Introduction

Lesson 1 placed needs assessment at the start of the program life cycle. Before a health authority funds a program, someone has to show that a problem exists, that it affects a definable group, that it is large enough to warrant action, and that current services leave a gap. Rossi, Lipsey and Henry (2019) treat the assessment of need as the first question an evaluator can ask about a program, because a program that addresses a problem few people have, or that duplicates an existing service, has limited worth however well it is delivered.

Needs assessment is also a planning activity in its own right, because its findings determine who a program should serve and what it should try to change. This section defines need, classifies it, shows how to estimate its size, surveys the methods of collecting evidence about it, and introduces asset-based approaches.

1.1 What Counts as a Need

Witkin and Altschuld (1995) define a need as a measurable discrepancy between the current state of affairs ("what is") and a desired or acceptable state ("what should be"). A need can be measured only once someone has stated the desired condition, so every needs assessment contains a value judgement about what is acceptable. The gap also concerns a condition of people, such as the proportion of older adults who are lonely. A statement such as "the region needs more community connectors" names a solution before the problem has been described.

Three related terms are often confused with need. A want is something people would like to have, whether or not it would change their health. Demand is the amount of a service that people seek, which depends on awareness, cost and access as well as on need. Service use is the amount actually received, which also depends on supply. Health care planners in the United Kingdom define need for health care as the population's capacity to benefit from it (Stevens & Gillam, 1998), which links need to the existence of an effective response.

Witkin and Altschuld (1995) also distinguish three levels of need. Level 1 needs belong to the people a program serves, such as lonely older adults; Level 2 needs belong to service providers, such as clinicians who lack a referral route; and Level 3 needs concern resources such as transport, space and data. A complete assessment describes Level 1 needs first.

1.2 Bradshaw's Taxonomy of Need

Jonathan Bradshaw (1972), writing about social services in Britain, observed that the word "need" was used in at least four different senses and that planners rarely said which sense they meant. His taxonomy remains widely used for classifying evidence about need in health and social care. Select each card to read its definition and the kind of evidence it rests on.

Bradshaw suggested that the four definitions could be combined, and that a need recognized under several definitions at once gives planners a stronger case for action. In practice the types often disagree, and the disagreements are informative. High normative need with low expressed need suggests that people are unaware of the problem, unwilling to seek help or unable to reach a service. High expressed need with low normative need suggests that demand reflects easy access or a service that suits people outside the intended target. A gap between felt and normative need may show that the standard itself deserves scrutiny.

1.3 Describing the Problem and the Target Population

Rossi, Lipsey and Henry (2019) set out the questions a needs assessment should answer: how the problem is defined, how large it is, how it is distributed, what its consequences are, and who should be the targets of an intervention. Prevalence, the proportion of people who have the condition at a point or over a period, matters for planning the capacity of a service. Incidence, the proportion who develop the condition over a period, matters for prevention and for forecasting how many new people a program will serve each year.

The same authors distinguish three populations. The population at risk is the group with a meaningful probability of developing the problem, such as older adults who have recently been widowed, moved or lost their driver's licence. The population in need is the group that currently has the problem, such as older adults whose loneliness scores meet the standard. The target population is the group a program actually intends to serve, defined by eligibility rules that planners can apply. Eligibility rules can err in two directions. Over-inclusion brings in people who do not have the need, which spends resources where they produce little benefit. Under-inclusion misses people who have the need. In epidemiological terms, an eligibility rule has a sensitivity and a specificity, and planners trade one against the other. The Cedar Valley rule accepts a score of 6 or higher or a clinician's judgement, and the second route increases sensitivity at some cost to specificity.

Estimating the population in need, with its uncertainty

Planners usually estimate the size of the population in need by applying a survey proportion to a population count. The estimate inherits the survey's sampling error, so it should be reported as a range. For a proportion p estimated from a simple random sample of n people, an approximate 95 percent confidence interval is given in the box below.

In the Cedar Valley survey, p = 392 ÷ 1,600 = 0.245. The standard error is √(0.245 × 0.755 ÷ 1,600) = 0.0108, so the 95 percent confidence interval runs from 22.4 to 26.6 percent. The region has about 46,000 adults aged 65 and older. Applying the point estimate gives 46,000 × 0.245 = 11,270 older adults with a score of 6 or higher, and applying the interval limits gives a range of roughly 10,300 to 12,240. The first-wave clinics serve about half of the region's older adults, or roughly 23,000 people, so about 23,000 × 0.245 = 5,635 of their patients would meet the normative standard. The 312 referrals in the first six months correspond to about 624 a year, which is about 11 percent of that estimate.

