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Gloucestershire Community Health Trainer Service

Quarterly Report: April ­ June 2010

Ian Preston, Community Health Trainer Coordinator & Isabel Romero, Community Health Trainer Project Officer

NHS Gloucestershire Community Health Trainers Quarterly Report: April ­ June 2010

Table of Contents

Report summary 1. Introduction and background 2. NHS Gloucestershire Community Health Trainer Programme 3. Events 4. Performance outcomes 5. Qualitative and non-Data Collection & Recording System 6. Learning from evaluation 7. Next steps Appendix 1: Community Health Trainer case studies Appendix 2: Client case study of an older person Appendix 3: Client case study of an offender in a probation setting Appendix 4: Client case study of an individual from a BME community Appendix 5: Client testimonial 3 4 6 7 8 12 13 15 16 19 20 21 22

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Report summary

This report details progress with the Community Health Trainer (CHT) Service in Gloucestershire, established in 2008/09 to support the health and wellbeing needs of individuals from communities where the greatest deprivation and health inequalities are experienced. The six CHTs working in parts of Gloucester, Cheltenham and Tewkesbury are supported by a Co-ordinator and a Project Officer, based in community premises in Tredworth, Gloucester. A multi-agency CHT Reference Group has supported and guided the service since the outset. Following successful completion of the City and Guilds Level 3 training, the CHTs have been engaging with communities and working with clients on an individual basis. Highlights from data monitoring from April to June 2010 include: · · · · · · · · · · Sixty-three individuals successfully engaged with a CHT. 78% of clients come from deprivation quintiles one and two, 51% and 27% respectively (Indices of Multiple Deprivation, 2007). 20% of clients come from BME communities. Ten clients are offenders based in Probation Approved Premises. 71% of clients self-referred to the service. Thirteen community events were attended, during which CHTs engaged with 361 people. 94% of clients have achieved or partly achieved their Personal Health Plan. Forty-one people have been signposted to other services/organisations e.g. NHS Gloucestershire Smoking Advice Service (GSAS) and Exercise on Referral or exercise opportunities (including health walks). Two CHTs have trained as Smoking Cessation Advisors. Weight management/diet and increasing physical activity make up 43% and 32% respectively of all issues that clients wish to address.

As the Gloucestershire CHT programme is still in its infancy, and only a few clients have completed the whole service pathway (i.e. assessment, personal health plan, progress reviews and sign off), this report focuses mainly on the outputs of the few months rather than on outcomes improved. Good progress has been made in relation to all the expected outcomes: · · · · Recruiting CHTs with the right skills to tackle health inequalities. Reaching `seldom heard, seldom seen' people. Supporting clients to make behavioural changes. Encouraging clients to use NHS and other local services to support behavioural change.

Next steps include expanding the CHT team to reach more individuals and communities, developing the role of Community Health Trainer Champions (volunteers) and increasing our profile across the county.

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1. Introduction and background

