The meaning of need within the framework
The concept of need has been variously defined in health care and prevention services and a variety of types of needs have been identified. Elsewhere we describe two broad sets of MSM needs: motivation needs and power needs. Men can be in need of motivation (they do not want to reduce risk) or in need of power (they are unable to reduce risks). The reasons for either can be varied. We recognise the following factors to be associated with not being motivated to avoid HIV transmission:
- not knowing what HIV is, what it can do it us and what that might mean;
- men without HIV, being unaware of the benefits of remaining uninfected and the costs of acquiring HIV;
- men with HIV, being unaware of the benefits of not passing HIV on and the costs of passing on infection;
- men’s positive significant others (people liked or admired) wanting or expecting them to acquire or pass on HIV;
- men’s negative significant others (people disliked or held in contempt) wanting or expecting them to remain HIV uninfected or to keep HIV to themselves.
A number of choices are related to HIV precautions and risks, and not having the power to enact a choice can occur for a variety of reasons. Broadly, we consider not having the power to reduce risks to include:
- not knowing about precaution / risk choices;
- not having the opportunity to choose precaution;
- not having the resources to choose precaution;
- not having the skills to choose precaution.
Men have unmet needs if they are unaware of HIV or STIs, ignorant or misinformed about them, disempowered in sexual relationships or activity, or ill-equipped to take protective action, including condom use. Men are also in need if they have little or no access to educational or clinical services, or they have access only to poor quality services. Need describes areas where a single man or group of men have the potential to benefit from an intervention or programme of work. An intervention may target the men themselves, or members of their social and sexual networks who in turn influence them. Need is defined as an intervention aim being unmet.
For a population of men there will always be a diversity of unmet needs and the dominant unmet needs in the population may not be the most crucial unmet need for any single individual. So individual interventions need to be sensitive to the specifics of an individual’s life, while programmes should be weighted towards the commonly unmet needs in the population.
As we are also attempting to increase the number and quality of community and peer-led interventions, men not being able to make interventions with their peers is also considered evidence of need. Since we require community infrastructures to do direct contact and social diffusion projects, the absence of community infrastructures is also considered as evidence of need. As are organisations being unable to contribute to the health promotion aims in the course of their work.
As health promoters and researchers require organisational structures, personnel, skills and planning data, the absence of these is also viewed as an HIV prevention need within the framework. Finally, policy and practices that unfairly discriminate against homosexually active men and people with HIV, and which make HIV prevention interventions less possible are in themselves evidence of need. An HIV prevention needs assessment for gay men and / or bisexual men could cover any or all these areas of need.
The sexual health needs of an MSM population cannot be derived from HIV incidence, STI prevalence or sexual behaviour. Needs assessment involves generating and considering evidence to make informed judgements about the extent to which health promotion aims are unmet. Resources are likely to be most efficiently used if they are employed in areas of greatest need. Alternately, health promotion activities may be inefficient simply because their aims are already well met for the target audience. An assessment of need may consider:
- the extent to which a specific aim(s) is met for an entire population;
- the extent to which all of the health promotion aims are met for a specific sub-population; or
- the extent to which specific aims are met for a specific sub-population.
A needs assessment for a population or sub-population should make an estimate of its size and relationship to other population groups. Needs assessment is not a single activity, event or report. It is an on-going process requiring the collation of information from a wide range of sources and cycles of review. Needs assessment and programme planning occur in parallel.
Needs assessment plays an important role in the delivery of service delivery. All PCTs currently have a statutory responsibility (Department of Health 2001, Department of Health 2003) to assess the HIV health promotion needs of their resident population. They also have a responsibility to commission services to meet as much need as possible in the most equitable manner. However, the extent to which some health promotion aims are met, the obstacles to them being met and the health promotion initiatives that may best achieve them, can transcend PCT boundaries. Some needs therefore require assessments across geographic areas larger than single PCTs. Provision and planning for such assessments will require support from Strategic Health Authorities, from the Department of Health, and from HIV and African organisations.
