The Health Trainers Initiative:

Learning from the USA

Shelina VisramPostgraduate Research Associate,

Health Improvement Research Programme

Health Improvement Research Programme

Well Being - Contextualisation;

- Understanding;- Needs analysis (of communities and

professionals)

Interventions for Health and Well Being- Professional roles (e.g. peer educators, health trainers,

leadership issues) - Processes (e.g. care

pathway implementation)

Part of the Community Health and Education Studies (CHESs) Research Centre at Coach Lane Campus

Knowledge Transfer

ActivitiesResearch; teaching and learning (under-/post-graduate curriculum

development and delivery, supervision); networking;

consultancy

MethodologiesSystematic reviews; appreciative

inquiry; service evaluation; health impact assessment; soft

systems methodology; participatory research; social

marketing

Background

Health Trainers are the personalised strand of the 2004 Choosing Health white paper, which states that they will: Offer tailored advice, motivation and practical support to individuals

who want help to adopt healthier lifestyles; Act as message-bearers between professionals and communities; Be recruited from, and representative of, their local communities; Work in local organisations, including the private, public and

voluntary sectors; Be funded in the 88 Spearhead PCTs from April 2006 and

throughout the country from 2007. More than 1,200 Health Trainers have now been trained,

including around 50 in the prison population.

Implementation of the Initiative

Twelve early adopter partnerships were identified in 2005 to test the recruitment, training and employment package, and local models of service provision for Health Trainers.

Three of these partnerships were located in the North East of England: Gateshead Health Economy Northumberland, Tyne & Wear Public Health Network County Durham & Tees Valley Public Health Network.

Previous HIRP Projects

A review of the evidence to support the implementation of Health Trainers (August 2005).

Evaluation of the early adopter phase of the Health Trainers project in the North East (April 2006).

Hosting a national Health Trainers evaluation meeting, in collaboration with Leeds Met University (May 2006).

Further evaluation of the initiative in County Durham & Tees Valley / a phenomenological study of what it means to be a Health Trainer (September 2007).

What was the evidence to support Health Trainers? Most published examples come from North

America and fall loosely into three categories: Lay health workers: unpaid “natural helpers” who are

trained to offer a community-based system of care. Peer educators: often used to deliver health education to

adolescents and young people. Advocates: mediate between clients and professionals to

ensure they are offered an informed choice of health care. Tend to be used as a “bridge” between the

formal health care system and typically marginalised or disadvantaged populations.

Key Findings from the Evidence

Programmes tend to have a particular disease or population focus, e.g. cancer prevention, cardiovascular health, diabetes, sex education.

Advantages: potentially reduce costs, provide cultural linkages with communities, increase communication and sensitivity.

Challenges: can be labour intensive, difficulty in recruiting from target communities, concerns about quality, high staff turnover.

Targeted Individual Approach

Work on a one-to-one basis with individuals from a particular target population or with a specific health issue, e.g. smokers, ethnic minority groups or those with diabetes

Targeted Community Approach

Provide advice and support to groups with specific health issues and concerns, e.g. adolescents, young mothers or coronary heart disease patients

Generic Individual Approach

Attempt to promote general health behaviour change on a one-to-one basis with individuals from a wide range of backgrounds

Generic Community Approach

Attempt to improve the overall health and wellbeing of a local population by using techniques grounded in community development and empowerment

Targeted

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Key Examples from the Literature

1. Project REACH, led by Dr Pattie Tucker Racial and Ethnic Action for Community Health Coordinated by the Centers for Disease Control and

Prevention (CDC) in Atlanta, Georgia.

2. NC-BSP, led by Professor Jo Anne Earp The North Carolina Breast Cancer Screening

Programme Coordinated by researchers at the University of

North Carolina (UNC) at Chapel Hill.

Week 1: Atlanta, Georgia

Centers for Disease Control and Prevention (CDC) One of the major operating components of the

US Department of Health and Human Services. CDC consists of: the Office of the Director, the

National Institute for Occupational Safety & Health, and six coordinating centres.

The Coordinating Center for Health Promotion incorporates the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), which coordinates Project REACH.

Project REACH www.cdc.gov/reach

Created in 2001 to address widespread health disparities among members of racial and ethnic minority populations.

Members of these groups are more likely than whites to have poor health and die prematurely.

CDC funded 40 projects to deliver practice and evidence-based programmes and culturally-based community activities to eliminate racial and ethnic disparities in health.

REACH Target Areas

Racial and ethnic groups

African American American Indian / Alaskan

Native Asian American Native Hawaiian / other

Pacific Islander Hispanic / Latino

Health priority areas

Breast and cervical cancer Cardiovascular disease Diabetes mellitus Adult / older adult

immunisation Hepatitis B Tuberculosis Asthma Infant mortality

Evaluating Project REACH

CDC helps communities to develop, implement and sustain effective interventions.

