Health Trainer Programme, Bradford and Airedale primary care trust

Background

The government visualises health trainers as important in tackling health inequalities through improving access to health advice, support, and services in disadvantaged communities. Spearhead primary care trusts were targeted for early implementation of the health trainer programme, and during 2007-8 it is being extended across the country. The programme was also seen as a workforce development project as it was a way of building capacity in public health by providing opportunities for unqualified people to gain skills in public health work. This is linked to the idea of a “skills escalator” where some health trainers might go on to develop careers in health. (More than 50% of the Bradford workforce is from local black and ethnic minority groups.)

Bradford’s health trainer programme resulted from the Choosing Health white paper and is based on the concept of recruiting health trainers who are able to relate to common concerns and offer a service that is accessible to individuals from disadvantaged communities. Bradford was one of 12 early adopters of the programme nationally in 2005-6. It was developed through the Bradford health trainer partnership with membership from local statutory and voluntary sector organisations.

What is the problem you are trying to solve?

The health trainer programme aims to reduce health inequalities by supporting individuals to make healthy lifestyle choices and improving access to high quality information and services.

What local organisations are involved?

The health trainer programme was developed through a partnership board with the following partners:

• Four Bradford District PCTs (now Bradford and Airedale PCT)
• Bradford District Care Trust
• Bradford Metropolitan District Council
• Bradford Vision (Local Strategic Partnership)
• Bradford Community and Voluntary Services
• Keighley Voluntary Services
• Confederation of Ethnic Minority Organisation
• Leeds Metropolitan University

The health trainer programme is a partnership at the point of delivery and has worked with over 77 different host organisations, including:

• GP practices and primary care teams
• Secondary schools and extended schools programme
• Workforce programme with Bradford Council
• Mental health resource centres
• Social services
• Healthy living centres
• Community centres
• Libraries
• Sports and leisure centres—council and private providers
• Drug services
• Sure Starts, children’s centres, and family centres
• A range of organisations working with people with learning disabilities, enduring mental illness, drug problems, homelessness, asylum seekers, vulnerable older people, the housebound, and black and minority ethnic communities.

How many people are running this project and who are they?

Health trainer programme coordinator, health trainer support worker, three senior health trainers, and 16 sessional health trainers.

What local population are you targeting?

People aged over 16 from disadvantaged communities and groups who often feel excluded from mainstream services.

How many people are you targeting?

No specific number of people being targeted but the health trainer programme has seen about 1100 clients to date.

Interventions

What interventions are you using to address the problem?

The health trainer programme is client centred in its approach with the health trainer working to support the health needs identified by the client. Clients usually want to deal with weight management, healthy eating, physical activity, smoking, and mental health and wellbeing, which closely reflect the priorities for local organisations seeking to improve health and wellbeing.

The role of the health trainer is to support, encourage, and motivate people to make and maintain health and lifestyle changes using a one to one “coaching” approach, and they see clients for up to an hour each session with an average of four sessions per client, but this varies according to the needs of the client.

Part of the role of the health trainer is to keep up to date with what is available locally and they signpost clients to new places and groups, accompanying them if they lack the confidence to attend by themselves. The most commonly signposted services are: Bradford Encouraging Exercise on Prescription, smoking cessation services, community groups, walking to health groups, and Healthwise.

Health trainers can also help people find out more about health issues.

Is the project design based on evidence? If so, please state reference.

National evidence

Past reviews of evidence on inequalities have concluded that interventions based on changing behavioural risk factors do have value, particularly where they focus on disadvantaged groups and individuals. These findings have been endorsed by the NICE guidance on behaviour change (2007), which sets out recommendations for interventions at the individual level that motivate and support people to set goals, make small changes, and cope with relapse. ¹ Stages of Change, which is used as a basis for the work with clients in Bradford, is a well established framework for supporting behaviour change. ²

A national evaluation, which will bring together local evidence and examine issues for delivery and implementation, is being commissioned by the Department of Health. Alongside this evaluation, a review of effectiveness of healthy lifestyle advisors is being undertaken; it is due to report in 2009.

Local evidence

An independent evaluation of the Bradford health trainer programme has been commissioned from the Centre for Health Promotion Research at Leeds Metropolitan University (LMU).

Phase 1 showed that the health trainer programme was successfully reaching hard to reach communities and supporting people experiencing the greatest health inequalities to make and maintain health behaviour changes in the areas of weight loss, physical activity, healthy eating, smoking cessation, and improving mental health and wellbeing.