From April 2008 the Local Government and Public Involvement in Health Act (2007) imposed a duty for PCTs and upper-tier local authorities to undertake Joint Strategic Needs Assessments (JSNAs) in order to better understand the current and future health and well-being needs of their populations. This system of joint strategic needs assessment currently informs the commissioning evidence base for interventions that result in improved health and well-being outcomes, and in the reduction of health inequality (Department of Health 2007). In addition to this, the Equality and Human Rights Commission (EHRC) operates to safeguard policy and practice responding to the particular needs of ethnic and sexual minorities. Support from the EHRC will be critical for those agencies and voluntary sector consortia seeking to ensure that the HIV prevention needs of MSM are appropriately met.
Segmentation and target description
We can describe sub-populations of MSM using any number of single variables: for example, demographically (Black Caribbean, young etc.); geographically (rural, Londoners etc.); socially (opera lovers etc.); clinically (men with hepatitis or HIV); sexually (men with ‘higher’ numbers of sexual partners) or by another means of HIV exposure (such as injecting drug use). These classifications will often overlap. Where they overlap and form meaningful groups within the larger population, we can identify segments which share characteristics.
Segments form meaningful groups of people who share sufficient knowledge, values, resources, opportunities and skills to make them targets of an intervention. Any information about the potential clients or users of a service or intervention can be used to describe the population of concern and the segments within it. The description of the population segments and the target chosen for the intervention can be distinguished from:
- the behaviours of concern (eg. men who have unprotected anal intercourse);
- the needs being addressed (eg. men without the knowledge, values, social norms, resources, or skills);
- the location in which the clients/users are encountered (eg. sauna using men);
- the medium used for the communication (eg. readers of a specific website).
Tailoring refers to the modification of intervention activities, vocabulary, imagery etc., to be attention catching and engaging to the segment chosen for the intervention.
Targeting refers to the choice of settings in which to carry out the intervention such that it is disproportionately (or exclusively) encountered by the target for the intervention.
Any purposeful activity might be described as an intervention. Interventions consist of doing something in order to bring something else about. An intervention may be continuous, or intermittent, or happen only once. They are rarely unique. Although different individuals and groups will have expertise at doing particular interventions, we all have a stake in knowing what interventions are required, where they can and cannot be done, who encounters them when they are done in different places and what they can do for the people who encounter them. Interventions are collective property.
An intervention can consist of very little activity or a very large amount of activity. Most interventions can be broken down into a number of smaller constituent interventions. A large intervention can be broken down into a number of smaller parts, each of which can have its own aim, target, objective, setting and resources.
A programme is a set of “activities designed to fulfil particular strategic goals and targets related to a (particular) priority” (Simnet 1995). Therefore any strategic combination of interventions may be thought of as a programme of work. However, as a minimum a programme should include at least two types of intervention working towards similar outcomes for the same target group.
In any area with several interventions occurring (possibly from a variety of agencies) clients may encounter more than one. People are influenced by and often do not distinguish between interventions and influences emanating from several sources. No agency has exclusive access to any one individual, and even where an individual encounters only one agency, they also encounter other community members, other services and other authorities.
Consequently single interventions cannot easily be independently prioritised as the desirability of each is dependent on what other interventions are occurring and what other community activity is taking place. The combined influence of different interventions should have a greater impact than any one intervention encountered separately. Moreover, contradictory or conflicting interventions may cancel each other out or cause harm neither could cause individually.
Programme planning is essential to use finite resources in the most effective and efficient way to address the unmet needs identified in needs assessment. As all programmes have access to finite resources, some prioritisation of activities needs to occur. Programme planners should have more plans for interventions than resources available.
Homosexually active men are a diverse population, who do not all go to the same places, or all know the same people. Since such diversity cannot be reflected in every health promotion activity; a successful programme must employ a variety of settings and methods. Different interventions (in either setting, methods or both) may be required to address the same unmet aims for different groups of men. However, it is not the case that each group of men that can be identified requires its own programme (or organisation). What is important is relevant group differences.
One of the reasons services and community groups may have little intended impact is because they are not collaborating with each other towards common goals.
So for example, where services and community members disagree about what they think MSM should do (what they expect of MSM in terms of the ten choices), they are unlikely to agree on what interventions should occur and what they should look like. Since communities are diverse, and the range of opinion and expectations of MSM are wide, no single position adopted by a service will correspond to the values and needs of the population it aspires to serve. This may be one reason why a diversity of agencies is desirable in the same way as a diversity of interventions is. However, all services should resist totalitarian responses to HIV which impose a single solution on the entire population (and which usually advocate withholding information or resources about other solutions).