This report provides an update to NHS Gloucestershire and partner organisations on the background, progress and current performance of the CHT service provided between April and June 2010. As part of the consultation exercise for the Public Health White Paper Choosing Health (DH 2004) respondents set out clear ambitions for their health, but commented that it was difficult to turn these intentions into sustained lifestyle changes. This resulted in the development of the national Health Trainer Programme, to work with adults from disadvantaged communities who find it hard to access services. The programme contributes to national and local ambitions and targets relating to staying healthy and to reducing health inequalities e.g. NI 123 (16+ current smoking prevalence), NI 120 (all age all cause mortality), LI 10 (number of adults gaining NVQ2 or equivalent qualification), LI 14 (number of smokers referred to NHS Stop Smoking Service from two most deprived quintiles of Super Output Areas in the county and who remain quit at four weeks). All CHTs have to successfully pass an accredited City & Guilds Level 3 Health Trainer qualification as well as core additional training. Once trained, they support and encourage individuals to make changes to their lifestyles to improve their health and wellbeing and to minimise their health risk. Community Health Trainer Champions can be recruited as volunteers to support the work of the CHTs, through community outreach. The Health Trainer Programme aims to reduce health inequalities by improving the health and wellbeing of targeted groups, communities and individual adults where the greatest health inequalities are experienced. The objectives are to: · Build the workforce (typically drawn from local communities) with the right skills to tackle health inequalities and promote health and wellbeing, as part of the Public Health Career Framework. · Target individuals whose lifestyles carry a number of risks to their health and wellbeing. · Offer an accessible service that meets local needs. · Work with individuals on a one-to-one basis to carry out an initial health assessment, leading to the development of a personal health plan. · Provide one-to-one support to enable individuals to achieve a positive impact on their health by making changes in their behaviour. · Support individuals to make more effective and timely use of health and wellbeing services by signposting, accompanying (where necessary) and supporting clients to access services where barriers may exist. · Access peer educators who can provide information and deliver health promotion messages to groups as well as individuals. · Help act as a "bridge" between the formal health and social care system and marginalised or disadvantaged populations. · Obtain and record client information on the DH National Data Collection Reporting System (DCRS) including changes in lifestyle behaviours, generating statistical analysis and reports to inform future commissioning and service delivery. The national DCRS is used to monitor outcomes and contribute to the national evidence base of effectiveness in achieving the aim of the programme. It focuses on those outcomes which represent the benefits this intervention can have for Health Trainers, clients and local communities.

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The four overall outcomes are: 1. A workforce with the right skills to tackle health inequalities. 2. Engaging with `hard to reach' or `seldom seen, seldom heard' people. 3. Ensuring sustained health improvement is delivered through behavioural change. 4. An appropriate take-up and use of NHS and other local health and wellbeing services. There are many additional and indirect outcomes including: an increase in community engagement and cohesion; better access to employment and training; increasing confidence and self-esteem; and increasing the number of people involved in volunteering.

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2. NHS Gloucestershire Community Health Trainer Programme The Community Health Trainer service in Gloucestershire was established towards the end of 2008/09 and consists of a Co-ordinator and a Project Officer along with six qualified CHTs. All are employed by NHS Gloucestershire and are contracted to work 0.5 wte (except for one CHT who is bank staff). Most of the CHTs are from the communities within which they work and some have no relevant formal qualifications, but plenty of appropriate experience to enable them to fulfill their role (see Appendix 1 for three case studies of CHTs). Four CHTs work specifically in the Barton & Tredworth, Matson and Podsmead wards of Gloucester. This includes one CHT who works with offenders at Ryecroft Approved Premises as part of a partnership with the Gloucestershire Probation Trust, originally funded through the South West Offender Health Board. In Cheltenham one CHT works in Hester's Way, Springbank, St Pauls and the Oakley ward areas. Tewkesbury also has one CHT who covers the Priors Park and Northway areas of the town. A CHT Reference Group, made up of stakeholders from relevant statutory and voluntary sector organisations, has helped support and guide the service from the outset and has contributed valuable insights as part of the ongoing action research to determine the best model of service provision. The CHTs completed their City & Guilds qualification in January 2010 and gradually started their one-to-one work with individuals in February 2010. During their training they were involved in community events and outreach to promote the service, which they still continue to do. They will typically engage on a one-to-one basis with a client for up to six 30 ­ 60 minute sessions over a three month period. During this time they will support clients to help create personal health plans to achieve behavioural life changes in relation to: Stopping smoking Being more physically active Eating more healthily Managing weight Drinking sensibly Improving mental health and wellbeing Introducing opportunities (signposting to other services) and accompanying where necessary. Links have been established with a variety of other services such as the NHS Health Checks, the Improving Access to Psychological Therapies (IAPT) programme and Community Agents. · · · · · · ·