The calculation rests on assumptions that the assessment should state. The interval reflects sampling error only and assumes a simple random sample; a survey with clustering or weights needs a design-based standard error. If lonely older adults were less likely to respond, which is plausible, the survey underestimates prevalence, and a household survey misses residents of long-term care homes. The gap between expressed and normative need also does not mean that 89 percent of lonely patients were missed, because some people who meet the standard do not want a connector or are already connected to services. The gap is a prompt for assessing felt need and access, and it is a poor basis for a referral target on its own.

1.4 Methods of Needs Assessment

No single method captures all four types of need, so most assessments combine methods. Altschuld and Witkin (2000) describe a three-phase process: a pre-assessment phase that clarifies purpose, scope and existing information; an assessment phase that collects new data; and a post-assessment phase that sets priorities and plans action. The table summarizes the four methods named most often in health planning, with the types of need each tends to measure.

Triangulation across methods strengthens the assessment. In Cedar Valley, the survey established normative need, interviews with clinicians explained the lack of a referral route, and forums at seniors' centres and the partner First Nation's community hall described felt need and barriers such as transport. A forum held in the evening in the regional centre, however, would hear little from rural older adults who do not drive at night.

1.5 Assets: Asset-Based Community Development

Needs assessment has a built-in orientation toward deficits, and its findings can describe a community mainly through its problems. Kretzmann and McKnight (1993), drawing on studies of urban neighbourhoods in the United States, argued that such a "needs map" leads residents to see themselves as clients of services and overlooks the capacities a community already has. Their alternative, asset-based community development, maps the skills of individuals, the associations they form and the institutions present in a community, and builds programs by connecting these assets. Morgan and Ziglio (2007) proposed a related health assets model, which treats the social networks, skills, places and institutions that sustain health as resources to identify and strengthen.

An asset map is an inventory, often drawn on a geographic map, of the people, groups, places and organizations that could contribute to addressing a need. Kretzmann and McKnight described three main categories of assets, and later practitioners have commonly added physical, economic and cultural assets. The accordion lists each category with Cedar Valley examples.

Assets and needs answer different questions, and a plan requires both: the needs assessment shows the size and distribution of the problem, and the asset map shows what a program can build on. Friedli (2013) cautioned that asset language can be used to shift responsibility for health onto communities and to justify withdrawing public services, particularly where poverty and discrimination drive a problem. Strengths-based approaches are also consistent with many Indigenous perspectives on wellness, which begin from relationships, culture and land; Lesson 4 develops Indigenous evaluation principles and the governance of First Nations data.

Introduction

A needs assessment almost always identifies more needs than a health authority can address. The Cedar Valley assessment, for example, found high rates of loneliness among older adults, but it also found rising fall-related emergency department visits and concerns about medication safety in the same population. Planners then have to decide which problems to address first, for whom, and where. These decisions are made in every organization, and the choice is between making them explicitly, with stated criteria and evidence, or implicitly, through habit, advocacy and whoever speaks loudest.

This section teaches explicit priority setting. It introduces the five criteria that most public health frameworks use, shows how to combine them in a scoring matrix and how to check whether the result depends on the weights, presents the Health Equity Impact Assessment tool, and shows how local data from British Columbia can be used to compare need across communities.

2.1 Why Priorities Have to Be Set Explicitly

Priority setting allocates resources that could have been used elsewhere, so it always produces people whose needs are deferred. Daniels and Sabin (2008) argued that reasonable people disagree about the principles that should govern such choices, and that the legitimacy of a decision therefore depends on a fair process. Their framework, accountability for reasonableness, sets four conditions. The decision and its rationale must be public (publicity). The rationale must rest on reasons and evidence that fair-minded people can accept as relevant (relevance). There must be a way to challenge and revise the decision as new evidence or arguments arise (revision and appeals). The process must be enforced so that the first three conditions are met (regulation). The criteria and scoring methods in this section are tools for meeting the relevance condition, and a planning committee still has to publish its reasoning and allow it to be revised.

