Empowerment or control? An analysis of the extent to which client participation is enabled during health visitor/client interactions using a structured health needs assessment tool.

The demand for explicitness in the way health visitors target their services has given rise to a plethora of different health needs assessment tools (HNATs). This paper describes an in-depth conversational analysis of the use in practice of these structured health needs assessment tools (HNATs) in two different NHS Community Trusts in England. These HNATs aimed to enable clients to participate in the assessment of their own health needs, as well as fulfilling the political requirements of justifying the expenditure of health visitor time where needs are identified. However, conversational analysis of 10 interactions showed that use of the instruments was associated with a failure to either identify needs that are relevant to the client or to enable clients to participate in the process. Use of the structured instrument simultaneously emphasises the significance of a professional lead, instead of client participation, and minimises the importance of inter-personal relationships and communication. In one site, a directly controlling style was apparent in the practice of health visitors who were, themselves, explicitly controlled by their managers. In the other site, professional expertise was emphasised, and a covert assessment style acted to disempower clients. The controlling nature of the interactions, the number of missed cues and the possibility of distress caused by the insensitivity of questioning style are all potentially harmful side effects of using structured instruments to assess needs. The problems seem to stem from the use of a pre-determined list of questions that form the basis for assuming that any family's health promotion needs can be categorised and predicted in advance. In conclusion, therefore, it is recommended that health visitors should use the open, conversational style of needs assessment that has been shown to be effective and acceptable, rather than an approach based on a structured instrument.