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Correspondence: Address correspondence to Jiska Cohen-Mansfield, PhD, Research Institute on Aging of the CES Life Communities, 6121 Montrose Road, Rockville, MD 20852. E-mail: cohen-mansfield{at}
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Abstract |
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Key Words: Aging in place • Community services • NORC • Screening • Unmet needs
Unmet Needs of Older Persons in the Community
Unmet needs of community-dwelling older persons span many domains and include medical needs, psychological needs, social needs, functional needs, mobility or transportation needs, home-maintenance needs, and needs related to nutrition and exercise. These needs often result from aging-related physical changes and the associated impact on social and mental health.
Needs Arising From Health and Functional Limitations
A generalized decrease in strength, often a normal aging phenomenon, could mean decreased ability to maintain a home (Quinn & Whitman, 1989). Young (1993) reported that the most common restrictions on function for community-dwelling older persons were moving heavy objects, washing windows, and cleaning the house. Medical problems and frailty may also make activities of daily living (ADLs) and instrumental activities of daily living (IADLs) more difficult to accomplish. Wexberg (1996) reported that, in New Jersey, more than 21% of the older respondents to a survey acknowledged difficulty in performing some ADLs. Older adults have a greater burden of chronic disease and consume more drug products than any other segment of the population, which sometimes results in a need for help in obtaining or taking medications (Murray & Callahan, 2003). Other health-related needs include health screening for early detection of certain diseases, health literacy, especially concerning medication, and stress management (Matteson, 1997).
Nutritional and Exercise Needs
Weight-related concerns are another area for which services may be required. According to a study in Taiwan, 48.4% of the older community-dwelling participants who lived alone were overweight, and 65.9% reported that they did not exercise (Huang & Lin, 2002). On the other end of the spectrum, older persons may experience a decline in food intake and in the motivation to eat, which could lead to being underweight (Donini, Savina, & Cannella, 2003). Brubacher, Monsch, and Stahelin (2004) found that 26% of a sample of 531 healthy community-dwelling adults older than 60 years of age had lost a significant amount of weight during a 10-year study, and this percentage increased to 42% when they looked only at participants over the age of 75. Being underweight, and therefore possibly malnourished, can lead to sarcopenia and impaired muscle function, decreased bone mass, immune dysfunction, anemia, reduced cognitive function, altered drug metabolism, and delayed recovery from surgery or rehabilitation (Donini et al.).
Mental Health Services
In 2004, almost 20% of the U.S. population older than 75 years of age experienced symptoms of depression, including sadness, hopelessness, or worthlessness (Beedon, 2006). Mobility limitations, as well as losses in social networks that occur in old age as a result of retirement or death of spouse or friends, often lead to loneliness, which has been associated with poor health, increased utilization of services, and negative psychological effects, including depression (Bazargan & Barbre, 1992; Cheng, 1992; Cohen-Mansfield & Parpura-Gill, 2006; Creecy, Berg, & Wright, 1985; Prince, Harwood, Blizard, Thomas, & Mann, 1997; Sorkin, Rook, & Lu, 2002). Despite such a high prevalence of depression in the older population, the literature has shown a low rate of utilization of mental health professionals (Waxman, Carner, & Klein, 1984).
Cognitive Impairment
Helmer and colleagues (2006) found dementia to be present in 17.8% of a large sample of older adults, but only 39% of those persons with dementia were in an institution. Such a high prevalence of persons with dementia remaining in the community can represent another source of needs, the most common of which include those associated with behavioral or mental state, social interaction, thinking and memory, and hygiene (i.e., dental care, bathing, and toileting; see Meany, Croke, & Kirby, 2005).
Transportation
Probably one of the most important factors in keeping older adults in the community is adequate transportation. Cvitkovich and Wister (2001) cited transportation systems as being crucial to older adults for minimizing social isolation, maintaining connections with the community, increasing access to health promotion and social programs, and improving access to medical services. Adequate transportation becomes more difficult to obtain as aging progresses. An AARP report showed that, in Utah, 28% of adults older than 85 years of age had a physical problem that prevented them from driving, and 21% had a physical problem that prevented them from riding public transportation. However, only 8% or less of the same population reported a physical problem that prevented them from taking a taxi, taking a community van, or using transportation for those with disabilities (Stowell-Ritter, 2006). Therefore, when older adults become less able to drive themselves or to use public transportation, alternative forms of transportation have to be available.
