• An ageing population has implications for community-based health promotion and disease prevention. There is concern about older people who do not fit into existing programmes and services yet need minimal support to maintain independence.
• A study was designed to develop approaches to gain access to this hard to reach population, assess needs and design and test interventions to integrate them into the community.
• The study, informed by theories of health promotion and social support, used action research methods. Participant observation documented in field notes, together with case notes and clinical assessments, provided a rich source of qualitative and quantitative data.
• This article discusses the needs assessment. Over a 3-year period, public health nurses linked with community groups in a predominantly francophone, urban community to identify the target group.
• Key characteristics of the target group included limitations with instrumental activities of daily living and low levels of social support combined with stressful life situations that challenged adaptation.
• Three patterns of inadequate support were identified.