Abstract

Defining a concept of health needs is essential for establishing limits to medical and sanitary interventions, whether at an individual or collective level. Like many expressions in current technical use, the meanings attributed to the expression “health needs” vary considerably. Thus, this work was driven by the hypothesis that the specialized literature lacks rigor in the definition and use of the term, posing an ethical and political problem for it can reverberate in issues such as resource allocation and in the definition of strategies and actions of a therapeutic project. To this end, articles published in the BVS and Pubmed databases in Portuguese, Spanish, and English, with the descriptors determinação de necessidades de cuidados de saúde, evaluacíon de necessidades, and needs assessment were submitted to thematic analysis. The results indicate that reflections on the concept of “health needs” are scarce in the literature. Moreover, the studies addressing the concept show a lack of conceptual definition, denoting a lack of uniformity in the theoretical understanding about this expression. The absence of a strictu sensu concept and the complexity of the factors involving the descriptor results in a diffuse use, with incipient problematization and, at times, convenient for the context used.

Keywords:
Health Services Needs; Philosophy; Science and Health

Introduction

Defining a concept of health needs is essential for establishing limits to medical and sanitary interventions, both individual and collective. Starting from the definition of medicalization by Conrad (2007CONRAD, P. The medicalization of society. Baltimore: Johns Hopkins University Press, 2007., p. 4) - “the process through which non-medical problems become defined and treated as medical problems, generally in terms of illness or disorder” - it is possible to identify the problem of defining when this process extrapolates the limits of what is ethically justifiable, that is, when intervention becomes truly necessary.

Like many other expressions of current technical use, the meanings attributed to the expression “health needs” vary considerably. In this article, our goal is to explore different definitions and meanings through a thematic analysis of articles published in scientific journals from different databases, considering that the academic production on the topic reflects the communis opinio doctorum of the scientific community relevant to health.

Furthermore, we hypothesize the idea that the specialized literature is excessively fluid and lacks rigor when defining and using the term, which, given the importance of this notion from the ethical and political point of view, is a problem in itself. Conceptual accuracy is a prerequisite for both philosophy and science in general. Failure to meet this prerequisite makes it difficult, or even prevents, a critical approach, obscuring possible unintended consequences from a given conceptual perspective (Bourdieu, 1989BOURDIEU, P. Introdução a uma sociologia reflexiva. In: O Poder Simbólico. Lisboa: DIFEL, 1989.; Foucault, 2012FOUCAULT, M. A Arqueologia do Saber. Rio de Janeiro: Forense Universitária, 2012.).

The challenge of defining health needs

The starting point of this work is the definition of the term presented by the structured vocabulary used by the Latin American and Caribbean Center on Health Sciences Information (BIREME), the Health Sciences Descriptor (DeCS). In the DeCS, the term “health needs” is described as the systematic identification of the needs of a population or the assessment of individuals to determine the most suitable level of service needs.

Hino et al. (Hino et al., 2009HINO, P. et al. Necessidades em saúde e atenção básica: validação de instrumentos de captação. Revista da Escola de Enfermagem da USP, São Paulo, v. 43, n. SPE2, p. 1156-1167, 2009. DOI: 10.1590/S0080-62342009000600003
https://doi.org/10.1590/S0080-6234200900... ) begin their discussion with Heller’s definition of what a Marxist concept of need would be:

These authors define two types of needs: those considered natural, because they concern the conservation of life and because they are bound to the demands of survival; and those which are necessary, determined by social issues, such as the act of being free and being independent to make one’s own decisions. This implies that not all needs reflect the lack of something, since they represent the social construction of human relations. Based on what a need is, the authors formulate a definition of health needs as socially and historically determined and situated between nature and culture; in other words, they do not concern only the conservation of life, but the fulfillment of a project in which the individual, a bridge between particular and generic aspects, becomes progressively humanized. Health needs are not only medical nor are they health problems (such as illnesses, suffering or risks); they also concern deficiencies or vulnerabilities which express ways of life and identities, expressed in what is necessary for good health and in what involves conditions necessary for enjoying life. (Hino et al., 2009HINO, P. et al. Necessidades em saúde e atenção básica: validação de instrumentos de captação. Revista da Escola de Enfermagem da USP, São Paulo, v. 43, n. SPE2, p. 1156-1167, 2009. DOI: 10.1590/S0080-62342009000600003
https://doi.org/10.1590/S0080-6234200900... , p. 1157)

Campos and Mishima (2005CAMPOS, C. M. S.; MISHIMA, S. M. Necessidades de saúde pela voz da sociedade civil e do Estado. Cadernos de Saúde Pública, Rio de Janeiro, v. 21, n. 4, p. 1260-1268, jul.-ago. 2005. DOI: 10.1590/S0102-311X2005000400029
https://doi.org/10.1590/S0102-311X200500... ) present the concept in a public health perspective using an approach that they call concrete-operational dimension. They propose the following definition:

