The Health Trainers Initiative: Learning from the USA

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The Health Trainers Initiative Learning from
the USA

• Shelina Visram
• Postgraduate Research Associate,
• Health Improvement Research Programme

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

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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.

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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).

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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.

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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.

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

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Week 1 Atlanta, Georgia
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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.

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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.

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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

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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.

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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.

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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.

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Visit to University of Alabama
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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.

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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.

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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.

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Implementation Framework
Community Health Advisors
REACH Coalition
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
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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.

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Accomplishments and Outcomes

• Identified and surveyed gt3,000 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.

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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.

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Week 2 Chapel Hill, North Carolina
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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, womens and childrens health, and
  nutrition and physical health.
• Interventions target four levels personal,
  interpersonal, institutional and cultural.

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Workshop on Evaluation
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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.

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Evaluation Planning Logic Models
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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.

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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.

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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.

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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.

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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
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NC-BCSP Intervention Effect (2)
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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

• 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.

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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.

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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.

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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.

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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. [phone]
• Email shelina.visram_at_unn.ac.uk

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Any Questions?