2.2 Five Criteria for Setting Priorities

Most public health priority-setting methods use some version of five criteria. Select each card for its definition, the evidence that informs it, and a Cedar Valley example.

The criteria overlap and can conflict. A problem with a large burden may have low modifiability, and the most equitable option may be the least feasible in the short term. Burden and equity describe the problem, while modifiability, feasibility and acceptability describe the response, so the criteria are best scored for a specific problem paired with a specific candidate response. Scoring loneliness in the abstract tells planners less than scoring a community connector program for lonely older adults.

2.3 Scoring Methods

A weighted scoring matrix is the simplest form of multi-criteria decision analysis, which Baltussen and Niessen (2006) recommended for priority setting in health because it makes the criteria, their relative importance and the performance of each option transparent. A committee scores each candidate on each criterion, agrees a weight for each criterion, multiplies scores by weights, and sums the products.

The table shows an illustrative exercise in which the Cedar Valley Health Authority's planning committee compared three problems among older adults, each paired with a candidate response: loneliness with a community connector program, falls with a community exercise program, and medication-related harm with pharmacist medication reviews. The committee agreed its weights before scoring, giving burden and equity 0.25 each, modifiability 0.20, and feasibility and acceptability 0.15 each.

Under the committee's weights, loneliness scores 0.25 × 4 + 0.20 × 3 + 0.25 × 5 + 0.15 × 5 + 0.15 × 5 = 4.35, and falls scores 4.05. Equal weights give the same order. When burden and modifiability each receive a weight of 0.35, falls ranks first with 4.50 against 3.95 for loneliness. The ranking therefore depends on how much weight the committee gives to equity and feasibility relative to burden and modifiability, which is a value judgement and should be reported as one. A sensitivity analysis of this kind belongs in every scoring exercise, and a result that changes under plausible alternative weights should be presented to decision-makers as a close call. In this example the committee also noted that the region already funded a falls prevention program, which reduced the gap that a new falls program would fill.

2.4 The Health Equity Impact Assessment

Priority setting compares problems, and equity is one criterion among five. The Health Equity Impact Assessment (HEIA) examines a single proposed program, policy or service change to identify its unintended effects on different population groups. The Ontario Ministry of Health and Long-Term Care developed the tool and published a workbook for it in 2012, and other Canadian organizations have since adapted it. The workbook organizes the assessment in five steps.

In the scoping step, the workbook prompts users to consider populations such as Indigenous peoples, age groups, people with disabilities, racialized and ethno-cultural communities, Francophone communities, people with low income, people who are homeless, rural and remote residents, and groups defined by sex, gender and sexual orientation, and to add any other groups relevant to the setting. The potential impacts step asks how the proposal could affect each group, including unintended effects. Mitigation adjusts the proposal. Monitoring specifies how effects on each group will be tracked, and dissemination shares the assessment with the people it concerns. Lesson 4 introduces Gender-based Analysis Plus (GBA Plus), the federal government's related analytic approach, and equity-focused evaluation more broadly.

2.5 Using Local Data to Compare Need Across Communities

Comparative need, and the equity criterion, require data for small areas. British Columbia organizes health planning geography in nested units: the regional health authorities are divided into health service delivery areas, local health areas and community health service areas. Several sources provide data at these levels, and the accordion describes the main ones.

Comparing survey estimates across local areas

The table divides the Cedar Valley survey by the region's four local areas. Each proportion has its own 95 percent confidence interval, calculated with the formula from Section 1.3, and each area's estimated number of older adults in need applies its proportion to its population.

The table supports two different conclusions, and planners need both. Kestrel Lake has the highest proportion in need, and its interval (27.8 to 43.7 percent) does not overlap with Cedar City's (19.0 to 24.9 percent), so the difference is unlikely to reflect sampling error alone. Cedar City, however, has the largest number of people in need, 4,834 against 1,357. An allocation based on numbers alone would concentrate resources in the regional centre, and an allocation based on rates alone would concentrate them in the smallest area. Proportionate universalism suggests serving every area, with more intensive support (such as transport funds and partner grants) where rates and barriers are highest. The sum of the area estimates (11,236) differs slightly from the regional estimate of 11,270 in Section 1.3 because the survey sample was not exactly proportional to each area's population; summing area-specific estimates is the better approach when the sampling fractions differ.