For Cecílio (2001CECÍLIO, L. DE O. As necessidades de saúde como conceito estruturante na luta pela integralidade e equidade na atenção em saúde. In: PINHEIRO, R.; MATTOS, R. A. de. Os sentidos da integralidade na atenção e no cuidado à saúde. Rio de Janeiro: IMS ABRASCO, 2001. p.113-126.), “health needs” is a taxonomy organized into four groups, namely: (1) having good living conditions; (2) having access to and being able to consume technologies that improve living conditions; (3) creating bonds between users and the team of health professionals; (4) and the needs of each person so that they can have greater autonomy and control of their life.

The understanding of “health needs” requires, therefore, an expanded understanding of health, which is not limited only to biological aspects of life, but is also closely linked to factors that involve the political, economic and social context of the individual and can present a range of orders that need to be examined.

Method

We conducted a survey of articles in the database using as a tool the descriptors in Health Sciences (DeCS) of the Virtual Library in health (VHL), defining as keyword the following expressions, according to their respective languages: in English, needs assessment was used; in Spanish, evaliación de necesidades; and in Portuguese, determinação de necessidades de cuidados de saúde.

For the Portuguese descriptor, the following terms, considered as synonyms, were established: determination of health needs, assessment of health care needs, determination of education needs.

And as for the definition of health needs established by the DeCS, the following description was found: systematic identification of the needs of a population or the assessment of individuals to determine the most suitable level of service needs.

The search strategy for articles related to the health needs descriptor was applied in two electronic databases: VHL and PubMed (bibliographic database of the National Library of Medicine of the United States of America). A general search was conducted and then the articles found were analyzed in two steps. To do that, it was necessary to outline specific searches and filters for each of the databases in question, so as to ensure limitations on the free and quantitative access of articles to be analyzed in the research stages established afterwards. The use of filters allowed us to identify an approximation of the search content about the expression health needs.

After the search filters were defined and the articles were selected, three more screening steps were performed with the following analysis proposals:

The research developed at different times over the period from June 2015 to June 2017. It presented specific characteristics in each of the databases, which are described below.

VHL

The bibliographic research on VHL started in June 2015 and was completed in November of the same year. The following filters were prioritized in the search: title, abstract, subject, full texts available in Portuguese, English and Spanish. They were selected considering the high amount of articles identified in a first general search that did not match the interest of this research.

According to the diagram in Figure 1, we found 184 articles in Portuguese published in the period from 1997 to 2013. Of these, only 60 were selected for analysis, and 20 articles were effectively matched the research interest.

For the English language, we used approximations of boolean functions in the expressions “Needs assessment” and “and review”, ensuring a search for full texts related to the review of the descriptor. We found 216 articles published in the period from 2000 to 2015, of which 25 underwent further analysis. Of these, 11 were considered relevant.

For Spanish, we also used approximations of boolean functions in “evaliación de necessidades”. We found 184 articles, of which 20 were chosen for analysis, and only 9 were selected to compose the meaning analysis stage. For Spanish, the period of publications found was from 1995 to 2014.

PubMed

The search on the PubMed platform took place between March and June 2017 using only the approximation of boolean function“Needs assessment”, given the high number of articles selected in a first general search that were not considered pertinent to this research. The use of boolean functions allowed a more consistent search on the expression of interest. In addition, to prioritize the selection of articles, the searches were centralized in the following filters: case reports, review and systematic review. Only full text and free access articles were selected.

The publication period found was from 2007 to 2017, in English, Portuguese and Spanish. The result, according to the diagram in Figure 1, was 59 articles in English, of which 22 were selected for analysis. Of those, 16 composed the meaning analysis.

Inclusion/exclusion criteria

Only articles presenting the meaning of the descriptor immediately in the abstract had their inclusion confirmed. Regardless of the keyword of the article being the descriptor of this research, in cases in which the abstract did not present its definition, it was not considered pertinent. In addition, the articles should be available for full reading. For this reason, articles that did not address the meaning of the descriptor, according to the DeCS, in their abstract were excluded.

Data extraction

Based on the inclusion criterion, the selected articles had data extracted. In this study, the variables considered were title, journal, author, pages, volume, year of publication, International Standard Serial Number (ISSN), place where field research was conducted (if this information is available), objective, methodology, and results or discussion.

The data were summarized and presented in separate spreadsheets for each database and language to facilitate the understanding of the information listed.

Meaning analysis

According to the data spreadsheets built with articles selected in the initial search, a new screening process was conducted with the reading of each article to identify the conceptual meaning of the term “health needs”.