Service Utilization of Older Persons in the Community
Despite all of the general knowledge on the needs of community-dwelling older adults, some research has shown that only 20% of this population was reported to participate in senior center activities (Calsyn & Winter, 1999). Moreover, less than two thirds of older adults with disabilities received any help at all with basic ADLs or household chores (Kassner, 2006). Because service utilization is low in this population, there remains a significant unmet need for these services, and researchers have been looking more closely at the possible reasons why these services are not more fully used (Calsyn & Winter; Krout, 1983; McCaslin, 1989). The Older Americans Resources and Services (OARS) methodology was developed in 1975 as a comprehensive assessment that permits the examination of functional status, service use, and the relationship between the two (George & Fillenbaum, 1985). The OARS assessment is divided into two sections, one for functional status (Multidimensional Functional Assessment Questionnaire; MFAQ) and the other for service use (Services Assessment Questionnaire; SAQ). Each question in both sections corresponds to the same five domains so that comparisons can easily be made. The SAQ contains 24 mutually exclusive types of generic services; for each generic service, information is gathered about the source and frequency of service use (or current service use), as well as the perceived service need. The SAQ is linked to the MFAQ through a transition matrix developed for the OARS methodology that separates the data into a more manageable classification system based on dichotomized values for each of the five functional dimensions. We did not find an article or study, however, that shows the relationship between service use and need and the functional assessment using the OARS methodology.
Perceived need refers to an individual's own judgment about the necessity or benefits of a particular service, and assessed need is based on a clinical or screening evaluation of an individual's level of impairment in a specific area pertinent to each service (Coulton & Frost, 1982). In one study, perceived needs for personal and medical care were clearly linked to objective impairments in related areas, although the link was weaker for mental health care (Coulton & Frost). A more recent study made a distinction between perceived service needs and unmet service needs (Calsyn & Winter, 2001). In that study, Calsyn and Winter define perceived service need as the need for services regardless of whether or not the services are currently used, whereas unmet service need represents the need for services that are not currently used. In the current study we examine the relationship between self-reported usage or potential usage of services (i.e., perceived needs) and assessed needs (i.e., needs determined based on assessments of level of function) of community-dwelling seniors. Although we did utilize some OARS items for assessed needs, it was necessary for us to develop items to capture perceived needs. Our perceived needs questionnaire items were based on our findings from focus groups of persons currently residing in naturally occurring retirement communities, known as NORCs, and from meetings with personnel from participating service agencies. Specific hypotheses are as follows.
First, persons with a specific need as determined by an objective screening test will be more likely to use services addressing the need than those without the need. Second, of persons not currently receiving services, persons with a specific need as determined from a screening test will be more likely to indicate that they would use a corresponding service than those screened as not being in need. Third, for those who already receive the service, the determination of need on the screening test will not affect interest in using the services.
In addition, we estimated the degree to which results of objective tests inform us of interest in usage of services and vice versa.
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Assessments
We developed the NORC Need Assessment Survey as a baseline survey for an ongoing project by Community Partners, an organization that helps older persons remain in their own homes by providing nursing, social work, activities, and transportation services. The baseline survey collected demographic information, screened for needs by use of objective measures, and included perceived need assessments, which were measured by querying potential use of services.
Screening: Assessed Needs Measurements
To measure the assessed needs of the participants, we administered the following screening tools in the domains of health and function, mental health, sensory functioning, and health behaviors.
Health and Function
Memory
We used three questions for memory from the Health and Retirement Study Questionnaire (The Institute for Social Research, 2000). The questions were as follows: "First, how would you rate your memory at the present time: is it excellent, very good, good, fair, poor, or don't know?," "Compared to last year, is your memory: better, the same, worse, or don't know?," and "Compared with that of other people your age, would you say your memory is better, the same, worse, or don't know?"