Although cooperation among those involved in service planning and delivery has long been seen as key to success, competitive tendering has fostered competition and an increasingly adversarial approach to change. The tactics used in debates about HIV prevention are akin to those used by political parties vying for power in government. However, given the complex influences on people’s health, no single agency can hope to meet all the health-related needs of any population.
Making it Count is a framework for the collaborative planning of HIV prevention. It is both an aid to collaboration and an aid to clarity of disagreement. We recognise that men will encounter, and probably be influenced by, many different interventions, from several different agencies. We recognise (and respect) individuals and other agencies right to disagree with the approach we have adopted. The collective task of those working within this framework is to choose activities so that they have the maximum impact on improving sex lives and reducing the harm associated with them. In other words, it is an attempt to identify the best combination of interventions to address the needs described elsewhere.
Describing interventions facilitates the construction and articulation of programmes. When the interventions under consideration are described in a comparable manner, they can be collected, compared and contrasted. This allows us to avoid replication and maximise impact. It also allows us to increase the equity of a programme by covering as much of the population of concern as possible, and to counter inequalities by targeting specific groups.
A programme can be audited by examining the different activities that make it up. These activities might include interventions, policies and procedures, as well as training and staff development. HIV health promotion is an on-going activity and sustained programmes are one of the keys to success. Comprehensive HIV health promotion programmes for a geographic area require collaboration between a number of agencies, important among which are clinical and non-clinical services. They include activity funded and resourced through a number of channels. Collaborating agencies and commissioners can make collective changes at the programmatic level to match changes in the unmet needs of the population.
Describing interventions using ASTORS
ASTOR is a way of describing an intervention that includes information about the Aim; Setting; Target; Objectives and Resources. There are three main reasons we might want to describe interventions:
- To buy and sell them. Funders need to be able to articulate what it is they are seeking to purchase when they put out tenders. Similarly, a provider seeking funding for an intervention will need to describe it to potential funders.
- To evaluate them. The first stage of making a judgement of something’s value is to describe it. Judgements of an interventions’ success are related to our expectations of what it consists of and what it should do. We have to be able to describe what interventions should do to make such judgements.
- To replicate them. If an intervention is judged to be of value, there will come a time in the future when someone will want to do it again. A clear and comprehensive record of what the intervention involves will help in its re-creation. If you’ve done something that worked, someone else, somewhere at sometime will want to do the same thing. Rather than start from scratch, knowing what you did will increase their effectiveness and efficiency.
Interventions become more transparent when they are fully described. Their strengths and weaknesses become more apparent and their value to different stakeholders can be judged more easily. Weaknesses can be addressed and avoided.
We suggest five elements of an intervention need to be described to understand it. These elements start with the letters A, S, T, O and R. The order varies but all five things must be covered:
Aim: the way in which the target is intended to change (choice, knowledge, awareness, skills, resources, motivation etc.).
Settings: where the interventions are done.
Target: who is intended to change as a consequence of the intervention.
Objectives: the activities the intervention consists of.
Resources: what is required to do the activities (time, money, skills, materials etc.).
Intervention planning can be needs-led (either target or aim) and can also be led by objectives, settings and resources. All planning is a backwards-and-forwards process between the five dimensions. No intervention does everything for everyone, or happens everywhere. In the first instance, ask the following questions to sketch out the five dimensions:
Target-led planning: you are concerned about a specific target group (eg. a group in a specific geographic area; an age group, an ethnic group etc.).
- Ask: What unmet needs do they have (A)? Where can you encounter them (S)? What activities can you do there that can change those unmet needs (O)? What resources are required (R)?
- Ask: Who most commonly has that need unmet (T)? Where can you encounter them (A)? What activities can you do there that will reduce that need (O)? What resources are required (R)?
Resource-led planning: you have some resources (time, skills, money, materials).
- Ask: What activities could they bring into being (O)? Where could they be done (S)? Who would encounter them (T)? What needs do they commonly have unmet which the activities could address (A)?
Setting-led planning: you have a location or place to do things in.