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3. Events

Throughout April, May and June 2010, members of the CHT team attended 13 community events, such as fun days, health events and health walks. During these events they engaged with 361 members of the public about the CHT service and offered advice about general health and wellbeing. At these events the CHT team: · Spoke to 195 people about the CHT service · Spoke to 23 people about smoking cessation, including six direct referrals to GSAS and six carbon monoxide tests · Spoke to 50 people about weight management (including physical activity and healthy eating) · Carried out 18 BMI checks · Completed 14 grip strength tests · Gave out two Chlamydia testing kits · Signposted three people to local services or opportunities · Received seven enquiries about being a CHT or CHT Champion · Received 18 direct referrals · Supported 49 people to complete resident surveys in Northway as part of the CHT service launch in Northway, Tewkesbury. Finding the time to attend such events has become increasingly difficult as the numbers of referrals for one-to-one support have increased, but we feel it is important to maintain visibility within the local communities in order to promote the service. We are in the process of recruiting volunteer Community Health Trainer Champions who will be able to assist with this aspect of the service.

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4. Performance outcomes ­ quantitative data from the DCRS

During their work with individuals, CHTs collect client data and record on the national DCRS, which is designed specifically for Health Trainer programmes. Some additional more qualitative data is collected that we feel adds to the overall picture to demonstrate effectiveness in improving outcomes. All data will soon be added to the Joint Strategic Needs Assessment (JSNA). This report is relevant to data collected during quarter one of 2010/11 (April - June inclusive). Sixty-three clients were registered on the DCRS, of whom: · · · · · · Ten have already been signed off as they have completed the programme. Ten are offenders based in Probation Approved Premises. Two are not registered with a GP (one was living in Gloucester on a temporary basis who was accessing Gloucester Health Access Centre). Three are registered as disabled. One recorded that they have a learning disability. One has mental health issues.

How clients heard about the CHT service Table 1 below shows that the majority of clients heard about the service from promotional events (32%), by word of mouth (29%) and CHT publicity materials (14%).

Table 1: How clients heard about the service

How clients heard about the service Promotional event Word of mouth Poster/ leaflet Via 3rd party From another NHS (lifestyle) service Drop in at CHT base / workplace Through their GP / primary care School or children's centre Magazine/ paper Work based setting / person No. of clients 20 18 9 5 4 2 1 1 1 1 Percentage 32% 29% 14% 8% 7% 3% 2% 2% 2% 1% Comparison against National Percentage

30% 14%

6% 5%

13%

NA

24%

NA NA NA

A total of 71% of clients self-referred to the CHT service; this is higher than the national figure of 38%. Additionally only 9% of clients came from a GP / NHS pathway. This is lower than the national average (see DCRS National Hub Report, Produced by BPCSSA, Version 9, May 2010) as we initially promoted ourselves within the target areas (e.g. at events and to local groups), and had only just started the work to promote ourselves to GPs and other health professionals. Organisations that have referred or sign-posted clients to the service include: · Community and voluntary groups such as GL Communities, the mental health charity Rethink and the Independence Trust. · NHS services such as Gloucester Health Access Centre. · Local authority services such as children's centres.

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CHT clients by area of deprivation One of the main aims of the CHT service is to engage with people from areas or communities experiencing health deprivation, to work towards reducing inequalities in health. Figure 1 shows that approximately 78% of all clients came from deprivation quintiles one and two (51% and 27% respectively). This figure is higher than the national average of 68% (46% and 22% for quintiles one and two respectively). Figure 1: Clients seen from areas of deprivation.

35 30 25 Number of clients 20 15 10 5 0 Q1 - Most deprived Q2 Q3 Q4 Q5 - Least deprived Unknown

Quintiles of deprivation

Client gender Of the 63 clients recorded on the DCRS during this quarter, 60% are female and 40% are male. This is slightly different to the national picture (56% female and 44% male).