Health
We used three questions for health from the Philadelphia Geriatric Center Multi-Level Assessment Instrument (PGC-MAI; Lawton, Moss, Fulcomer, & Kleban, 1982; Madlyn and Leonard Abramson Center for Jewish Life, 1982). The questions were as follows: "How would you rate your overall health at the present time: excellent, good, fair, or poor?," "Do your health problems stand in the way of you doing the things you want to do (not at all, a little, or a great deal)?," and "How would you say your health compares with most people your age: better, about the same, or not as good?" The reliability for these questions was 
= 0.76 (Lawton et al.). Two of these items were originally used in the OARS assessment (Duke Center for the Study of Aging, 1978).
Functional Status
We measured functional status with a nine-question IADL scale (PGC-MAI; Madlyn and Leonard Abramson Center for Jewish Life, 1982) that covered using the telephone, getting to places out of walking distance, shopping for groceries, preparing meals, doing housework, doing handyman work, doing the laundry, taking medicine, and managing money. The IADL items are used as in the OARS assessment, that is, they ask whether the person can perform the task, thereby avoiding problems associated with gender-role or situation-limited aspects of an IADL (e.g., cooking, using public transportation; see Lawton et al., 1982). The reliability for all of the IADL questions (including the following questions in mobility and financial management) was = 0.91 (Lawton et al.).
Mobility
We measured mobility by using the mobility question from the IADL scale: "Do you get [to] places out of walking distance? (without help, with some help, or don't go at all)?" (PGC-MAI; Madlyn and Leonard Abramson Center for Jewish Life, 1982). This item is very much like the item originally used in the OARS assessment (Duke Center for the Study of Aging, 1978).
Financial Management Needs
We measured financial management needs with this IADL question: "Do you manage your own money?" We also used another question: "Thinking about your money situation, would you say you can't make ends meet, have just enough to get along, or are comfortable?" (PGC-MAI; Madlyn and Leonard Abramson Center for Jewish Life, 1982).
Mental Health
Depressed Affect
We measured depressed affect with the five-item Geriatric Depression Scale; = 0.80 (Hoyl et al., 1999).
Loneliness
We used a one-question assessment for loneliness (Mullins, Woodland, & Putnam, 1989): "How often would you say you feel lonely: never, rarely, sometimes, often, or very often?" This assessment has also been used elsewhere in the literature (Cohen-Mansfield & Parpura-Gill, 2006; Mullins & Dugan, 1990; Mullins & Tucker, 1992). In a previous study (Cohen-Mansfield & Parpura-Gill), this assessment was found to correlate significantly with the 4-item UCLA Loneliness Scale (r =.714, p <.001, n = 214) and with the UCLA 21-item scale (r =.643, p <.001, n = 161; see Russell, 1996).
Sensory Functioning
We assessed vision by means of this question: "Do you have any problems with your vision (yes or no)?"
Health Behaviors
We measured nutritional and exercise needs by using the body mass index (Department of Health and Human Services, 2006). A person with a score below 18.5 is defined as being underweight, and this score is indicative of nutritional needs. A person with a score above 25 is considered overweight, and one with a score above 30 is considered obese.
Perceived Needs Assessments
For this study, we represent perceived needs in two ways: as reported interest in services and as current use of services. We assessed the perceived needs of the participants by asking participants to indicate if they currently use, would use, have no need to use, or do not want to use specific services. Those answering that they would use the service were considered to be interested in the service for the purpose of our analysis. We created a list of items pertaining to perceived needs that tap the following domains: health and function, mental health, sensory functioning, and health behaviors.
Health and Function
Memory
We asked participants about the use of and interest in memory-improvement training.
Health
We asked participants 14 questions about medical and nursing services (health monitoring, medical equipment, on-site medical services, emergency call services for medical concerns, home visits by physicians or nurse practitioners, an escort to medical appointments, delivery of medications, physical therapy and rehabilitation services, end of life or hospice care, home health care, assisted living, nursing home, 24-hour nonemergency assistance, and getting one's home or apartment adapted to one's changing needs or to prevent falls).