- Ask: Who goes there (T)? What needs do they commonly have unmet (A)? What activities could be done there that would reduce identified need (O)? What resources are required (R)?
Objectives-led planning: you have a method you want to use.
- Ask: Who do you want to influence (T)? Where do they go where you can use the method (S)? What unmet needs do they have which the method can address (A)? What resources are required (R)?
The amount of information you put into the description is determined by its purpose: who are you describing it for, what are they to do with it? In planning interventions, more detail is usually better because the description highlights weaknesses that can be addressed. If the description is by and for the person doing the intervention, it may consist of a few words to remind them of a sequence of events. Descriptions shared between colleagues to describe what has happened may also be sparse. On the other hand, if the descriptions are for people who the author will not meet but who are expected to replicate the intervention, the description will need as much detail as possible. A description of an intervention should be detailed enough for someone to replicate it if it is being recommended that the intervention be replicated.
Intervention descriptions are tools, and as such should be appropriate to the task in hand. If this is representing a large amount of activity in a simple and clear way, the units will have to be relatively large, and the amount of detail small. An intervention description and evaluation report on the other hand will need to contain far more detail.
Describing target groups: Who is intended to change? Be explicit and precise about the target group. In order to be able to say something about (a) the proportion of a population who encountered an intervention (its coverage) and (b) how like the people intended to encounter it were the people who did encounter it, we need a good idea of who is supposed to encounter an intervention.
The people who encounter any intervention can be described in terms of an endless array of characteristics. When planning an intervention specify who should be over-served by it. After an intervention has occurred we can ask: What is the profile of the people who encountered the intervention? Were the prioritised groups over-served (ie. were they more likely to encounter it)?
Describing aims: You can think of the ‘aim’ as the direction in which change is intended and ‘outcomes’ as the specific distances travelled. A broad indication of aim (eg. increase knowledge of PEP) can be specified in ever increasing detail (eg. know about the existence of PEP; know when PEP may help, where and when to get it; feel happy and confident about PEP knowledge). Alternatively, an aim can become more general (eg. reduce HIV prevention need) if the intervention includes objectives which determine what unmet needs will be addressed.
After an intervention has occurred, we can ask: What was different after the intervention has occurred? What changed? Who got what out of it? Was it effective (did it do what was intended)? Were there unintended outcomes (was what it did desirable)?
Describing objectives: Objectives, including methods, cover what the intervention consists of. To describe what the intervention consists of mention what you actually do, who does it, which elements of the method are essential, and which are optional etc. A common mnemonic for objectives and setting and resources is that they should be ‘SMART’: specific, measurable, achievable, realistic and time-scaled. This is a useful check-list for remembering the qualities of objectives and your descriptions of what you do.
Specific: be precise about who does what when during the course of the intervention.
Measurable: objectives should be monitorable; you should be able to count them or say whether or not they happened.
Achievable: you want to be able to do them in that setting within those resources; but you will not always know this before you implement the intervention. This is the quality of feasibility.
Realistic: this is the same as achievable but SMAT is not a word.
Time-scaled: the time-line goes with the specificity of description; who does what by when?
Describing settings: The setting covers where all the parts of the intervention are done. For interventions that require advertising, the setting includes the places in which advertising appears. Settings of interventions determine who encounters the intervention as well as the objectives or tailoring of the intervention.
After an intervention has been implemented we can ask: How did people come into contact with the intervention? How does the setting enhance or hamper its effectiveness? Was the intervention easy or difficult in this setting? Is the location limiting its access?
Describing resources: Resources could just include money, but often interventions require things that money cannot buy. Try to describe the prerequisites for the intervention, rather than just its cost. Often an intervention will be unfeasible because the resources needed are absent. What is required to do the activities (time, money, skills, materials etc.)? How much time is needed to plan and do the intervention? What resources are necessary to do it?
Features of successful interventions
A comprehensive review of the features of successful sex education for younger people (Kirby et al. 2007) identified 17 characteristics of effective programmes that can be usefully applied to most interventions. The 17 characteristics can be grouped into planning, aims, activities and delivery processes.
Planning characteristics of successful interventions
1. Competent designers - Intervention planning involved a variety of people with a range of expertise in theory, research and sex / HIV education.
