The Health Trainers Initiative: Learning from the USA

1. The Health Trainers Initiative: Learning from the USA Shelina Visram Postgraduate Research Associate, Health Improvement Research Programme

2. Activities Research; teaching and learning (under-/post-graduate curriculum development and delivery, supervision); networking; consultancy • Interventions for Health and Well Being • Professional roles (e.g. peer educators, health trainers, leadership issues) • Processes (e.g. care pathway implementation) • 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 Health Improvement Research Programme Part of the Community Health and Education Studies (CHESs) Research Centre at Coach Lane Campus

3. 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.

4. 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.

5. 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).

6. 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.

7. 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.

8. Targeted Community Individual Generic

9. Targeted Sunderland Easington South Tyneside Sedgefield NorthTyneside Newcastle Community Individual Langbaurgh Gateshead Northumberland Generic

10. Key Examples from the Literature • 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. • 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.

11. Week 1: Atlanta, Georgia

14. 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.

15. 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.

16. 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 REACH Target Areas

18. 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.

19. 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.

20. 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.

21. Visit to University of Alabama

22. 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.

23. 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.

24. Community Action Plan (CAP) • Coalition members decided the CAP should have the following components: • 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.

25. Implementation Framework REACH Coalition Community Health Advisors Individual level – intervention Community level – health fairs, church activities Agents of change – community leaders Mini-grants Individual level Community level Agents of change Technical support, training, facilitation Investigators

26. Role of the CHAs • 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.

27. 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.

28. Lessons Learned • 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.

29. Week 2: Chapel Hill, North Carolina

30. 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.

31. Workshop on Evaluation

32. 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.

33. Evaluation Planning: Logic Models

34. 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.

35. 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: • Outreach – primarily through trained lay advisors; • Inreach – provider education and training; • Access – mobile mammography vans, cost reduction, transport assistance.

36. 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.

37. 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.

38. NC-BCSP Intervention Effect (1) *Had a mammography in the last two years. Overall increase: Intervention +23.3% Comparison +17.4% Difference of differences +5.9 %

39. NC-BCSP Intervention Effect (2)

40. 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.

41. 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.

42. 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.

43. Ongoing and Future HIRP Projects • 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. • 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.

44. Ongoing and Future Projects (2) • 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. • 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.

45. 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 6682 Email: shelina.visram@unn.ac.uk

46. Any Questions?