It also supports them to evaluate programmes and disseminate strategies that work.

Evidence from such evaluation demonstrates that health disparities can be reduced and the health status of groups traditionally most affected by these disparities can be improved.

REACH Risk Factor Survey

The BRFSS assesses improvements in health-related behaviours in 27 REACH communities.

Survey results from 2001-04 include: cholesterol screening amongst African Americans

to above the national average. Narrowing gap in cholesterol screening rates between

Hispanics and the national average. use of medication for high blood pressure amongst

Native American Indians. cigarette smoking amongst Asian American men.

The Use of Lay Workers

20 REACH programmes involve the use of some form of lay health workers or patient navigators.

These workers are community members trained to deliver outreach or educational activities at local venues, or to act as patient advocates.

Programmes often utilise the ‘natural helper’ model, drawing on resources that already exist within local communities.

Visit to University of Alabama

Alabama REACH

The Alabama Breast and Cervical Cancer Control Coalition consists of 18 local, state, university, faith-based and healthcare organisations.

Breast cancer mortality is higher among African American women than white women, despite a lower incidence rate.

African American women suffer more than twice the number of cervical cancer deaths per 100,000 population compared with white women.

Lay community advisors represent one strategy used to encourage women to access cancer screening services.

Alabama REACH Methods

This programme is based on empowerment theory and uses community-based participatory research to best meet the needs of local people.

The Alabama REACH methods involve: Coalition building Formation of a volunteer network Conducting a needs assessment Developing a population-specific cancer screening

and cancer management Community Action Plan.

Community Action Plan (CAP)

Coalition members decided the CAP should have the following components:

1. Address the barriers to screening identified during the needs assessment with local communities.

2. Include activities directed at targeted women, the community system and health care providers.

3. Activities should be conducted by community health advisors, assisted by representatives from the health care system and local churches (forming the Core Working Group).

The Core Working Group consists of 169 community health advisors, 49 clergy representatives and 23 health professionals.

Implementation Framework

Mini-grants

Individual level

Community level

Agents of change

Community Health Advisors

Individual level – intervention

Community level – health fairs, church activities

Agents of change – community leaders

REACH Coalition

Technical support, training, facilitation

Investigators

Role of the CHAs

1. Conduct baseline surveys with women in local communities.

2. Contact women before and after their scheduled mammogram and Pap smear appointment.

3. Conduct follow-up assessment with an assigned group of women.

4. Disseminate cancer awareness messages in the community.

Accomplishments and Outcomes

Identified and surveyed >3,000 women to assess their screening behaviour.

Maintained contact with 2,500 to remind them of appointments and address barriers to screening.

1,539 remain active in the study after 4.5 years. The disparity between mammography screening

has reduced from 14% in 2001 to 6% in 2006, based in part on the efforts of the REACH coalition and Community Health Advisors.

Lessons Learned

1. Appreciate and respect individual differences and commonalities.

2. Maintain open lines of communication; address unspoken and uncomfortable issues.

3. Be flexible and open to change; foster an environment of mutual learning and sharing skills, resources and experiences.

4. Keep commitments and follow through with plans.

5. Address problems in a calm, non-judgemental fashion.

Week 2: Chapel Hill, North Carolina

Promoting and Cultivating Health Disparities Research Conference Hosted by North Carolina Central University, in

conjunction with the University of North Carolina. Bringing together researchers and activists

working in the field of health disparities. Showcasing research related to HIV/AIDS,

mental health, women’s and children’s health, and nutrition and physical health.

Interventions target four levels: personal, interpersonal, institutional and cultural.

Workshop on Evaluation

Terms Definitions

Monitoring (outputs, service statistics, etc.)

Units of service or product

Quality of effort and client satisfaction

Outcomes

(goals, objectives, results, etc.)

Measurable and achievable change, improvement or enhancement

Policy indicators / systems change

Large-scale change or impact

Recommendations for Evaluation

Collaborative and community-based participatory approaches can enhance the utility of evaluation and project monitoring.

Tools used in data collection should be culturally appropriate and fit for purpose.

There should be some measure of wider impact, e.g. policy or systems change.

Assess fidelity as well as effectiveness. Logic models can be useful as evaluation plans.

Evaluation Planning: Logic ModelsGoals and Objectives

Activities (inputs)

Performance measures (outputs)

Monitoring evidence

Outcome evidence

What do you want to do?

What purpose does the programme serve?

What is it trying to achieve?