At this stage, only articles considered relevant to the process of constructing the meaning analysis were selected, prioritizing reflections on the concept of health needs. Based on that, a summary of each selected article was outlined, presenting an interpretation of the meaning applied to the expression “health needs”. Of those articles, 30 were from the VHL, 10 were in Portuguese, 9 were in Spanish and 11 were in English; while 16 were from PubMed, all in English.

Result

Meaning analysis refers to the way in which the term “health needs” is used and how it becomes a reference. To provide a better understanding of their meanings, categories were built among the articles as the needs are reflected in different areas of health.

To do that, new categories were created, characterizing the highlighted meaning or defining from what place the article portrayed the experience of the work described. It was possible to identify the following classifications: Primary Care, Secondary Care, Evaluation Instrument, Oncology, Oral Health, Mental Health and Social field, as described below:

Table 1 shows the categorization of the meaning analysis found in both VHL and PubMed databases.

The selected articles correlate the descriptor in question as one of the evaluation tools that allows identifying the various fields of life of users that require attention and demand health actions.

Issues related to health needs permeate the universes of social, existential, symptomatic - whether physical or psychological - and therapeutic spheres. The interweaving of health care involves several types of illnesses: diabetes, hypertension, mental health, cancer, oral health; and several types of users: people living with HIV/AIDS, people with special needs, the elderly, newborns.

In addition, several structural aspects surround the situations of accessibility, equity and quality of services that also dialogue with the needs of individuals. The boundaries between one need and another become blurred and turn into a whole. As evaluations are performed, this whole is arranged in a hierarchy according to the determination of the magnitude and impact of the needs.

Furthermore, health needs are present in the lives of both users and their caregivers - whether or not they are family. Throughout the relationship with the other’s illness, they also need some degree of attention and specific support, not only regarding the management of the user’s illness itself, but also in how they care for their own health.

The evaluations presented are conducted using different instruments - questionnaires, medical records analysis, computer programs - which allow pointing out the needs for improvement in both the health services and in the management of the process of self-management of care, if these are observed as requirements.

From the conclusions presented among the analyzed studies, the evaluation and identification of needs guide the formulation of new protocols and guidelines for treatment of a given illness and management with the individual, providing support for an increasingly rational alignment when conducting the therapeutic process.

We emphasize that in almost all of the articles examined, there is no major concern with formally defining the “health needs” construct, as they appear to be reduced to instrumental aspects. Although the contributions of these studies to health care in general are not contradictory to each other and may be relevant, they are always partial appropriations of a complex reality that, on account of its reductionist and uncritical character, can easily result in a strengthening of medicalizing processes, for example.

Discussion

It should be noted that the reflection on what is meant by health needs requires a broader understanding of the care processes of each individual within the context of a given illness. In this sense, it is necessary to consider, therefore, intrinsic characteristics to the individual’s way of life, whether or not related to his illness. It is therefore necessary to understand the definition of health and illness, to understand the demands of the field and to distinguish individual needs from those that are intrinsic to the collective context. These are concomitant processes. Canguilhem (1966CANGUILHEM, G. Le normal et le pathologique, augmenté de Nouvelles réflexions concernant le normal et le pathologique. Paris: Presses Universitaires de France, 1966.), for example, criticizes the idea that illness is the absence of health, and health is, therefore, the absence of illness. This tautology makes little progress toward understanding the phenomenon, and it does not consider the many factors which affect the development of an illness in an individual. Among these factors, it is possible to list some: access to health technologies, medication, health services, and understanding of the process of illness of the body itself. It is also relevant to consider the issues involving socio-economic conditions. In criticizing this view, the author proposes as an alternative the concept of normativity, which would be the individual’s ability to recreate norms based on their health conditions.

Berlinguer, in A Doença (The Disease, 1988), highlights that “health and illness are, however, distributed unevenly among individuals, classes and peoples” (Berlinguer, 1988BERLINGUER, G. A doença. São Paulo: CEBES/HUCITEC, 1988., p.11) since, depending on the individual’s place, work or social position, certain manifestations in the body can be considered as diseases or not. In some cases, it is possible to observe the denial of the disease, ignoring signs and symptoms that the body expresses.

Camargo Jr. (2018CAMARGO JR, K. R. de. On health needs: the concept labyrinth. Cadernos de Saúde Pública, [s.l.], v. 34, n. 6, p. e00113717, 2018. DOI: 10.1590/0102-311X00113717
https://doi.org/10.1590/0102-311X0011371... ), when analyzing what encompasses the expression “health needs”, points out that within biomedicine the definition of disease would consist of something that is compatible with a validated lexicon in biology, that is, something explained by using expressions such as “molecules, cells, mechanisms, causes and effects”. The author recalls that throughout the history and evolution of medicine, a structured vocabulary of diseases - organized by the International Classification of Diseases (ICD) - has been progressively articulated and revised, indicating that the production of knowledge about “diseases” has undergone constant transformation reflected by the creation and improvement of this taxonomy.