Functional Status
We asked participants about their use of and interest in 14 household and personal care services in order to assess their perceived needs for help in instrumental ADLs (needing assistance with shopping, doing other errands, doing inside housework or laundry, preparing meals, delivering meals, eating, bathing or showering and performing other personal care, dressing, performing outside chores or yard work, making telephone calls, taking medication, moving around the house, doing handyman work, and doing odd jobs).
Mobility
To assess the perceived need for mobility assistance, we asked seven questions about transportation use (curb-to-curb bus, shuttle bus, taxi, ride from friends, scheduled ride by reservation, shared cab, and hired driver).
Financial Management Needs
We asked participants whether they needed assistance with bill paying, checking, and banking.
Mental Health
Depression
To assess participants' perceived need for services to address depressed affect, we asked participants about their use of three types of counseling services: personal counseling, mental health counseling, social work, or case management; life management classes or support groups; and support group to talk about one's condition with others who have it.
Loneliness
For loneliness, we calculated the perceived need by using two separate assessments. In the first, we asked three questions about the social needs of participants: "[Are you interested in having] someone to visit you regularly? Someone to call you to chat regularly? Someone to call to check on you daily?" In the second assessment, we calculated the perceived requests for loneliness-related services on the basis of interest in participation in 13 group activities (craft, arts, exercise, safety, dance, trips and tours, games, clubs, special functions, activities with children and young people, life management classes or support groups, health education and wellness groups, and educational programs).
Sensory Functioning
Vision
We measured the perceived need for vision services with two questions (pertaining to the use of visual aids and services for the visually impaired).
Health Behaviors
Nutrition and Exercise
We measured the nutritional service needs of the participants with three personal care questions (pertaining to assistance with meal preparation, meal delivery, and assistance with eating). We assessed the exercise need levels by participant wishes to participate in exercise or in dance classes.
Analytic Approach
We performed analyses for individual services as well as for aggregate measures formed by combining the services in each domain. In order to examine the first hypothesis (that persons with a specific need determined by an objective screening test will be more likely to use services addressing the need than those without the need), we used a chi-square analysis to compare the percentage of persons scoring as having the need who reported they were using the services to the percentage of persons scoring as not having the need who were using the services. The match of need with service is sometimes very straightforward. For example, problems with the IADL of handling finances were matched with a service that offers assistance with finances. However, at other times the matching process is less clear. For example, in the case of loneliness we may match the respondent with two types of services: one is a personal contact service, such as someone who calls or visits regularly, and the other is an activity-group service, such as a craft group or an exercise group. Criteria for determining who has an assessed need are provided in column 1 of Tables 2<--CO?6--><--CO?7--> and 4.
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We analyzed the third hypothesis (that the determination of need on the screening test will not affect the level of interest in using the services for those who already receive the service) by comparing the level of interest in the service of those who screened as having the need to those not having the need; we did this by means of a chi-square analysis. Finally, we estimated the degree to which the use of objective tests informs us of interest in services and vice versa by examining the percentage of persons who scored as being in need yet did not express an interest in services and the percentage of persons who scored as not being in need yet requested the services. Please note for the analyses that there was no fixed number or n for each variable, because the number of participants who have a screened need (Table 2), the number who do not currently use specific services (Table 3)<--CO?8--><--CO?9-->, or the number of those who use a given service (Table 4)<--CO?10--> determined the n in each analysis. In addition, any missing demographics are attributed to participant preference to withhold this information.