Activities to implement to achieve the states goals and objectives

Expected outcomes or results for each activity

Often reflects change, e.g. increase x or decrease y

Evidence of activities and quality

Data collected to

demonstrate the activities have occurred

Evidence of results

Data collected to demonstrate the specified outcomes have been achieved

Ongoing Projects at UNC

On Our Terms (OOT): use of Lay Health Advisors to reach out to African Americans with end-stage cancer and other terminal illnesses.

ALMA: use of promotoras to offer coping skills, knowledge and support to other Latinas, with the aim of reducing mental health stress.

Body & Soul: church-based initiative aiming to increase fruit and vegetable intake, based on the principles of Motivational Interviewing.

BEAUTY and TRIM: interventions delivered in beauty salons and barber shops, dealing with multiple early detection and screening behaviours.

NC-BCSP http://bcsp.med.unc.edu

Goal: to reduce breast cancer mortality among rural African American women in eastern North Carolina by:

Increasing use of mammography; and Increasing early detection and treatment of cancer.

The intervention involves:(i) Outreach – primarily through trained lay advisors;(ii) Inreach – provider education and training;(iii) Access – mobile mammography vans, cost

reduction, transport assistance.

NC-BCSP (2)

Lay health advisors are identified by community members as being ‘natural helpers’.

Complete 12 to 15 hours of training, informed by focus groups involving around 250 women.

Provide one-to-one support, organise events and deliver group presentations.

Raise awareness through careful branding of the programme, using t-shirts and necklaces.

NC-BCSP Evaluation

Aim: to assess the effectiveness of the intervention. Did it increase mammography use? Did it reduce racial disparities in health?

Design: quasi-experimental community trial. Baseline survey (1993-1994), first follow-up (1996-1997) and

second (1999-2000). Four cohorts: black, white, intervention, comparison. Systematic random sample – 2,296 eligible women were

approached; 1,316 completed the second follow-up. Found improvements in screening amongst all groups,

but some of the greatest benefits were for women whom other types of interventions usually fail to reach.

NC-BCSP Intervention Effect (1)

Increased Mammography Use in Black Women*

44.6

58.9

67.9

76.3

0

10

20

30

40

50

60

70

80

90

Intervention Comparison

%

Second follow-up

Baseline

*Had a mammography in the last two years.

Overall increase:

Intervention +23.3%

Comparison +17.4%

Difference of differences

+5.9 %

NC-BCSP Intervention Effect (2)

Income level

White Black Difference at baseline

Difference at 1st follow up

Overall 67% 41% 26% 16%

High 74% 56% 18% 23%

Low 54% 37% 17% 1%

NC-BCSP Conclusions

A LHA outreach strategy can have a positive impact on health disparities.

Community-based strategies are likely to be a necessary component of interventions targeting behaviour change amongst disadvantaged populations.

The next step is to institutionalise the programme within local organisations.

Challenges

Tight funding for long-term staffing costs. Undervalued role of social networks in promoting

health. Professional culture that equates “real work” with

office work and paperwork. Strong emphasis on treatment, de-emphasising

outreach and education. Low commitment to building culturally sensitive

community partnerships.

Implications for Health Trainers

Peer education is known to be a successful technique to provide information and facilitate behaviour change in a culturally competent way.

The use of lay workers can also be a sustainable model when funding for projects ends.

Multi-level interventions are likely to have the most significant impact on health disparities.

Evaluation should address fidelity and effectiveness at all levels of the intervention, as well as seeking wide stakeholder participation in order to enhance utility.

Ongoing and Future HIRP Projects

1. An evidence synthesis seeking to examine the effectiveness and cost-effectiveness of different versions of the health-related lifestyle adviser format.

Funded by the Health Technology Assessment (HTA) Programme.

18-month project, commencing 1st November 2007. In collaboration with colleagues at Newcastle University and

University College London.

2. A scoping exercise of the implementation of the Health Trainers initiative on a national scale.

Funded by the Department of Health (proposal submitted 27th September).

In collaboration with colleagues from Newcastle Uni and UCL.

Ongoing and Future Projects (2)

3. An in-depth study to explore the experiences and outcomes for clients as they progress through the Health Trainers service in the North East.

Funded by the Research for Patient Benefit programme. In collaboration with local Health Trainer Hub leads.

4. A PhD proposal to investigate the processes of engagement and behaviour change amongst clients of Health Trainers.

Funded by the Medical Research Council (MRC). Proposal to be submitted by 12th October, to commence

September 2008. In collaboration with Newcastle University, UCL and UNC.

Contact Details

Shelina Visram (Postgraduate Research Associate)Health Improvement Research Programme

Address: H011, CHESs Research Centre,Northumbria University, Coach Lane Campus East,Newcastle-upon-Tyne,NE7 7XA.

Tel.: (0191) 215 6682Email: shelina.visram@unn.ac.uk

Any Questions?