Outcome

What outcomes or planned outcomes are you measuring?

Client outcomes are measured in terms of progress towards behaviour change described in their action plans and goals set.

Programme outcomes include whether the health trainer programme is reaching out to those living in areas of deprivation.

Do you have any outcomes or results yet? If so, what are they?

An independent evaluation of the Bradford health trainer programme was carried out by Leeds Metropolitan University (LMU).

According to the draft report they found strong evidence of the success of the programme in three key areas:

1. Health trainers were able to successfully work with clients to support lifestyle change. Clients identified wide, diverse, and complex needs that closely fitted the Choosing Health priorities of weight management, exercise, and mental health and wellbeing. Findings from both interviews and monitoring data indicated that health trainers were able to help people make positive changes to their health and move along the process of behaviour change
2. Successful recruitment, preparation, and support for health trainers taking on a new role
3. Development of effective referral processes and placements. The programme was successful in attracting Asian women, people with learning disabilities, and those with mental health problems.

• Client outcomes were measured in terms of progress towards their behaviour change action plans, and goals set. Of the clients who had completed their pathway through the health trainer service , 61% made progress in achieving their goals in behaviour change and of this group 31% had made excellent or good progress. This compares favourably with outcomes of other behaviour change programmes, including the national smoking cessation programme
• Progress towards health action plans showed that good or excellent progress was related to the number of appointments attended with a health trainer. The more appointments a client attended the greater the progress towards health goals
• Most clients (75%) did not focus on one issue but worked on multiple issues—for example, smoking and stress relief, and weight loss and meeting people
• The health issues clients chose to work on fit neatly within the Choosing Health priorities and the changes in behaviour that underpin other health inequality target areas regarding obesity, smoking, mental health and wellbeing, and physical activity.

Summary of evidence from independent evaluation report:

• Heath trainers working in 77 locations by October 2007 based in super output areas and with excluded groups. A total of 1064 clients were referred to the service during this time period.

Reach of health trainer programme

The health trainer programme was successful in reaching out to those living in areas of deprivation. ³

• Around 45% of the clients accessing health trainers lived in areas of Bradford classified in the top 10% (band 1) of deprived areas in England
• The health trainer programme was successful in reaching out to those living in areas of deprivation. Around 57% were living in super outputs areas (SOAs) in the top 20% most deprived areas in England
• The service was able to respond to the needs of the diverse client base both in terms of ethnicity and age. Most clients were women, although there was a proportional increase in the numbers of men being referred to health trainers from 17% in year 1 to 23% in year 2
• The age structure of the clients referred to the programme reflects Bradford’s broader population profile, showing the ability of the service to meet the needs of a wide age range of clients
• Health trainers continue to engage an ethnically diverse client group, reflecting the ethnic mix of Bradford. The service is able to meet the needs of a changing population profile—for example, Eastern European and Chinese clients, albeit in small numbers but showing the responsiveness of the programme.

Is your project relevant to a government target or guideline?

The programme is relevant to several national targets identified within the Choosing Health white paper, including reducing obesity, healthy eating, increasing physical activity, alcohol, and mental health and wellbeing. It also addresses other government targets to reduce the number of people out of work and to increase opportunities to support people into paid work.

Feedback

What obstacles did you have to overcome to set up this project?

The programme has attracted a huge amount of support locally, and there were relatively few obstacles to overcome in setting up the programme.

What have you learned about the project so far?

The independent evaluations that have been carried out confirm that the programme has been successful in supporting individuals from disadvantaged and excluded communities to make and maintain changes in behaviour that will improve their health and wellbeing.

There is also a vast amount of anecdotal evidence from clients that shows the benefits of this service to people in the community.

The programme effectively supports people to make and maintain lifestyle changes.

The programme effectively signposts people into other mainstream services and health improvement services.

What would you do differently?

We trained 40 people in two cohorts of training. To manage the rapid expansion in numbers we put a support system in place and appointed senior health trainers who continued to carry a client case load as well as providing local coordination, support, and mentoring. With hindsight we would have appointed seniors in a clearer supervisory role with less overlap in role with health trainers.

References:

1. NICE. The most appropriate means of generic and specific interventions to support attitude and behaviour change at population and community levels. London: NICE, 2007. http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11868
2. Prochaska JO, DiClemente CC. Stages of change model—the transtheoretical approach: crossing traditional boundaries of change. Homewood, Ill: Dow Jones-Irwin, 1984.
3. Evaluation of the Health Trainer Programme. Leeds Metropolitan University, December 2007