2. Needs assessed - The specific risk behaviours being displayed by the target group are assessed, as well as the extent of the unmet needs contributing to those behaviours (eg. ignorance, skills, values).
3. Theorised - intervention designers should articulate a chain of influence between their activities, the needs of clients, their behaviours and the health gains hoped for.
4. Feasible and acceptable plans - the planned activities are possible in the setting and within budget, and are acceptable to both service providers and clients.
5. Piloted or pre-tested - intervention activities are given a dry-run and feedback from providers and clients used to improve them and iron out problems.
Aims of successful interventions
6. Health goals are explicit and specific - the intervention explicitly focuses on clear health goals (eg. more likely to have pleasurable sex; less likely to pick up and pass on HIV).
7. Precaution / risk behaviours are explicit and specific - the intervention explicitly focuses on specific actions and behaviours (patterns of action) that lead to health goals (eg. attending saunas; avoiding anal intercourse; using condoms), addressing the situations that might give rise to them and how to attract or avoid them.
8. Needs addressed are explicit and specific - the intervention explicitly tries to change the motivation interventions factors (eg. awareness of consequences of actions, judgements of outcome probabilities, values placed on outcomes, perceived social norms) and power factors (opportunities, resources, skills) that affect behaviours.
Activities of successful interventions
9. Scene setting and safety - attention is paid to the comfort and safety of participants creating a safe social environment.
10. Multiple activities - the intervention consists of a variety of different tasks and exercises.
11. Participatory learning methods - clients are actively engaged in their own learning through participation and engagement, being encouraged to personalise and contextualise information.
12. Activities are feasible and acceptable to clients - activities, images and language are appropriate to the clients culture, age and experiences.
13. Logically sequenced - the activities and content is covered in a logical sequence that builds upon itself.
Implementation processes of successful interventions
14. Support is sought from gate-keepers and authorities - interveners have secured consent and at least minimal support from stakeholders who have power to close down or support the intervention (eg. other community organisations, police, health authorities).
15. Trained and supported staff - those delivering the intervention are acceptable to the clients and adequately trained, monitored and supervised.
16. Promotion - the activities are advertised and obstacles to attending addressed
17. All parts of intervention is delivered - planned interventions are delivered as planned rather than piecemeal.
Attention is these 17 characteristics can greatly increase the probability of an intervention influencing behaviour by impacting on needs.
Prioritisation of activities to include in a programme must attend to the principle that all men are equally entitled to having control over their sexual life and to pursue a sex life that is of value to them. However, HIV infection is not equally distributed among all homosexually active men (either geographically or by social networks). Men who have poor quality sex lives are not necessarily the same men who are most likely to be involved in HIV transmission. To have maximum impact on HIV incidence, programmes should attempt to provide a combination of universal interventions intended for the entire population and targeted interventions delivered to those most likely to be involved in HIV transmission during sex. Either approach alone is likely to be of limited benefit.
We explicitly recognise that these three principles of prioritisation (impact on incidence, impact on sex life quality and impact on equity of sexual health) may be in conflict. For example, men who have little or no sex and are unhappy about that have a poor quality of sex life but also a low incidence of HIV infection. The following three principles should be considered together when making programming decisions:
To maximise impact on HIV incidence: Prioritise interventions that are disproportionately encountered by men more likely to be involved in HIV transmission (such as men with undiagnosed HIV infection, men in sero-discordant relationships, men with many male sexual partners, men with lower educational qualifications).
To maximise equity of health: Prioritise interventions that are disproportionately encountered by population groups who have many sexual health needs unmet compared with other population groups (such as men with lower educational achievement, men under 20 or over 50, behaviourally bisexual men).
To maximise impact on sex life quality: Prioritise interventions that are disproportionately encountered by men with poor quality sex lives. Further research is required to identify which segments of the MSM population these are.
To maximise impact on all three: Prioritise interventions which address needs which are poorly met for a large proportion of the population.
In addition, prioritising interventions should attend to their performance in meeting their specified aims.
Evaluating interventions and programmes
The performance of an individual intervention at influencing the men who encounter it can be distinguished from the impact of programmes of interventions on the strategic targets for a population over a sustained period of time.
To judge whether an HIV prevention intervention or programme has failed or succeed it must be sufficiently specified. Only by being specific can the useful be distinguished from other interventions.
