntary organisations(Stevens and Gillam, 1998). At the same such an approach could blurs the difference between need and demand or between science and vested interest (Stevens and Raftery, 1996). If we compare prevalence of hepatitis c in Europe and Pakistan (South Asia) then we conclude that hepatitis c is much lower in Europe as compared to South East Asia. So, chances of getting screened for disease are more in Europe as health system is far much better than the South East Asian countries (Esteban et al., 2008). Epidemiological approach in health needs assessment is referred to describe and measures the distribution of the disease (who gets, how, where when etc.). It does involve explanation of determinant factors such as biological, social, economic, environmental or behavioural causing disease spread (Bryant et al., 2010) and to predict the changes expected from the interventions; particularly from the control measures. However there are some problems related to the epidemiological approach like its time consuming, expensive and routing sources could be inaccurate. Moreover it is not necessary that incidence and prevalence of disease equate with the need but it is useful tool to describe the burden of disease though (Stevens and Gillam, 1998). The principle activities involved in health needs assessment are the assessment of incidence and prevalence, health service effectiveness and baseline services. These three gears form the basis of health triangulation (Stevens and Raftery, 1996).
According to Marmot Review (2010), individuals and local communities should be empowered in participating and decision making to achieve the maximum outcome of the health services offered. Stevens (2004) further argue that epidemiological approach to health needs assessment is based on the components such as statement of problem which is to precise and context the problem of disease by outlining the major issues and controversies related to the epidemic. Sub categories are another important tool to predict and plan services when considering health needs assessment. The most important part of the epidemiological approach is to identify the frequency of disease occurrence and therefore prevalence and incidence are more fruitful if they are directly related to the sub-categories. Availability of health services available and their costs do play a vital role when considering health needs assessment. Similarly effectiveness and cost effectiveness is another major component of health needs assessment which helps estimating whether the services provided any benefits or if so at what cost. Furthermore, quantified models of care and recommendations, outcome measures, audit methods targets and information and research requirements are considered while assessing the health needs of population.
In Pakistan there are limited Government health related strategies, programmes and detoxification centres to control hepatitis C infection but the main providers are national and international NGOs. However, a programme called Prime Minister Program for prevention and control of hepatitis was launched in 2005 to reduce the prevalence of hepatitis C in Pakistan (Sami et al., 2009)). Thus the aim of the program was to focus on surveillance strengthening, drugs and vaccination procurement, safe blood screening and proper waste disposal (Bosan et al., 2010) but due to poor management, misuse of funds and lack of transparency, the program loss public confidence hence fruitless. Another program called Chief Minister’s Initiative for Hepatitis free Sindh (Shaikh et al., 2012) was introduced by the Government which focuses on prevention of new infections, addressing the issue of long term injections, broadening public awareness, environment policy changes and surveillance strengthening. The program is still in place and working to achieve its goal.
In addition, sometime the establishment of healthcare system itself becomes barrier such as geographical access, financial access and quality of health facilities for the service users (Shaikh and Hatcher, 2005). Poor health referrals system in rural and backword areas of Pakistan do prevent the HCV patients from accessing the necessary healthcare facilities. The research study done on healthcare system in Pakistan shows that specialized health services are located in the cities (urban areas) which are not within reach of a common man (Asghar, 2012). In most cases it takes up to several hours followed by long waiting list and delays to get to the health services. Treatment for HCV in private health set up in Pakistan are available but at high cost which a poor patient cannot afford. A research study done in 2012, argue that approximately U.S $700 cost is required to treat a HCV patient with standard interferon and ribavirin whereas treatment with PEGylated interferon and ribavirin cost around U.S $4000 (Umar and Bilal, 2012). Furthermore there is no national health insurance system in Pakistan. Therefore while assessing the health needs of population all these issues have to be addressed. Hence, the role of the community and the government is important and crucial to tackle HCV infection spread.