Age standardization

Crude rates can mislead when areas differ in age structure. Rural areas in British Columbia often have older populations, and most health problems become more common with age, so a higher crude rate in a rural area may partly reflect its age structure. Direct age standardization applies each area's age-specific rates to a common standard population, so that the resulting rates can be compared as if the areas had the same age structure.

The next table compares emergency department visit rates among older adults in Cedar City and Kestrel Lake, using the region's population aged 65 and older (26,000 aged 65 to 74, 14,000 aged 75 to 84 and 6,000 aged 85 and older) as the standard. All rates are illustrative visits per 1,000 older adults per year.

The crude rates differ by 56.8 visits per 1,000. In Kestrel Lake, 15.8 percent of older adults are aged 85 and older, compared with 10.0 percent in Cedar City. After standardization, the difference falls to 22.6 visits per 1,000. Kestrel Lake's rates are higher in every age group, so some excess remains, but more than half of the crude difference reflects age structure. A needs assessment that reported only the crude rates would overstate the comparative need for emergency care in Kestrel Lake.

Three further cautions apply to small-area comparisons. Rates based on small numbers are unstable from year to year, so planners should pool several years or report intervals. Many data providers suppress counts below a small threshold to protect privacy, which can hide exactly the small communities that equity analysis is meant to reveal. Inferences from area-level data apply to areas and may not hold for individuals within them, which is the ecological fallacy. Planning geographies also rarely match clinic catchments, so an analyst often has to approximate a clinic's population from the areas it serves.

Introduction

A needs assessment shows what problem a program should address and for whom, and priority setting shows which problems come first. Neither tells planners what the program should do. Planning frameworks fill that gap. They give a structured sequence of questions that moves from a health problem to its behavioural and environmental causes, from those causes to the factors that can be changed, and from those factors to the components of an intervention. A plan built this way contains an explicit account of why the program should work, which is the program theory that Lesson 3 turns into a logic model and a theory of change.

This section covers three frameworks that are widely used in health promotion and health services: PRECEDE-PROCEED, Intervention Mapping, and the Behaviour Change Wheel with its COM-B model of behaviour. Each is applied to the fictional Cedar Valley Connector program. The section then compares what each contributes and closes by placing all three within the Medical Research Council framework for developing and evaluating complex interventions.

3.1 PRECEDE-PROCEED

Lawrence Green and colleagues introduced the PRECEDE model in 1980 as a diagnostic approach to health education planning, and Green and Marshall Kreuter added the PROCEED phases in 1991 to extend the model into implementation and evaluation. The fourth edition of their text (Green & Kreuter, 2005) presents the eight-phase version described here, and a 2022 edition led by Green and colleagues continues the model. PRECEDE stands for Predisposing, Reinforcing and Enabling Constructs in Educational/Ecological Diagnosis and Evaluation. PROCEED stands for Policy, Regulatory and Organizational Constructs in Educational and Environmental Development.

The model's central idea is that planning should begin with the desired result and work backward. The planner first asks what quality of life the community wants, then what health problems stand in the way, then what behaviours and environmental conditions cause those problems, then what factors drive those behaviours and conditions, and finally what program and policy resources are needed to change those factors. Implementation and evaluation then run forward through the same chain.

Phase 1, the social assessment and situational analysis, engages the community to identify its quality-of-life concerns. Phase 2, the epidemiological assessment, identifies the health problems that most affect those concerns and the behavioural, environmental and genetic factors that cause them. Phase 3, the educational and ecological assessment, classifies the factors that drive the target behaviours and environmental conditions into three groups. Phase 4, the administrative and policy assessment and intervention alignment, matches program components to those factors and checks the resources, organizational barriers and policies that will affect delivery. In PROCEED, Phase 5 is implementation, Phase 6 is process evaluation, Phase 7 is impact evaluation of changes in the factors, behaviours and environments, and Phase 8 is outcome evaluation of changes in health and quality of life. Section 4 uses the same distinction between impact and outcome to classify objectives.