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Results |
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Hypothesis 1: Persons With a Specific Need as Determined by an Objective Screening Test Will Be More Likely to Use Services Addressing the Need Than Those Without the Need
We obtained significant results that concur with the hypothesis (Table 2) for the following: the functional domains of IADLs [odds ratio or OR = 2.1; 
2(1) = 6.56, p <.01], mobility [OR = 2.5; 2(1) = 5.15, p <.05], finance management [OR = 19.0; 2(1) = 26.26, p <.001], the personal contact services for loneliness [OR = 3.0; 2(1) = 8.45, p <.01], and the sensory functioning domain of vision [OR = 3.9; 2(1) = 13.58, p <.001]. In other words, in each of these domains, persons who scored as more needy were already utilizing significantly more services (Table 2). The results were in the opposite direction to the hypothesis for the health behavior. Persons who were overweight were less likely to be involved in exercise than nonoverweight persons (Table 2). Results were not significant for services for depressed affect, and they were not significant for other services (activities) for loneliness.
Hypothesis 2: Of Persons not Currently Receiving Services, Persons With a Specific Need as Determined From a Screening Test Will Be More Likely to Indicate They Would Use a Corresponding Service Than Those Screened as not Being in Need
The results for this hypothesis are presented in Table 3.
For 5 out of the 11 aggregate domains of services, the results were statistically significant and consistent with the hypothesis, specifically for the domains of memory [OR = 3.2; 2(1) = 19.60, p <.001], physical health, and medical or nursing services [OR = 6.8; 2(1) = 7.77, p <.05], of IADLs and functioning services [OR = 3.0; 2(1) = 5.51, p <.05], vision [OR = 2.2; 2(1) = 4.49, p <.05], and for loneliness with the aggregate of personal contact services [OR = 3.6; 2(1) = 16.12, p <.001]. As for the other 6 service domains, there were no significant differences between those individuals with the assessed needs and those without them in terms of interest in the service. Participants with needs related to transportation, exercise, and depressed affect were slightly less likely to express interest in the corresponding services than were persons without these assessed needs, though the differences were not statistically significant. Whereas lonely persons were more interested than others in personal contact services (someone to call, visit, or check on them; OR = 3.6), they were not more interested in activity groups than were persons who did not score as lonely (OR = 0.6, ns; see Table 3).
For each of the aggregate domains of services where findings agreed with the hypothesis, results were also consistent with the hypothesis at the level of individual services in most cases. In other words, those scoring as having the need were more likely to indicate they would use the service than those scoring as not having the need (Table 3). However, the relationship was significant only for some services. For example, those scoring as having problems related to their physical health were much more likely than others to request physical therapy and rehabilitation services (OR = 3.9) and an escort to medical appointments (OR = 2.5). In contrast, these individuals were not more interested than others in on-site medical services, and the differences between them and others was not statistically significant for services such as medical equipment or delivery of medications.
Hypothesis 3: The Determination of Need on the Screening Test Will not Affect the Level of Interest in Using the Services for Those Who Already Receive the Service
Because of the low numbers of persons receiving the services in several domains, we could examine this hypothesis in only four domains. For two of these, physical health and interest in activities as it relates to loneliness, the results agree with the hypothesis: Among those individuals receiving the services, those with the need have similar rates of interest in other related services as those without the need. In contrast, persons receiving services to assist with daily functioning who reported limitations in performing IADLs were more likely to request such services as compared with those receiving services and not reporting such limitations [OR = 2.3; 2(1) = 4.40, p <.05; see Table 4]. The opposite was true for mobility: More clients who did not score as having a need for services requested these, despite already receiving transportation services, than those who screened as having a need for services.
To What Extent Does the Objective Screening Test Inform Us of Interest in Services for Those Individuals not Currently Receiving Services?
As seen in the discussion of Hypothesis 2, persons who scored as needing services were often significantly more likely to request the respective services; however, for many of the services there was no significant relationship. Furthermore, most persons who were screened as in need of services did not express an interest in those services (see Table 3, column 3, regarding the percentage of those with the condition who are interested in the service). For individual services where there was a significant relationship between assessed needs and requested services, between 4.2% and 62% of those individuals screened as in need were interested in receiving services (Table 3, column 3). The percentages are higher for aggregate services, ranging from 20.7% to 94.4% (Table 3). The lack of clear relationships between assessed needs and requested services is evident not only in those individuals who screen as in need but do not request the service but also in those who do not screen as in need and do request the service. For example, 71% of those who do not pass the threshold of physical health problems also want at least one type of medical service.