Berlinguer (1988BERLINGUER, G. A doença. São Paulo: CEBES/HUCITEC, 1988.) also suggests looking at the disease from five perspectives: disease as suffering, as diversity, as danger, as a sign and as a stimulus. Moreover, he proposes lines of action that help understand the concept of “disease”. Suffering? Reduce it with suitable treatment. Diversity? Prevent it from being viewed it as a deviation and from producing marginalization. Danger? Distinguish true risk from false risk, fight the disease, not the patient. Sign? Increase it and interpret it. Stimulus? Point it toward knowledge, toward solidarity, toward prevention, toward transformation.

In this context, it is imperative to highlight that the needs that the human body emits are not only those related to the physical body itself, but above all they are present in the therapeutic itinerary outlined by the individual. Often, the individual’s path will tell more about his body than his own appearance or the results of the tests requested. His choices as a worker, a social, emotional, spiritual and financial being outline traits capable of leading to the design of his demands.

Based on this, health needs expand and gain strength for an analysis that goes beyond biomedical aspects. Listening to the user allows shaping the real demands of his care process and allows meeting the main needs through a reconfiguration of the service and his way of relating to it.

Pine . (2005PINHEIRO, R. et al. Demanda em saúde e direito à saúde: liberdade ou necessidade? Algumas considerações sobre os nexos constituintes das práticas de integralidade. In: PINHEIRO, R.; MATTOS, R. A. de Construção social da demanda: direito à saúde, trabalho em equipe, participação e espaços públicos. Rio de Janeiro: CEPESC/UERJ: ABRASCO, 2005. p. 11-31. ) propose a distinction between “demand” and “need”, suggesting that the demand is constituted by voicing one’s needs through a collectivity in the spaces involving decisions in health, thereby ensuring social participation. The authors also agree with Cecílio (2001CECÍLIO, L. DE O. As necessidades de saúde como conceito estruturante na luta pela integralidade e equidade na atenção em saúde. In: PINHEIRO, R.; MATTOS, R. A. de. Os sentidos da integralidade na atenção e no cuidado à saúde. Rio de Janeiro: IMS ABRASCO, 2001. p.113-126.) regarding the importance of formulating the concept of “health needs” that can be appropriate and implemented by workers in the field, understanding that this would contribute to a more humanized and qualified practice of health care.

Camargo Jr. (2007CAMARGO JR, K. R. de. As armadilhas da “concepção positiva de saúde”. PHYSIS: Revista de saúde coletiva, Rio de Janeiro, v. 17, n. 1, p. 63-76, abr. 2007. DOI: 10.1590/S0103-73312007000100005
https://doi.org/10.1590/S0103-7331200700... ) questions important points that can help direct the actions and services. The author warns of the risk of adopting a “positive definition” (quotation marks from the source text) as guidance, as this may lead to a generalization of the idea of health care that goes further toward extreme medicalization of the population and affects the design of public policies, since regarding “everything” as health, understanding that a number of factors that have an impact on the search for a healthy lifestyle, one may incur the risk of diverting resources that would be used in health care to meet the demands of what would have been the responsibility of another department, or even to invest in popular therapies which, though culturally significant, have no proven effectiveness from a technical-scientific point of view.

This has a direct impact on the definition of needs and how they are managed. Camargo Jr. (2018CAMARGO JR, K. R. de. On health needs: the concept labyrinth. Cadernos de Saúde Pública, [s.l.], v. 34, n. 6, p. e00113717, 2018. DOI: 10.1590/0102-311X00113717
https://doi.org/10.1590/0102-311X0011371... ) stresses the need to recognize that there is a framework of health professionals with different types of expertise to contribute to this distinction, and that only by collaborating and sharing these notions can the debate move toward paths that aim to better meet the demands of the population.

Conclusion

The descriptor “health needs”, although widely used in research in several areas of health, is in essence a little explored object in a perspective involving a self-reflection. The expression is referenced as a keyword in academic papers, but the literature review points out that its definition is not uniform across discussions. Another crucial point observed was the lack of a clear conceptual presentation that allows us to characterize the relationship between the object of study and the applied descriptor in question.

In light of that, we can notice the different facets that health needs present in health practices. From primary care to the social field, this literature review exposes the wide range in which the descriptor is included, reflecting a debate that deserves to achieve a conceptual thinking encompassed in its relevance, both theoretical and in the way of acting in all the aforementioned contexts.

The reflections raised in the literature review conducted in this study suggest that, given the lack of a strictu senso concept and the complexity of the factors that involve the descriptor “health needs”, the term is used in a diffuse manner, with an incipient reflection that is often convenient to the context used.

Acknowledgements

The authors thank FAPERJ, CNPq and UERJ for funding the project of which this article is a result.

References

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