Predisposing, enabling and reinforcing factors

The educational and ecological assessment is the part of the model most often used on its own. Predisposing factors are a person's knowledge, attitudes, beliefs, values and perceived needs, which provide the motivation for a behaviour. Enabling factors are the skills, resources and conditions that make the behaviour possible, such as availability, accessibility, cost and transport. Reinforcing factors are the rewards and feedback that follow the behaviour and sustain it, such as encouragement from family, peers and providers. The table classifies the factors that affect whether a Cedar Valley participant joins and keeps attending a community activity.

PRECEDE-PROCEED gives a plan its overall architecture. It ties the program to community-defined quality of life, it requires attention to environmental and policy factors as well as individual behaviour, and it builds the evaluation into the plan from the start. Its limitation is that it says little about how to choose specific intervention methods once the factors are known, which is where Intervention Mapping and the Behaviour Change Wheel add detail.

3.2 Intervention Mapping

Intervention Mapping was developed by L. Kay Bartholomew, Guy Parcel and Gerjo Kok (1998) as a protocol for developing theory- and evidence-based health promotion programs. The fourth edition of the text (Bartholomew Eldredge et al., 2016) organizes the protocol in six steps, each with defined tasks and products. The steps are iterative, and the product of each step becomes the input to the next. Open each step for its main tasks.

A matrix of change objectives

The matrix is Intervention Mapping's distinctive product. Each row is a performance objective, each column is a determinant, and each cell states a change objective: what must change in that determinant for the person to carry out that action. The illustrative matrix below addresses the Cedar Valley behaviour "the participant takes part in a chosen community activity at least weekly."

Each change objective can then be matched to a change method. Low self-efficacy for a first visit might be addressed with guided practice and with modelling, for example a connector accompanying the participant to the first session or a peer volunteer describing their own first visit. Because the matrix specifies what each component is meant to change, it also gives the evaluation its short-term indicators. Intervention Mapping is thorough and transparent, and its main limitation is the time and expertise it demands; a full application can take many months.

3.3 The Behaviour Change Wheel and COM-B

Susan Michie, Maartje van Stralen and Robert West (2011) developed the Behaviour Change Wheel by synthesizing 19 existing frameworks of behaviour change interventions into a single structure. At its hub is the COM-B model, which states that a behaviour (B) occurs when a person has the capability (C), the opportunity (O) and the motivation (M) to perform it. Each component has two subcomponents, and the model is drawn as a system in which behaviour also feeds back on its sources.

Psychological capability is the knowledge and cognitive skills to perform the behaviour, and physical capability is the physical skill and stamina. Physical opportunity is what the environment provides (time, resources, location and prompts), and social opportunity is what the social and cultural environment provides (norms, social cues and support). Reflective motivation involves plans, evaluations and beliefs about consequences, and automatic motivation involves habits, emotions and impulses. Around this hub the wheel places nine intervention functions and, around those, seven policy categories that enable the functions to be delivered.

Michie, Atkins and West (2014) turned the wheel into an eight-step design process in three stages. In the first stage, planners define the problem in behavioural terms, select and specify the target behaviour (who does what, when, where, how often and with whom), and identify what needs to change using COM-B. In the second, they select intervention functions and policy categories. In the third, they select specific behaviour change techniques from the Behaviour Change Technique Taxonomy (v1), which defines 93 techniques (Michie et al., 2013), and choose a mode of delivery. At each choice point the guide applies the APEASE criteria: affordability, practicability, effectiveness and cost-effectiveness, acceptability, side-effects and safety, and equity.

3.4 Comparing the Frameworks

The three frameworks overlap, and each was designed for a somewhat different task. The table compares them on the questions a planner most often asks.

3.5 The MRC Framework for Complex Interventions

The three planning frameworks sit within a broader framework that covers the whole life of an intervention. The United Kingdom Medical Research Council (MRC) and the National Institute for Health and Care Research published an updated framework for developing and evaluating complex interventions in 2021 (Skivington et al., 2021), revising guidance first issued in 2000 and updated in 2008. The framework treats an intervention as complex because of its own properties, such as several interacting components, demanding skills for those who deliver or receive it, several groups or settings, or permitted flexibility, and because of the way it interacts with its context. The Cedar Valley Connector program is complex in each of these senses.