To What Extent Does Interest in a Service Inform Us of an Assessed Need for Those not Currently Receiving Services?
As we can see in the last column in Table 3, for the vast majority of services, less than half of those expressing interest in the service also screened as having a need for it. The lowest percentage is for shuttle bus services, for which only 5% of those who were interested in the service reported mobility difficulties. The opposite extreme was evident in consultation services for the visually impaired (not shown in the table because of small numbers), for which 83.3% of the participants who requested this service reported impaired vision.
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Discussion |
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In order to determine if the participants not currently receiving services were aware of their need for these services, we asked them to request services they may use. We then examined the relationship between assessed needs and perceived needs (estimated according to requested services). Out of the 11 types of services, the results show a significant positive relationship between the assessed need and at least 1 of the respective requested services in 5 (Table 3). Such a relationship does not exist, and may even be reversed, for health behaviors, as those who are heavy are less likely to request exercise services. Even when a significant relationship was found, it was often limited to specific services. For example, those with health problems were very interested in (were more likely than others to request) physical therapy and rehabilitation services as well as escort to medical appointments, but as likely as others to be interested in on-site medical services (in which close to half of both groups expressed interest), and, similarly to others, not particularly interested in medical equipment (in which around 10% of each group expressed an interest). Similarly, persons who were lonely were more likely than others to request personal social visits or checks, but were not more likely than others to be interested in activity groups. Interest in activity groups was, however, high in both groups, being reported by around 80% of the sample.
Despite a statistically significant relationship between assessed needs and respective requested services, the relationship between these is limited. In the vast majority of the individual services, less (and sometimes much less) than half of the persons with assessed needs report an interest in the related services. Similarly, in most of the individual services, less than half of the persons who request the service have an assessed need for it. These results have implications for planners and evaluators of services. It is important to clarify whether the goal of the program is to respond to requests for services or to alleviate assessed unmet needs.
Often, community services cannot be limited only to those with assessed needs. If the evaluation then includes all those who utilize the services, the apparent impact on the need may be diminished, because many of those who indicate they would use a service do not need it—by the criteria of common screening assessments. Conversely, the fact that the majority of participants who had an assessed need did not report an interest in the corresponding service suggests that community-dwelling older adults are often either not aware of their own needs, are unaware of the potential of the service to alleviate their need, find the service unacceptable for whatever reason, or are unwilling to address the needs. In terms of service planning, this indicates that introductory services may be required. Such services would provide education or other interventions to enhance the willingness of the individual to use the service. It would also be important to explore potential clients' preferences for types of services and modify the service to be more acceptable to the potential users. One area for which this would be particularly relevant is exercise for those with high body mass index scores.
For the hypothesis that the presence of an assessed need should not affect the level of interest in services if the participants are already receiving these services, we found conflicting results. In the domain of physical health, the hypothesis was supported: Among those persons not receiving services, an interest in some medical or nursing service was expressed by close to all of those with an assessed need, and by 71% of those without an assessed need. In contrast, among those receiving such services, the rate of those interested in such services was 83% regardless of assessed need. Although the results concerning group activity programs for lonely persons seem to support the hypothesis because the rates of interest among those already involved in such activities are similar (around 89%) regardless of degree of loneliness, an examination of the results for those not receiving services shows similar findings for that population.
Over three fourths of older adults in our sample were interested in some group activities, regardless of level of loneliness or of current participation in such activities. The results concerning IADLs did not support the hypothesis. Of the clients who were currently involved in services, the participants who showed an assessed need for IADL services were more likely to request these services than participants who did not show a need. This suggests that the IADL services currently provided were either insufficient or do not efficiently address the need. Results concerning mobility services also did not support the hypothesis and, in fact, showed the opposite relationship from that found for IADL, whereby those without the need were significantly more likely to request the service. Among those not receiving any such service, there was a similar but statistically insignificant trend. Our interpretation of this result is that although the interest in the mobility services we discussed (e.g., shuttle bus, curb-to-curb bus, or scheduled rides) was expressed by over 40% of those persons without difficulties in mobility and of those with such difficulties who were not receiving services, those who had a difficulty in mobility and were receiving assistance already had a system in place that addressed their mobility needs. Additionally, these persons may have had a degree of difficulty in mobility that precluded them from using the services described and that necessitated a higher level of service (such as being escorted from the home for transportation). This could indicate a need for more comprehensive services, or it could indicate that persons with mobility difficulties have given up on going out, or that they manage with the services currently available.
