Lay Health Trainers in the NHS:Lay Health Trainers in the NHS:Learning from the USALearning from the USA

Shelina VisramShelina Visram

Postgraduate Research AssociatePostgraduate Research AssociateCommunity, Health and Education Studies (CHESs) Research CentreCommunity, Health and Education Studies (CHESs) Research Centre

Aims of the PresentationAims of the Presentation

1.1. To explore the challenges in recruiting, To explore the challenges in recruiting, supporting and evaluating lay health supporting and evaluating lay health trainers in a UK context.trainers in a UK context.

2.2. To highlight examples of good practice in To highlight examples of good practice in involving lay advisors in public health, involving lay advisors in public health, drawing on case studies from the USA.drawing on case studies from the USA.

BackgroundBackground

Health Trainers were the personalised strand of Health Trainers were the personalised strand of the ‘Choosing Health’the ‘Choosing Health’ white paper (DoH 2004)white paper (DoH 2004)..

It stated that Health Trainers would: It stated that Health Trainers would: Offer tailored advice, motivation and practical support Offer tailored advice, motivation and practical support

to people who want help to adopt healthier lifestyles.to people who want help to adopt healthier lifestyles. Be recruited from, and representative of, their local Be recruited from, and representative of, their local

communities.communities. Be funded in the 88 Spearhead PCTs in England from Be funded in the 88 Spearhead PCTs in England from

April 2006 and across the country from April 2007. April 2006 and across the country from April 2007. More than 1,200 Health Trainers have now been More than 1,200 Health Trainers have now been

trained, including 50+ in the prison population.trained, including 50+ in the prison population.

Previous ResearchPrevious Research

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

An evaluation of the early adopter phase of the Health An evaluation of the early adopter phase of the Health Trainers project in the North East – April 2006.Trainers project in the North East – April 2006.

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

A visit to two key sites in the USA – August 2007.A visit to two key sites in the USA – August 2007. Further evaluation of the initiative in County Durham & Further evaluation of the initiative in County Durham &

Tees Valley / a phenomenological study of what it means Tees Valley / a phenomenological study of what it means to be a Health Trainer – September 2007.to be a Health Trainer – September 2007.

Evidence ReviewEvidence Review Lay or peer support has been widely used across diverse Lay or peer support has been widely used across diverse

conditions and population groups.conditions and population groups. Most published examples come from North America and Most published examples come from North America and

fall into one of two main categories:fall into one of two main categories: Peer or lay advisersPeer or lay advisers: tend to be unpaid “natural helpers” who are : tend to be unpaid “natural helpers” who are

trained to offer a community-based system of care.trained to offer a community-based system of care. Patient advocatesPatient advocates: mediate between clients and professionals to : mediate between clients and professionals to

ensure they are offered an informed choice of care.ensure they are offered an informed choice of care.

Tend to be used as a “bridge” between the formal health Tend to be used as a “bridge” between the formal health care system and typically disadvantaged populations.care system and typically disadvantaged populations.

Successful interventions remain flexible and responsive to Successful interventions remain flexible and responsive to local needs, which are continually assessed.local needs, which are continually assessed.

Targeted Individual Targeted Individual ApproachApproach

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

Targeted Community Targeted Community ApproachApproach

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

Generic Individual ApproachGeneric Individual Approach

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

Generic Community ApproachGeneric Community Approach

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

Targeted

Generic

Individual

Community

Easington

Northumberland

Gateshead

Langbaurgh

NewcastleNorth Tyneside

South Tyneside

Sedgefield

Sunderland

Targeted

Generic

Com

munityIn

divi

dual

Findings from Local EvaluationsFindings from Local Evaluations There was felt to have been a previous gap in the There was felt to have been a previous gap in the

workforce dedicated to engaging with local communities.workforce dedicated to engaging with local communities.

““It’s about going that extra mile and making services accessible It’s about going that extra mile and making services accessible in the true sense of the word, rather than expecting everyone to in the true sense of the word, rather than expecting everyone to get to services, and understanding what will meet expected get to services, and understanding what will meet expected needs” needs” [Manager][Manager]

However, the amount of support the Health Trainers However, the amount of support the Health Trainers themselves would need had been underestimated. themselves would need had been underestimated.

““We hadn’t accounted for the amount of support and supervision We hadn’t accounted for the amount of support and supervision that would be required – lots of issues around red tape and that would be required – lots of issues around red tape and policies people need to know about if they are employed by a policies people need to know about if they are employed by a PCT” PCT” [Manager][Manager]

Findings from Local EvaluationsFindings from Local Evaluations Emphasis was placed on local knowledge and Emphasis was placed on local knowledge and

interpersonal skills, not work experience or qualificationsinterpersonal skills, not work experience or qualifications

““……people are identifying with the fact that you know the area, you live in people are identifying with the fact that you know the area, you live in the area, you know the problems of the area. You’ve dealt with the the area, you know the problems of the area. You’ve dealt with the problems, you’ve had them yourself, sort of thing.” problems, you’ve had them yourself, sort of thing.” [Health Trainer][Health Trainer]