Client ethnicity Table 2 shows that 75% of clients fall into the white British category, with 16% from an Asian background and 4% from the Black or Black British category. This reflects the profile of the areas within which we are working and the fact that two of the CHTs are from local Asian communities. Table 2: Client ethnicity Ethnicity White - British Other White Background Asian or Asian British - Indian Asian or Asian British - Pakistani Black or Black British - Caribbean Black or Black British - African Any Other Ethnic Group

Number of people 47 2 7 4 1 1 1

Percent 75% 3% 11% 5% 2% 2% 2%

Comparison against National Percentage

71% 3%

3% 5%

2%

2%

1%

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Client age ranges Table 3 shows the age range of clients seen. This reflects our marketing activity and the settings in which the work has been focused but is likely to change as more referrals come through from other pathways, for example, the NHS Health Checks (targeting people aged 40-74 years). Table 3: Age Profile of Clients Age ranges Number of people 18 - 25 7 26 ­ 35 36 ­ 45 46 - 55 56 - 65 Over 65 18 16 10 9 3

Percent 11% 29% 25% 16% 14% 5%

Comparison against National Percentage

9%

16%

20% 18%

15%

12%

Clients' lifestyle goals Figure 2 shows that diet (usually in order to lose weight) and increasing physical activity make up 43% and 32% respectively of issues that clients wish to address. `Other' includes alcohol, stress and anxiety. `Not recorded' includes individuals that may have been signposted or have not yet set a Personal Health Plan. Compared to the national pattern diet is lower at 43% (60% nationally) while exercise is higher at 33% (26% nationally) while smoking is the same as national levels at 4%. Figure 2: Primary lifestyle goals set by clients

35 30 25 Number of clients 20 15 10 5 0 Not recorded Diet Exercise Is s ue s addre s s e d Other Smoking

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Personal Health Plans Once a client has identified the issue they wish to address, the CHT will support them to create a Personal Health Plan to help achieve their goals. An individual's Personal Health Plan typically contains four SMART goals. If a client has met all of the goals in their Personal Health Plan then they have `achieved' the Personal Health Plan. If only some of their goals have been met they are known as `part achieved', and `not achieved' if they have been unable to meet any of their goals. During this quarter, 94% of clients either achieved or part achieved their Personal Health Plan (78% and 16% respectively). There were no recorded `not achieved' for this quarter mainly due to start up of service and small client numbers. These figures are significantly higher than national figures where 74% achieved, 16% part achieved and 10% did not achieve their Personal Health Plan.

Onward signposting CHTs have a wealth of local knowledge and use this to signpost individuals to other local services and opportunities such as those seen in Table 4. Table 4: Client signposting routes from CHT Service Signposting to Exercise on referral or exercise opportunities e.g. health walks Gloucestershire Smoking Advice Service (GSAS) Community groups e.g. GL Communities, Learning Champions Housing organisations Other, e.g. Guide & PALS

Number of people 16 12 6 4 3

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5. Qualitative and non-DCRS data

Some of the information that is collected by the CHT Service is not recorded on the DCRS. This may be due to a chance brief intervention or because the nature of the enquiry is not applicable to the DCRS recording system. However this may be useful for overall client profiling, such as clients with housing benefit issues or medical issues beyond the remit of the CHT service. Where possible, CHTs will try and direct a client to the appropriate service/organisation and may even accompany them in the first instance, if required. We are often approached at community events or contacted at the office by people who are interested in becoming a CHT. During this quarter, 14 people have enquired about becoming a CHT, and most have heard about the role through word of mouth. We collect case studies and client testimonials to document qualitative data that give a fuller picture of the effectiveness of the service in meeting clients' needs. The client case studies and testimonial in appendices 2-5 illustrate some of the work we have done with clients.

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6. Learning from evaluation of the first few months

Although the CHT service is still in its infancy, our monitoring data suggests that we are making a positive impact on improving the health and health awareness of our clients and the communities within which they live. As there is no `one size fits all' model for Health Trainer services in the UK we are aiming to identify the best model for Gloucestershire, through taking an action research approach.