The framework describes four phases. Development or identification designs a new intervention or selects one that already exists. Feasibility tests whether the intervention and its evaluation can be delivered as planned. Evaluation asks whether the intervention achieves its intended outcomes, and also how, for whom and in what circumstances. Implementation covers deliberate efforts to bring an intervention that has been shown to work into routine use. The phases need not be followed in order, and work can begin at any of them, as when a program already in use is evaluated for the first time. At every phase the framework asks the team to attend to six core elements: context; program theory, which is developed, refined and tested; engaging interest holders; key uncertainties; refining the intervention; and economic considerations.

PRECEDE-PROCEED, Intervention Mapping and the Behaviour Change Wheel are tools for the development phase, and each produces the program theory that the core elements ask a team to state, refine and test. PRECEDE-PROCEED’s evaluation phases and the sixth step of Intervention Mapping reach forward into the evaluation phase. For Cedar Valley, the eighteen-month pilot in two clinics can be read as the feasibility phase, the first wave and its evaluation as the evaluation phase, and the second-wave rollout as a question of implementation. Two pieces of MRC guidance that apply the framework to particular tasks appear later in the course: process evaluation in Lesson 5 and natural experiments in Lesson 8.

Introduction

The products of the first three sections (a description of need, a set of priorities and a planning framework's account of what must change) have to be turned into commitments that a program can act on and an evaluation can test. Goals and objectives are those commitments. A well-written objective states who will change, in what way, by how much and by when, and how anyone will know. The program plan then gathers the objectives together with the activities, timeline, responsibilities and budget needed to achieve them. This section teaches how to write goals and objectives, how to set targets that are ambitious without being implausible, how to write a needs statement, and how to assemble a program plan. It closes with a worked example of a needs statement and objectives for the Cedar Valley Connector program.

4.1 Goals and Objectives

A goal is a broad statement of the long-term result a program intends to contribute to. It sets direction and is usually not measurable in itself, for example "older adults in the Cedar Valley region have the social connections they want." An objective is a specific, measurable statement of a result that the program commits to achieving within a stated period. A program normally has one or two goals and a small number of objectives under each, arranged in a hierarchy in which lower-level objectives are expected to contribute to higher-level ones.

4.2 SMART Objectives

George Doran (1981) proposed that management objectives should be specific, measurable, assignable, realistic and time-related, and the acronym SMART has since become standard in public health planning. HSCI 207 Lesson 2 Section 4.2 (Developing a Research Question) applies the same criteria to the objectives of a research study and is optional reading. Public health versions usually read specific, measurable, achievable, relevant and time-bound, and some equity-focused planners add inclusive and equitable (SMARTIE) to prompt attention to who benefits. The table defines each element and the question it asks of a draft objective.

In practice, a measurable objective contains five parts: the population (who), the result (what will change or be delivered), the target with its baseline (how much), the time frame (by when) and the data source (how it will be known). Including the data source in the objective, or in an accompanying table, ensures that the objective can be evaluated, and it anticipates the indicator specifications that Lesson 5 teaches.

4.3 Process, Impact and Outcome Objectives

Health promotion planners in the PRECEDE-PROCEED tradition classify objectives by the level of result they describe, matching the three evaluation phases of PROCEED. The tabs define each level and give a Cedar Valley example.

4.4 Setting Targets

Targets should be set from three kinds of evidence. The baseline describes the current level, from the needs assessment, routine data or a pilot. The evidence from similar programs, ideally from systematic reviews, describes what change is plausible. The program's capacity (its staff, budget and reach) sets an upper limit on how many people it can affect. A target that ignores any one of these is likely to be either trivial or impossible.

A population-level target shows the importance of capacity. Suppose the steering committee proposes the objective "within two years, the proportion of older adults in the region who score 6 or higher will fall from 24.5 percent to 22.0 percent." The region has 46,000 adults aged 65 and older, so a fall of 2.5 percentage points means about 0.025 × 46,000 = 1,150 fewer people above the cut-off. If all 24 clinics refer at the first-wave rate, the program will receive about 312 × 2 × 2 = 1,248 referrals a year, and at the first-wave rate of 77.2 percent about 964 of them will attend a first meeting. Even if 40 percent of those participants moved below the cut-off and stayed there, the program would move about 386 people a year, or about 771 over two years. That is 1.7 percentage points of the region's older population, before accounting for new cases of loneliness and for people who would have improved without the program. The proposed target is therefore implausible for the program alone, and it belongs among the population indicators the program contributes to.