There was a perceived lack of awareness and support There was a perceived lack of awareness and support for the role amongst other professional groupsfor the role amongst other professional groups

““I think a lot of us felt that we had apron strings wrapped around us. And I think a lot of us felt that we had apron strings wrapped around us. And it was, well, the feelings, the personal feelings from me, I would describe it was, well, the feelings, the personal feelings from me, I would describe it as, well, I felt that they above thought ‘well, she hasn’t got any it as, well, I felt that they above thought ‘well, she hasn’t got any qualifications, she’s never done this kind of work before, we can’t let her qualifications, she’s never done this kind of work before, we can’t let her out loose on people’, kind of thing, you know. ‘In case she does out loose on people’, kind of thing, you know. ‘In case she does something drastic.’” something drastic.’” [Health Trainer][Health Trainer]

NHSEmphasis on formal

qualifications and work experience

COMMUNITIESEmphasis on local knowledge

and life experience

Health Trainer

Negative forcesStereotypesLabelingLack of awarenessUncertainty

Positive forcesShared identityEmpathyDedicated timeCommunication

Positioning of the Health Trainer rolePositioning of the Health Trainer role

Conclusions (1)Conclusions (1)

A number of different Health Trainer models A number of different Health Trainer models have emerged as a result of prior experience, have emerged as a result of prior experience, areas of identified need and available resources.areas of identified need and available resources.

The degree of complexity presents a significant The degree of complexity presents a significant challenge for evaluation of the initiative.challenge for evaluation of the initiative.

There remains a lack of clarity about the roles There remains a lack of clarity about the roles and responsibilities of the NHS Health Trainer.and responsibilities of the NHS Health Trainer.

This has implications for the way the service is This has implications for the way the service is perceived by professionals and the public.perceived by professionals and the public.

Learning from the USALearning from the USA

1.1. Project REACH, led by Dr Pattie TuckerProject REACH, led by Dr Pattie Tucker RRacial and acial and EEthnic thnic AAction for ction for CCommunity ommunity HHealthealth Funded and coordinated by the Centers for Disease Funded and coordinated by the Centers for Disease

Control and Prevention (CDC) in Atlanta, Georgia.Control and Prevention (CDC) in Atlanta, Georgia.

2.2. NC-BCSP, led by Professor Jo Anne Earp NC-BCSP, led by Professor Jo Anne Earp The The NNorth orth CCarolina arolina BBreast reast CCancer ancer SScreening creening

PProgrammerogramme Coordinated by researchers at the University of Coordinated by researchers at the University of

North Carolina (UNC) at Chapel Hill.North Carolina (UNC) at Chapel Hill.

North Carolina Breast Cancer North Carolina Breast Cancer Screening ProgrammeScreening Programme

The goal was to reduce breast cancer mortality The goal was to reduce breast cancer mortality among rural African American women by among rural African American women by increasing early detection and treatment.increasing early detection and treatment.

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

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

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

The Beaded Necklace The Beaded Necklace

By a woman who rarely performs BSE

By a woman who occasionally performs BSE

By a woman who performs breast self-examination (BSE) every month

By a healthcare provider giving a clinical breast exam

On a woman’s first mammogram

This size lump may be found by getting mammograms every 1-2 years

Photo taken from the NC-BCSP website, http://bcsp.med.unc.edu/index.htm

Photos taken from the NC-BCSP website, http://bcsp.med.unc.edu/index.htm

‘‘Save Our Sisters’ T-shirtsSave Our Sisters’ T-shirts

NC-BCSP EvaluationNC-BCSP Evaluation

Aim: To assess the effectiveness of the intervention in Aim: To assess the effectiveness of the intervention in increasing mammography use and reducing disparities.increasing mammography use and reducing disparities.

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

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

approached and 1,316 completed the second follow-up.approached and 1,316 completed the second follow-up.

Found improvements in screening amongst all groups.Found improvements in screening amongst all groups. Some of the greatest benefits were for women that other Some of the greatest benefits were for women that other

types of interventions usually fail to reach.types of interventions usually fail to reach.

Intervention Effect Intervention Effect

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 %

Intervention Effect Intervention Effect

Income Income levellevel

WhiteWhite BlackBlack Difference Difference at baselineat baseline

Difference at Difference at 11stst follow up follow up

Overall Overall 67%67% 41%41% 26%26% 16%16%

HighHigh 74%74% 56%56% 18%18% 23%23%

LowLow 54%54% 37%37% 17%17% 1%1%

Conclusions (2)Conclusions (2)

An outreach strategy involving lay health advisors can An outreach strategy involving lay health advisors can have a positive impact on health disparities.have a positive impact on health disparities.

Challenges to the success of the intervention included:Challenges to the success of the intervention included: Tight funding for long-term staffing costsTight funding for long-term staffing costs Professional culture that equates “real work” with office work and Professional culture that equates “real work” with office work and

paperworkpaperwork Strong emphasis on treatment, de-emphasising outreach and Strong emphasis on treatment, de-emphasising outreach and

educationeducation Low commitment to building culturally sensitive community Low commitment to building culturally sensitive community

partnerships.partnerships.

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

Implications for Health TrainersImplications for Health Trainers

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

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

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

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