What's working well The competence, commitment and enthusiasm of the CHTs is key to the success of the programme. Nationally there is a relatively high drop-out rate both during and after the City and Guilds Level 3 training, but this has not occurred in Gloucestershire. Recruiting from within the target communities of geography or interest has been a significant achievement. This contributes locally to building the workforce with the right skills and experience to tackle health inequalities (expected outcome 1). The number of referrals is increasing in line with marketing of the service. As the service develops there appears to be two general pathways from which people can access the service - we have labelled them as the core and general pathways. Core pathways include primary and secondary care services, along with specialist services such as smoking cessation, mental health and alcohol and drug services. General pathways include selfreferral and any other community groups or organisations that we link with in order to identify and support clients, e.g. housing associations and neighbourhood projects. CHTs in turn will signpost back to the core and general pathways where applicable. In order to maintain an appropriate level of referrals in relation to the capacity of the CHT team, we have drawn up clear criteria for partners to use when referring clients to the programme. Overall we are reaching clients from the specified target groups and communities, ensuring that people who are `seldom seen, seldom heard' are reached with appropriate support (expected outcome 2). In relation to delivering sustained health improvement through behavioural change (expected outcome 3), our data is showing that the programme is making a significant contribution. With the majority of clients to date achieving or part achieving their health goals, we can expect that this will make an impact on their overall health and wellbeing ­ and that of their families and communities. Clients have benefited from being signposted to other support services, especially the NHS Gloucestershire Smoking Advice Service (GSAS) and community learning and activity opportunities (expected outcome 4). The CHT working in Ryecroft Probation Approved Premises currently has 10 clients. Initially residents were free to visit the CHT if they wanted, but this resulted in many residents not engaging with the service. The CHT has subsequently engaged with Ryecroft staff and has now put in place new procedures: any new resident moving into the premises is automatically given an appointment with the CHT as part of their induction pathway. This has resulted in 100 per cent of new residents seeing a CHT at least once and in most cases more than once. However as it is not a mandatory requirement to become a client, residents can decline the service if they wish to.

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The main issues that residents express are similar to those seen in the wider community apart from a proportionately higher number of residents interested in giving up smoking. Additionally, Ryecroft clients usually have 30 minute appointments (the norm in the community is 1 hour) as this suits the nature of the client and environment in which they are based. See appendix 3 for a client case study of an offender in a probation setting. We have put in a successful bid to the South West Offender Health / Health Trainer Partnership to recruit a female CHT to work at the ISIS Women's Centre in Gloucester, which supports women offenders and women at risk of offending.

Key issues we need to address We need to recruit, train and retain volunteer Community Health Trainer Champions from the target communities of geography and interest, in order to relieve the pressures of time on the CHTs. As referrals increase, the balance between CHTs doing outreach and seeing clients on an individual basis will need to shift. The introduction of Community Health Trainer Champions will be beneficial. We receive requests and referrals from partner agencies, communities and individuals who fall outside of our geographical areas and target groups. Plans are in place to expand the service to reach more geographical communities in areas of deprivation and communities of interest e.g. travellers and gypsies. Being clear about the criteria is essential to managing expectations of the service. Once clients have completed the whole service pathway, CHTs aim to follow up clients after four weeks, three months and six months to offer further support and establish if and to what extent the behaviour changes have affected their overall health and wellbeing, and whether behaviour changes have been maintained.

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7. Next steps

Developing the capacity and reach of the CHT service in line with national and local priorities will include: · · · · Recruitment of four more CHTs to work in identified areas of deprivation or communities of interest. Partnership working with the ISIS Women's Centre to identify the best way to integrate a female CHT to work with women who have offended or are at risk of offending. Becoming a Royal Society of Public Health approved training provider, to allow us to deliver the Level 2 Award in Understanding Health Improvement to the Community Health Trainer Champions, to strengthen the service. Linking CHTs within NHS Health Checks. The CHT service has been potentially identified as one of the five main referral routes for GPs and their teams to refer clients to for lifestyle advice and behavioural change support following an NHS Health Check. Increasing the profile of the service across the county. The CHT service is currently in the process of being commissioned out. The initial pre-qualification questionnaire for interested organisations needs to be submitted to NHS Gloucestershire by mid-October 2010, and the successful bidder will be selected in 2011.

