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The Health Trainers Initiative: Learning from the USA


Title: Public Health Research in England: Evaluating NHS Health Trainers Author: Tisblab1 Last modified by: Shelina Visram Created Date: 8/7/2007 7:12:26 PM – PowerPoint PPT presentation

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Title: The Health Trainers Initiative: Learning from the USA

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
  • 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
  • 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

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
  • 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
  • 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

South Tyneside
North Tyneside
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
  • Coordinated by researchers at the University of
    North Carolina (UNC) at Chapel Hill.

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.

Project 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

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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.

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
  • 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
  • Address the barriers to screening identified
    during the needs assessment with local
  • 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
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
Role of the CHAs
  1. Conduct baseline surveys with women in local
  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

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.

Lessons Learned
  1. Appreciate and respect individual differences and
  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

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
  • 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.

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 Models
Goals 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

NC-BCSP http//
  • 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
  • The intervention involves
  • Outreach primarily through trained lay
  • Inreach provider education and training
  • Access mobile mammography vans, cost reduction,
    transport assistance.

  • 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
  • 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,
  • Systematic random sample 2,296 eligible women
    were approached 1,316 completed the second
  • 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)
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
  • The next step is to institutionalise the
    programme within local organisations.

  • Tight funding for long-term staffing costs.
  • Undervalued role of social networks in promoting
  • 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
  • An evidence synthesis seeking to examine the
    effectiveness and cost-effectiveness of different
    versions of the health-related lifestyle adviser
  • Funded by the Health Technology Assessment (HTA)
  • 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.

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
  • In collaboration with local Health Trainer Hub
  • 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 6682
  • Email

Any Questions?