Hepatitis C which is a global health problem is characterised by two stages acute and chronic stage (Shepard et al., 2005). The infection is often asymptomatic in acute stage and about in 20% cases infection may resolve spontaneously while in remaining 80% of the patient it progress to chronic stage leading to liver chronic diseases such as liver cancer and cirrhosis (Leone and Rizzetto, 2005). The research study shows that prevalence of HCV vary in different regions and even different groups of same population (Asghar, 2012). About 75% people infected by HCV even don’t realize or are unaware of the infection (Mitchell et al., 2010). So, interventions could be made by educating the people by providing related information and knowledge about hepatitis C. Highest burden of HCV is in developing countries like Pakistan (Ali et al., 2009). Pakistan is a Muslim country and circumcision amongst boys is a common practise due to religious commitment. The study reveals that in poor groups especially in rural areas of Pakistan circumcision is done by the barbers at small cost who use the same unsterilized razor on most of the cases (Khadduri et al., 2008). Facial and armpit shaves are even practised by these barbers ignoring the infection preventive measures (Janjua and Nizamy, 2004).
Campaigns and media whether it is social, print or entertainment could be used to create awareness about the HCV. Most of the barber shops in Pakistan got television so message could be delivered by broadcasting through famous actors or sport personality through dramas or news. Similarly nose and ear piercing is practise on daily basis which is considering traditional beautification for feminine with the same unsafe procedure in most parts of Pakistan (Idrees et al., 2008). Another research study shows that on average a woman has 4 to 5 children (Ali et al., 2009) and around 65% birth deliveries are at home by local midwife called Dai, who has no or little formal training for infection control measures hence aid in spreading HCV (Asghar, 2012). So, need is required to educate and provide proper training on hygiene, infection control and child labour techniques. Similarly training workshops and health learning sessions could be offered at free to tackle HCV spread. Another cause of Hepatitis C spread is unsafe sexual practise with multiple partners (Alter, 2007). Hence, people should be informed about the importance of safe sex. Condoms availability could be made at easy approach at reasonable cost or could be free for poor people to reduce financial burden. Disclosure of disease to spouse is another big issue in Pakistan hence can express regret and shame which could lead to physical and sexual distance. Therefore counselling services should be available for the people to discuss their problems. Poor system of blood transfusion is also practised as donors in poor sector sell their blood for money. A research study reveals that only 25% of the blood banks screen the blood (Hamid et al., 2004) reasons are being lack of resources, weak infrastructure, ill equipped resources and poorly trained staff (Raja and Janjua, 2008). Therefore, blood screening should be done before donating blood. Injecting drug users should be banned for selling blood. Easy excess to cheap repacked used syringes from unregulated dispensaries is contributing to HCV spread (Asghar, 2012). Injecting drug users are another factor spreading the infection by sharing needles (Thorpe et al., 2002).They live a pathetic life and discriminated by the society in Pakistan. Neglected attitude further push them to drug use resulting in more prone to infection. Therefore health needs assessment requires protective measures such as needle exchange programme should be introduced in Pakistan which should focus on availability and provision of clean needles, swabs, plaster and wound dressings. Free Medical advice should be available at easy approach. Rehabilitation services should be provided to encourage and motivate the injecting drug users to change. Moreover, drug education could be made compulsory at school level to tackle the drug abuse. Likewise lot of road dental surgeries are routinely done which encourages the virus to spread. So Government should take steps to ban all illegal quack and dental surgeries involved in poor hygienic practise causing hepatitis C spread. As mentioned earlier hepatitis C treatment is costly and is not within range of poor people. So health needs assessment for hepatitis C could focus on providing free screening and treatment for the infected people in Pakistan.
Health need assessment has a vital role as it helps to identify immediate need for a targeted population. However some form of health need assessment has always been necessary in health plan services (Bani, 2008). Therefore health need assessment is justified as there is a hope for control of hepatitis C in Pakistan by adopting preventive precautions whether they are environmental or behaviour related. Focused local or national campaigns are required to encourage people to be tested for HCV and get treated if positive. Awareness and education helps promoting HCV screening thus aiding early detection providing quick treatment (Coughlin, 2015). Harm reduction programmes could be enforced. Behaviour change could be promoted and interventions should be made to encourage and motivate safe practices among high risk groups within population. Hepatitis B immunisation should be practised as it is the co-factor for hepatitis C progression. Screening and treatment of HCV could be available within reach at free or easy cost, improved surveillance system should be placed to tackle the deadly disease. Professional training could be provided to the healthcare staff. Furthermore the aim of health need assessment is to provide information to plan, argue and alter the services for health improvement.