· ·

If you wish to contact us or require more information about this report please call the Community Health Trainers team on 01452 554408 or email [email protected]

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Appendix 1: Community Health Trainer case studies

Case study 1: Thirty five year old white British male Community Health Trainer working in Probation Approved Premises What did you do before you became a Health Trainer? For over 10 years I was a drug addict and in and out of prison for drug-related offences. When in recovery I lived in and was a service user of many supporting housing projects in Gloucester, including Ryecroft Approved Premises. I then worked as a Supported Housing Officer in a number of projects, most of which I had formerly been a service user at. During a brief period of unemployment I was approached by a former employer from one of the projects about the Community Health Trainer role at Ryecroft. Why did you want to become a Health Trainer in Ryecroft? When I was approached about the Community Health Trainer role at Ryecroft I was immediately interested as it would involve working in an environment with offenders which I understood. I felt I could offer the residents the benefit of my experience and empathise with their situation. After a number of roles in supported housing, I also felt the role as a Community Health Trainer with the NHS offered a good career opportunity, as it offered training and career potential, something which was sometimes limited in supported housing. What do you find most rewarding about being a Health Trainer? I most enjoy the one-to-one work with clients, and the opportunity to develop the Community Health Trainer role in a new setting for Gloucestershire. I also find it very rewarding when clients have successes and I see them making positive progress and changes. What gets in the way of you doing your job as a Health Trainer? Time restrictions and fitting everything in to my 30 hours ­ my work with residents at Ryecroft, my work with other clients in the community, promoting the service and attending events, catching up on office-based work, and training. What helps you to do your job as a Health Trainer? · My knowledge, skills and experience, including the City & Guilds Level 3 Certificate for Health Trainers, and my previous work experience · I enjoy talking to people and supporting them to change their behaviour · Understanding my job role and client group · Support from the Community Health Trainers team · Local knowledge of criminal justice and support services If you move on to another job, what would you like it to be? Specialist drug support role within the NHS, and eventually I would like to manage a service in the field of substance misuse. Is there anything else you would like to say about being a Health Trainer? A lot of projects and services, new and existing, within criminal justice and probation are exploring having a Health Trainer as part of the service. I hope this happens as a Health Trainer could play an important part in these services. However, I feel that some part-time Health Trainer opportunities (such as mine) miss out on potentially excellent candidates applying, because a) the roles are part time and a lot of people need the security of full time work, and b) ex-offenders may feel their record will go against them, especially with a large employer such as the NHS, so do not apply.

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Case study 2: Thirty eight year old British Indian female Community Health Trainer working in Gloucester What did you do before you became a Health Trainer? I worked for the family-run business for many years, raised a family, and more recently (before becoming a Health Trainer) I volunteered as a Peer Educator working with people from the local Asian community with diabetes. Why did you want to become a Health Trainer? I am interested in health and wellbeing and enjoyed the voluntary work as a Peer Educator, which introduced me to the health needs of the community I live in and am part of. What do you find most rewarding about being a Health Trainer? I enjoy helping people make small changes in their lives which may have a big impact on them in the long term, for example, preventing them developing a condition such as diabetes. What gets in the way of you doing your job as a Health Trainer? · People who expect instant results and don't want to put any effort in. · People who just want a freebie such as free membership to leisure facilities. What helps you to do your job as a Health Trainer? · Support from the Community Health Trainers team · City & Guilds qualification ­ this helped me to understand my job role and how to support people to make positive changes · Flexibility, both in terms of the role and practicalities such as working hours If you move on to another job, what would you like it to be? I am not sure but I would like to continue to work in health and wellbeing. Is there anything else you would like to say about being a Health Trainer? It is a worthwhile role, as some people need just a little bit of support and encouragement to make positive changes in their life.

