Transcript Public Health Research in England: Evaluating NHS Health

The Health Trainers Initiative:
Learning from the USA
Shelina Visram
Postgraduate Research Associate,
Health Improvement Research Programme
Health Improvement Research Programme
Part of the Community Health and Education Studies (CHESs) Research Centre at Coach Lane Campus
Activities
Research; teaching and learning
(under-/post-graduate curriculum
development and delivery,
supervision); networking;
consultancy
Well Being
- Contextualisation;
- Understanding;
- Needs analysis (of communities
and professionals)
Knowledge
Transfer
Methodologies
Systematic reviews; appreciative
inquiry; service evaluation; health
impact assessment; soft systems
methodology; participatory research;
social marketing
Interventions for Health
and Well Being
- Professional roles (e.g. peer
educators, health trainers,
leadership issues)
- Processes (e.g. care pathway
implementation)
Background

Health Trainers are the personalised strand of the 2004
Choosing Health white paper, which states that they will:
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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
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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
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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.
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Tend to be used as a “bridge” between the
formal health care system and typically
marginalised or disadvantaged populations.
Key Findings from the Evidence
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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
Generic
Community
Individual
Targeted
Targeted
South Tyneside
Sedgefield
North Tyneside
Newcastle
Langbaurgh
Gateshead
Northumberland
Generic
Community
Individual
Easington
Sunderland
Key Examples from the Literature
1.
Project REACH, led by Dr Pattie Tucker
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2.
Racial and Ethnic Action for Community Health
Coordinated by the Centers for Disease Control and
Prevention (CDC) in Atlanta, Georgia.
NC-BSP, led by Professor Jo Anne Earp
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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)
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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
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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 culturallybased community activities to eliminate racial
and ethnic disparities in health.
REACH Target Areas
Health priority areas
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Breast and cervical cancer
Cardiovascular disease
Diabetes mellitus
Adult / older adult
immunisation
Hepatitis B
Tuberculosis
Asthma
Infant mortality
Racial and ethnic groups
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African American
American Indian / Alaskan
Native
Asian American
Native Hawaiian / other
Pacific Islander
Hispanic / Latino
Evaluating Project REACH
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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
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The BRFSS assesses improvements in healthrelated behaviours in 27 REACH communities.
Survey results from 2001-04 include:
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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
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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
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The Alabama Breast and Cervical Cancer Control
Coalition consists of 18 local, state, university, faithbased 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
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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)
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Coalition members decided the CAP should have the
following components:
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3.
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Address the barriers to screening identified during the needs
assessment with local communities.
Include activities directed at targeted women, the community
system and health care providers.
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
REACH Coalition
Community Health Advisors
Mini-grants
Individual level – intervention
Individual level
Community level – health fairs,
church activities
Community level
Agents of change – community
leaders
Agents of change
Technical support, training, facilitation
Investigators
Role of the CHAs
1.
2.
3.
4.
Conduct baseline surveys with women in local
communities.
Contact women before and after their
scheduled mammogram and Pap smear
appointment.
Conduct follow-up assessment with an
assigned group of women.
Disseminate cancer awareness messages in
the community.
Accomplishments and Outcomes
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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
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Appreciate and respect individual differences and
commonalities.
Maintain open lines of communication; address
unspoken and uncomfortable issues.
Be flexible and open to change; foster an environment
of mutual learning and sharing skills, resources and
experiences.
Keep commitments and follow through with plans.
Address problems in a calm, non-judgemental fashion.
Week 2: Chapel Hill, North Carolina
Promoting and Cultivating Health
Disparities Research Conference
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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
Monitoring
(outputs, service
statistics, etc.)
Definitions
Units of service or product
Quality of effort and client
satisfaction
Outcomes
Measurable and achievable
(goals, objectives, change, improvement or
enhancement
results, etc.)
Policy indicators Large-scale change or impact
/ systems change
Recommendations for Evaluation
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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 Models
Goals and
Objectives
What do you
want to do?
What
purpose
does the
programme
serve?
What is it
trying to
achieve?
Activities
(inputs)
Activities to
implement
to achieve
the states
goals and
objectives
Performance
measures
(outputs)
Monitoring
evidence
Outcome
evidence
Expected
outcomes or
results for
each activity
Evidence of
activities
and quality
Evidence of
results
Data
Data
collected to
Often reflects collected to demonstrate
change, e.g. demonstrate the specified
increase x or the activities outcomes
decrease y
have been
have
achieved
occurred
Ongoing Projects at UNC
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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
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Goal: to reduce breast cancer mortality among
rural African American women in eastern North
Carolina by:
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Increasing use of mammography; and
Increasing early detection and treatment of cancer.
The intervention involves:
Outreach – primarily through trained lay advisors;
(ii) Inreach – provider education and training;
(iii) Access – mobile mammography vans, cost
reduction, transport assistance.
(i)
NC-BCSP (2)
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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
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Aim: to assess the effectiveness of the intervention.
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Design: quasi-experimental community trial.
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Did it increase mammography use?
Did it reduce racial disparities in health?
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*
90
*Had a mammography in
the last two years.
80
70
60
Overall increase:
76.3
Intervention +23.3%
67.9
Second follow-up
40
Baseline
%
50
30
20
Comparison +17.4%
58.9
44.6
Difference of differences
10
+5.9 %
0
Intervention
Comparison
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.
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Challenges
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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
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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.
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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.
A scoping exercise of the implementation of the Health
Trainers initiative on a national scale.
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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.
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4.
Funded by the Research for Patient Benefit programme.
In collaboration with local Health Trainer Hub leads.
A PhD proposal to investigate the processes of
engagement and behaviour change amongst clients of
Health Trainers.
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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:
Tel.:
Email:
H011, CHESs Research Centre,
Northumbria University,
Coach Lane Campus East,
Newcastle-upon-Tyne,
NE7 7XA.
(0191) 215 6682
[email protected]
Any Questions?