Targets for change among participants raise a different problem. The Cedar Valley program enrols people because they score 6 or higher, and people selected for a high score on a measure with day-to-day variation will, on average, score lower when measured again even without any intervention. This is regression to the mean, which Lesson 7 treats as a threat to internal validity. In the first six months, the mean score among the 188 participants with both measurements fell from 7.1 to 6.3, a fall of 0.8 points, and part of that fall would have occurred without the program. An outcome objective written as a pre-post change can still guide practice and monitoring, but the plan should state that whether the program caused the change is a question for the evaluation design, which Lessons 6 to 8 address. A stronger outcome objective states the expected difference relative to a comparison group once the evaluation design is known.

4.5 The Needs Statement

A needs statement is the section of a program plan or funding proposal that establishes the problem the program addresses. It is usually 300 to 750 words long and follows a consistent structure. It defines the problem and the population affected, states the size and distribution of the problem with local data and their sources, describes the consequences of leaving it unaddressed, summarizes the causes and contributing factors that the program can address, describes the assets and current responses and the gap that remains, and explains why action is needed now. It cites data that a reviewer can check, reports the uncertainty in estimates, and describes the problem before it describes the program. It avoids presenting a solution as the need (for example, "the region lacks connectors"), and it avoids presenting a community only through its deficits.

4.6 Assembling the Program Plan

A program plan brings together the needs statement, goals and objectives, the target population and eligibility rules, a description of the program and its theory, the activities and work plan, the budget outline, the partnerships and governance arrangements, and an outline of the evaluation. Lesson 3 develops the program theory as a logic model and theory of change, and later lessons build the evaluation. This section covers the two operational parts: the work plan and the budget outline.

A work plan lists each major activity with the person or role responsible, the start and end dates, the resources required and the output that marks completion. Each activity should be traceable to at least one objective, and each process objective should have activities that deliver it. A Gantt chart shows the same information on a timeline and makes dependencies visible, such as the need to hire connectors before referrals open. The table and chart show an illustrative work plan for the first year of the Cedar Valley second wave.

A budget outline at the planning stage lists the main cost categories and links each to the activities and objectives it supports. It is less detailed than the costing that Lesson 10 teaches, and it shows a reviewer whether the resources match the plan. The table organizes the first-wave annual budget of $840,000 in this way. Personnel accounts for $755,000, or 89.9 percent of the total, which is typical of programs delivered by people, and which means that the number of connector positions sets the program's capacity.

4.7 Worked Example: A Needs Statement and Objectives for Cedar Valley

The following example applies Sections 4.1 to 4.5 to the second wave of the fictional Cedar Valley Connector program. It uses the illustrative figures introduced in Sections 1 and 2.

Bringing It All Together

This lesson followed the planner’s work from the identification of a problem to a written program plan. A need is a gap between a current and a desired condition of people, and Bradshaw’s taxonomy shows that evidence about need comes in four forms (normative, felt, expressed and comparative) that often disagree in informative ways. A needs assessment estimates the size and distribution of the problem with its uncertainty, distinguishes the populations at risk, in need and targeted, and combines indicators, surveys, key informants and forums. Asset-based community development balances this deficit-based picture by mapping what communities already have.

Because needs exceed resources, planners set priorities. The criteria of burden, modifiability, equity, feasibility and acceptability can be combined in a weighted scoring matrix, and a sensitivity analysis shows whether the result depends on contested weights. The Health Equity Impact Assessment examines a single proposal for unintended effects on different groups, and local data from health authorities, BC Stats, Statistics Canada and Population Data BC allow need to be compared across communities when analysts report intervals and standardize for age.

Planning frameworks turn priorities into program designs. PRECEDE-PROCEED provides an architecture from quality of life to evaluation, Intervention Mapping links determinants to theory-based change methods through its matrices, and the Behaviour Change Wheel links a COM-B diagnosis to intervention functions and techniques. Goals and SMART process, impact and outcome objectives turn the design into commitments, and the program plan connects them to a work plan and budget. The fictional Cedar Valley Connector program illustrated each step, and its needs statement and objectives now sit alongside the program description from Lesson 1.

The final reflection asks you to apply the whole lesson to a new program, from evidence of need to objectives and the choice of a planning framework.

Final Knowledge Assessment

This glossary defines the terms, frameworks and people introduced in Lesson 2, and you can search it at any point in the lesson.