It is against changes in the related health promotion aims that individual interventions should be judged. Descriptions of interventions should include what is done (objectives and methods), where (setting), with what (resources), to achieve what change (aims) for whom (target), as well as the behavioural choice the intervention seeks to influence (for example, using condoms for anal intercourse).
Only if these dimensions of an intervention are specified can information on their actual performance be gathered. If these dimensions are specified the following seven qualities of the intervention can be considered:
Feasibility - Is it possible to carry out the intended objective in the specified setting with the finite resources? Can it be done?
Cost - How many resources does it take (eg. money, people, equipment)? How much is related to the setting (recruitment costs) and how much to the objectives (unit costs)? What is the overall cost per target group member who encountered the intervention?
Acceptability - What do the target think of the objectives, particularly in that setting? What do others think of the intervention, including the intervenor.
Coverage and access - How many (or what proportion) of the target group encounter the objectives and how do they differ from the target group members who do not encounter them? What are the biases in access to the intervention?
Needed - Is the aim already true for the target before they encounter the objectives? Are the specific needs the intervention addresses (awareness, knowledge, resources, skills etc.) already met?
Effectiveness - Do the objectives bring about a change in the aim for the target? Which target members who encounter the intervention benefit most and least?
Efficiency - Were all the resources used in the intervention necessary to bring about the change that occurred? How does the intervention compare to others that bring about the same amount of change for the same people?
Judgements of the worth of interventions are best made when they attend to as many dimensions of intervention performance as possible. Attending to one quality to the exclusion of others (effectiveness for example) is likely to result in a partial assessment of an interventions worth. In addition, changing any one dimension of an intervention (for example, the place it is done, or the men who are intended to benefit from it) will alter other qualities of the intervention.
Qualities of interventions should not be assumed unless they have been observed in practice. Learning from observation of interventions in practice can be shared among practitioners without recourse to formal evaluation. Discussion between those making interventions is central to judging intervention performance.
Formal evaluation and / or documentation of interventions will be most useful if they include data about all qualities of interventions, including costs. This is not an endorsement of one research design over another in evaluation. Data about the performance of interventions can be gathered through a number of mechanisms to suit a variety of questions. The most desirable design generates the most information about the specific questions being asked. Assessing whether interventions were needed, effective and efficient usually requires more substantial research designs to answer than does assessing whether they are feasible, their cost, accessibility and acceptability. When a range of interventions are both feasible and acceptable to achieve a particular aim with a particular population group, logic suggests we maximise efficiency of programmes by:
- Prioritising interventions that are the most efficient at reducing common needs.
The effectiveness of a programme in influencing the population targets is not determined solely by the range of methods it includes. The fit between the values and needs of the population, the range of settings and objectives used for interventions and the broader social and legal context are all important.
Even where an intervention is effective, if it does not address the priority needs of its target population it may make no substantial contribution to increasing the quality of sex lives or reducing the harm associated with them. Effective and efficient interventions are necessary but not sufficient to best direct resources: they also must be matched to values and needs.
It is unlikely that in any geographic area a single agency can meet the entirety of local MSM’s sexual health needs. Hence, the following MSM population targets cannot be expected to be achieved by any one agency. Rather, change in the targets will be a consequence of all related activity of all agencies in an area working collaboratively.
- Population Target #1: Reduce the average length of time between HIV infection and HIV diagnosis in men who become infected.
- Population Target #2: Increase the proportion of MSM with diagnosed HIV who are on fully suppressive anti-retroviral therapy.
- Population Target #3: Reduce the average number of sexual partners between STI screens.
- Population Target #4: Reduce the frequency with which men have unprotected anal intercourse without knowing whether or not they and their partner are HIV sero-concordant.
- Population Target #5: Increase the length of time since having an extra-relational sex partner, among men with a regular male sex partner.
- Population Target #6: Decrease the proportion of sexual sessions between men that feature anal intercourse.
- Population Target #7: Increase the proportion of anal intercourse events that feature condoms from the beginning of intercourse.
- Population Target #8: Reduce the frequency with which ejaculation occurs into a mouth or rectum without a condom.
- Population Target #9: Reduce the frequency with which men use poppers during receptive anal intercourse.
Page last updated: 26 March 2012