Rapid assessment: an international review of diffusion, practice and outcomes in the substance use field
Introduction
During the past two decades, rapid assessments (RA)—including rapid rural appraisals, situational analyses, needs assessments, and contextual assessments—have been used to quickly gather cultural, social, and institutional information in order to develop policies and programmes (Beebe, 2001; Chambers, 1980; Larson & Manderson, 1997). Endorsed by national, international, and United Nation agencies (e.g. Médecins Sans Frontières, 1998; UNICEF, 2002; US DHHS, 1999), the approach has been re-orientated from its origins in agricultural studies and primary care to address and respond to health problems including nutrition (Scrimshaw & Hurtado, 1987), water hygiene (Almedon, Blumenthal, & Manderson, 1997), reproductive health (Manderson, 1996), and most recently, substance use and HIV/AIDS (e.g. International HIV/AIDS Alliance, 2000; Stimson, Fitch, & Rhodes, 1998a; UNDCP, 1998).
Drawing on qualitative and quantitative techniques, RAs are typically undertaken in situations where data are needed quickly, where resource constraints rule out conventional research approaches (such as large-scale surveys, or in-depth qualitative studies), and where agencies require information to develop, monitor, or evaluate intervention programmes. Given the rapidity with which public health problems can emerge (as seen with natural disasters) and spread (as witnessed in ‘explosive’ HIV transmission among drug injectors), and the propensity for problems to occur in ‘time and resource poor’ settings, RA approaches have been welcomed by commentators as a logical development (Rhoades, 1992).
However, despite endorsement, discussion about the scientific and public health merit of RA has not been precluded. Whilst advocates continue to undertake RAs across a range of global settings, concerned observers have noted that there has been no demonstrable evidence that RA can achieve rapidity of response (McKeganey, 2000), produce data of a quality which meaningfully informs interventions (McKeganey, 2000), be cost-effective (Harris, Jerome, & Fawcett, 1997), or lead to outcomes which will not inadvertently harm already marginalized non-elite communities (Friedman, 2000). As Friedman summarises, “[t]o put it bluntly, we probably do not know if ‘rapid assessment’…is a good thing…in spite of my basic respect for some of the underlying theory” (Friedman, 2000).
Numerous responses have been made to such ‘challenges’ for evidence. Some have retorted that critics are overly concerned with measurable indicators, arguing that RA's strength lies in its process of mobilising often-disparate actors and including them in the assessment process (Greig & Kershnar, 2000). Others have observed that such challenges are unfair, noting that evaluation criteria have not been applied to other research or intervention methods (such as applied epidemiological assessments). Some commentators, meanwhile, have remarked that evaluation is usually the last thing on RA practitioners’ minds, with the generation of knowledge for action taking priority over preparing journal articles.
This paper makes an initial contribution of empirical data to this discussion, both to encourage others to begin constructing a RA ‘evidence base’, and also to describe developments within the substance field in the application, diffusion, and outcomes of RA. Drawing on findings from an international review conducted for the World Health Organization (WHO) on the use of RA in the substance use field, the paper considers three key issues: (1) understanding—how is RA conceptualised among those working in the field?. (2) application—what different models of RA practice are used, and to what extent? and (3) outcomes—in terms of intervention and change, what outcomes can be attributed to RA studies? Whilst the majority of data presented are specific to the substance use field, the paper also considers the wider consequences and implications for RA practitioners working on other health issues.
Section snippets
Methodology
The study was contracted by WHO to map the emergence of RA in the substance use field, to describe different models of practice, and to identify linked outcomes. The study was conducted January–July 2001 using three research methods. (1) A literature review of published documentation (undertaken in bibliographic databases including Medline, World of Science, BIDS, and IDS), and a review of unpublished literature through requests to study participants, focal points, and libraries. (2) A brief
Results: understanding and conceptions
The aim of ‘rapid assessment’ is simple—to combine the “speeding up of social science research” with “the explicit linking of assessment to action” (Rhodes, Stimson, Fitch, Ball, & Renton, 1999). However, whilst most conceptions of RA incorporate these ambitions, they often also supplement ‘rapidity’ and ‘intervention’ with a raft of additional aims and principles. Consequently, those asking ‘what is RA?’ are confronted with a range of methodological options, rather than a definitive answer.
Application and models
Some commentators note that we are experiencing an ‘epidemic’ of RA (Manderson & Aaby, 1992). Although the study did not highlight wholly epidemic progression, RAs were reported across a range of global settings, and in a variety of designs. In this section, we firstly present data on the diffusion of RA approaches in the substance use field; secondly, we consider issues of ‘rapidity’; before thirdly, outlining basic RA typologies and ‘models’.
Interventions and outcomes
RA approaches have the potential to not only generate public health information, but to also develop interventions and bring about change. However, although the intention underpinning RA is clear, what is less apparent is whether such potential is realised in practice, and if so, what intervention types are being developed? In this section, we describe reported intervention outcomes from the 83 identified RA studies, before considering the relationship between RA and intervention development,
Conclusion
This paper has made the case that RA methods have the potential to generate important public health information that can be used to develop intervention programmes. In support of this, it is clear that at least 83 RA studies have been conducted between 1993 and 2001, with the approach being used in at least 70 countries. Amongst these studies, one in four were reported as being associated with medical or non-medical interventions, or policy change initiatives (a figure which rises to one in two
Acknowledgements
This paper is based on data and experience obtained during the WHO Drug Injection Study Phase II—a project coordinated and sponsored by WHO, and implemented by the WHO Phase II Drug Injection Collaborative Study Group. Further study details and resources can be found at www.RARarchives.org.
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Also at College Research Unit, The Royal College of Psychiatrists, 83 Victoria Street, London, UK.