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Case study 3: Thirty year old British Bangladeshi female Community Health Trainer working in Gloucester

What did you do before you became a Health Trainer? I worked at a Children's Centre as a Community Family Worker working with families in crisis, and running groups such as family time and a dads group. Why did you want to become a Health Trainer? I wanted a new challenge and something different, but still working within a community setting. I liked the idea of focusing on people's health and wellbeing. What do you find most rewarding about being a Health Trainer? I enjoy motivating and encouraging people to reach the goals they have set themselves, and making a difference in people's lives, however small or big. What gets in the way of you doing your job as a Health Trainer? · Clients not using the service correctly, such as not attending appointments, and not having a valid reason for this. · Unsuitable referrals. · People just wanting a freebie, such as free gym membership. What helps you to do your job as a Health Trainer? · Having useful and appropriate resources and tools to hand · Support from the Community Health Trainers team · Partnership working with other agencies and organisations If you move on to another job, what would you like it to be? I would like to move up and gain promotion but at the moment I am not sure what I would like to do, maybe be a Senior Health Trainer. Is there anything else you would like to say about being a Health Trainer? The role can be challenging but is very rewarding.

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Appendix 2: Client case study of an older person Client is a 69 years old female who found out about the Community Health Trainers through the Age Concern newsletter. She came to me because she wanted to lose some weight through increasing physical activity. At our first meeting I listened to her issues and suggested she complete a food diary. She did this and by looking at it together we found that her diet was ok, although she did identify a few things that she could cut out and she also suggested introducing more fruit to her diet. She also told me that she used to be quite active but a recent injury had prevented her from being active, and that she wanted to become more active again, and she was especially interested in accessing opportunities in the community. In our second session together we wrote a personal health plan which included the following: · · · · · I suggested she join in a local health walk and accompanied her for her first one. She now attends a regular health walk. I informed her about the local GP exercise referral scheme; she spoke to her GP about this, she is now a member of the scheme. The client suggested increasing her fruit intake to at least one piece a day. I asked if this was realistic and she thought it was; she reaches this goal most days. She expressed an interest in going to an exercise class with people of her own age. I sourced a local aqua class, as this was for over 50s and also suitable for her because it is low-impact. She now goes to this class weekly. The client mentioned that she has a bike but hasn't ridden it for a while. I suggested she cycle to the aqua class, which she now does.

The one-to-one contact really helped this client, and when we got going she loved to talk and explore ideas and suggestions. After our first few sessions she was very upset because she hadn't lost much weight. However, I gave her a lot of support and motivation and reinforced that slow weight loss is a positive step. By giving motivation and support throughout the sessions I feel I provided her with the opportunity to gain confidence and become her own Health Trainer. I found that the client was very hard on herself and it was sometimes difficult to get her to see the positives. I overcame this by praising and motivating her; she thanked me for this and said it helped. When I first met this client I was not sure whether to suggest increasing physical activity because of her recent injury and current health problems. To overcome this difficulty, I asked the client what guidance she had received from her physiotherapist (they said exercise would be beneficial), and also her GP had referred her to the exercise referral scheme so I knew exercise would be good for her. The client's achievements and the changes she has made to her lifestyle are: · · · · · · · · Aqua aerobics twice a week. Walking three times a week. Cycling 2-3 times a week to exercise referral sessions and aqua class. Increased confidence to access local classes and opportunities. Weight loss about 8lbs. Eating a piece of fruit every day. Drinking more water, especially when exercising. She can now get out of a chair a lot more easily ­ before she had to use her arms to push herself up but now doesn't need to.

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Appendix 3: Client case study of an offender in a probation setting

Describe your client, e.g. age, gender, ethnicity, special needs etc, and how you made contact with this person? Male, 29 years old, white British, ex-offender (drug-related offences), made contact through my role as a Community Health Trainer at Ryecroft Approved Premises What did they want help with (primary issue and any other issues)? I started seeing the client each week to work with him regarding the stress and pressure of resettling into the community. After working with him a few weeks he was stable enough with his drug and stress issues and felt ready to address his smoking. How did you help this person and what worked well? Initially we discussed his drug and stress issues. I demonstrated understanding of prison and hostel life and offending, as I am an ex-offender myself. This worked well to build up rapport with the client. When he was ready, we addressed his smoking. I signposted him to smoking cessation services, by making an appointment for him at the Quit Stop shop. I prepared the client for the visit to the Quit Stop shop, for example, `next week we will make an appointment', `this is what will happen when you go to the Quit Stop...' I maintained my support for the client alongside the smoking cessation service's support, which resulted in him giving up smoking. What difficulties did you have and how did you overcome them? The client was on an hourly sign in, meaning he had to report back to Ryecroft every hour. This made it difficult for him to attend appointments. I liaised with the team at Ryecroft to allow the client to have a longer sign-in period so he could attend the Quit Stop appointment. What did this person achieve, including changes to their lifestyle? Quit smoking ­ the client has now been smoke free for 5 weeks. We are now exploring physical activity options for him. We've talked about gym memberships and also identified his personal interests, which include basketball, snooker and racquet sports, and we are looking at opportunities for him to participate in these in the community. What did you learn from helping this person? What would you do differently next time? That support is available from the probation team at Ryecroft to help clients achieve their goals.