The results strongly suggest that, for some types of services, there is a strong relationship between the perceived needs of the participants and their assessed needs. Nevertheless, the concepts do not completely overlap, as substantial proportions of the sample requested the services despite the absence of an assessed need. A substantial portion also did not request a service despite showing an assessed need. This fact points out the complexity of determining need as well as the match between need and service usage. People with difficulties in doing laundry may choose not to get help because they feel they can still perform the task, albeit with difficulty, and that it is good for them to make this effort, or they may reject the intrusion of a caregiver or deny the need for service. Information from both perceived needs and assessed needs is important in understanding the actual need for services, and the similarities and discrepancies between these require more in-depth qualitative investigation.
The terminology to describe needs of persons in the community can vary. In this article we discuss perceived needs and assessed needs as methods to approximate actual needs. In the literature, there are other nomenclatures for the needs of a population. Four types of needs have been described (Bradshaw, 1977; Lawton, 1999): normative, perceived, expressed, and comparative. Normative needs relate to the gap between a person's status and a set standard or an accepted norm. Perceived needs are those felt by individuals, which, once articulated, become expressed needs. Comparative needs are those identified by comparing different groups or individuals with each other. Assessed need can be equated with normative need, as it compares function to a normative state. In this study, we did not differentiate between perceived and expressed needs, but a qualitative analysis that would compare assessed needs with expressed needs may highlight in what cases the discrepancy is accounted for by a perceived yet unexpressed need. The concept of comparative need highlights the fact that, in our results, a number of persons who are less needy according to a screening test are actually accessing certain services more than persons who actually seem to need them.
The nomenclature used for services in the interview questions may also have to be addressed. The screening questions do not always match perfectly with the services. In addition, the assessed need of depression was compared to counseling services (which were not described in the baseline questionnaire only as focused specifically on depression). This may explain some of the weak relationships in the data. Future research should clarify the discrepancies: Why do those persons not screened as in need request services, and why do some of those persons who screen as needing services not request them? Such further investigations will likely result in improvement in the methodologies of screening assessed and perceived needs. It may also clarify the range of services perceived as adequate for different subgroups, such as the possibility that persons with mobility problems who currently use some services may need a more intensive type of service than others.
We found significant relationships between perceived and assessed needs in some cases. The extent of such relationships may be slightly exaggerated because of the possibility of getting significant results by chance as a result of the large number of comparisons. Despite such a possibility, it is evident that both current use of services and interest in services were linked to the assessed needs of the participants in about half of the domains measured. In contrast, the lack of significant relationships may in some cases be attributed to insufficient power. In addition to supporting a relationship between perceived and evaluated needs, the results clarify the incomplete information provided by each type and the need to examine both perceived and evaluated needs in order to understand the needs of a community. Findings also show a high prevalence of needs among older adults and yet low service use by those with the most need for these services. The present study thus underscores the need for mental health, physical health, IADL, and memory-related services to be made more readily available to this population, targeting especially those with demonstrated need. The findings highlight the complexity of the process of ascertaining the need for services. The assessment of needs is an intricate, often imprecise process. A network of factors interacts when one is making the transition from experiencing needs, manifesting needs on screening instruments, perceiving needs, expressing them, and seeking or utilizing services to meet these needs.
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Footnotes |
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1 Research Institute on Aging of the CES Life Communities, Rockville, MD.
2 Tel-Aviv University Sackler Faculty of Medicine and Herczeg Institute on Aging, Israel.
3 George Washington University Medical Center, Washington, DC.
Decision Editor: William J. McAuley, PhD
Received for publication August 29, 2007. Accepted for publication December 6, 2007.
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