In 50 words or less, please tell us how the client benefitted from working with you The client had peace of mind that the Community Health Trainer service is confidential, free, and accessible, and also felt comfortable that he was speaking to somebody who had been through the criminal justice system, and understood where he was coming from. He was empowered to achieve his lifestyle change goals.

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Appendix 4: Client case study of an individual from a BME community Describe your client, e.g. age, gender, ethnicity, special needs etc, and how you made contact with this person? Female, 36, born in India, has lived in Gloucester for 12 years. She saw a poster at a community venue, looked on our website, saw that she knew me so contacted us. What did they want help with (primary issue and any other issues)? Interested in losing weight through increasing physical activity How did you help this person and what worked well? We developed a personal health plan around physical activity including the following: · She walks to school every day so I suggested increasing the pace at which she walks. · For religious reasons she wears a veil and has been to a local ladies-only gym before, but felt intimidated, didn't know who to ask for help and couldn't fill in the forms because she doesn't write English. I went with her to this gym, helped her fill in the induction form and asked a gym instructor to do an induction with her. She is now planning on going this week to the gym on her own. Providing practical support helped build this client's confidence. · The client cannot write English so I sourced a local English class, went with her to enquire about it and then enrolled her on it. She is now half way through the course of English classes and is enjoying it. · She says she now feels more confident and would like to learn how to swim. I have sourced free swimming lessons and given her this information. The client also expressed an interest in learning more about healthy eating. I found a local class on healthy eating which she went to even though there were only two sessions left. She would like to do more healthy eating classes in the future. What difficulties did you have and how did you overcome them? I felt that the client was not always truthful about their weight and diet. I tried to overcome this by building a rapport so she felt she could tell the truth, describing portions, being nonjudgemental and encouraging her to talk openly. What did this person achieve, including changes to their lifestyle? She now feels more confident in going to the gym on her own. She also says she feels better in herself and more motivated. The client now wants to do the next level of English and maybe start computer classes. What did you learn from helping this person? What would you do differently next time? Clients not always truthful and it takes time to build up a rapport. I would do the same next time because I wouldn't want to discourage a client from seeing a Community Health Trainer. In 50 words or less, please tell us how the client benefitted from working with you She now feels confident to go to the gym by herself. Has nearly completed foundation English course which has increased her confidence to further her education. She has also recommended the Community Health Trainers to a friend because of her positive experience.

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Appendix 5: Client testimonial Client is a 29 year old white British female. "I'm really enjoying seeing my Community Health Trainer. In my first session, she suggested I fill in a food diary and this exercise alone has made me a lot more aware of what I eat and when. She has also helped me identify small changes I can make to my eating habits, such as eating breakfast (I used to skip it), thinking about portion control, drinking more water and how I can include more fruit and vegetables in my diet. I was at a community event recently where there was a plate of biscuits; I was about to tuck in out of habit, but then realised what I was doing and just had two, which is a reasonable portion. Already, even after a couple of weeks, I am starting to feel more replenished and better about myself. My Community Health Trainer has also been helping me come up with ideas on how I can increase my physical activity, as I find it difficult with small children and no family around to help with babysitting. She has told me about lots of activities going on locally which I can do around my childcare issues. I have a friend who is also seeing a Community Health Trainer so we give each other extra motivation to be healthier."

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Information

Quarterly report ­ July 2010

22 pages

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