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Minded to changeThe link between mental wellbeing and healthier lifestyles

Findings from the health trainer service in England

November 2015

Minded to change The link between mental wellbeing and healthier lifestyles

• BrightonHealthTrainerService

• CornwallHealthTrainerService,HealthPromotionService

• GloucestershireCommunityHealthTrainers,IndependenceTrust

• HounslowandRichmondHealthTrainerService

• HerefordshireHealthTrainerService

• LeicesterCityHealthTrainers,LifestyleReferralHub

• LewishamHealthTrainerService

• LiverpoolHealthTrainerService

• MindinBexleyHealthTrainers

• SouthEastEssexHealthTrainers,deliveredbyParkwoodHealthcare

• SwindonHealthTrainerService

• TamesideHealthTrainerService

• TelfordHealthyLifestyleTeam

• TowerHamletsHealthTrainerService

• WalsallEmotionalHealthandWellbeingService

• WarringtonWellbeingService

• WiltshireHealthTrainerService

List of contributors

EY ETEST

OPHTHALMIC OPTICIANS 18,000

HOSPITAL PORTERS 21,000

FIRE SERVICE OFFICERS 33,000

DENTAL PRACTITIONERS 43,000

BEAUTICIANS AND RELATED OCCUPATIONS 78,000

HAIRDRESSERS AND BARBERS 144,000

KITCHEN AND CATERING ASSISTANTS 377,000

TEACHING ASSISTANTS 299,000

PHARMACISTS 50,000

LEISURE AND THEME PARK ATTENDANTS 24,000

PARAMEDICS 19,000

HEALTH TRAINERS 2,900

Section Page

Foreword – Shirley Cramer CBE 1

Foreword - Tony Coggins 2

Executive summary 3

Introduction 4

Methodology 5

What is a health trainer? 5

Promoting mental health and wellbeing 5

Connection between mental and physical health 9

A growing challenge 13

Conclusion 14

Appendix 14

References 16

Contents

EY ETEST









PHARMACISTS 50,000


PARAMEDICS 19,000


Foreword

Positivementalwellbeingisintegraltoouroverallhealth,acriticalingredientformakinghealthylifestylechoices.Inspiteofthis,mentalhealthandwellbeingisoftenoverlooked,seenasanissueofsecondaryimportance,withgreaterprioritygiventophysicalhealthissuesandservices.Thislackof‘parityofesteem’ismistaken,andhugelymisguidedifwearetoreducethefinancialburdenofavoidableillness.

Thereisoftenatendencytolookatunhealthylifestylechoices,suchasapoordietorsmoking,inisolationwithoutconsideringthewiderfactorsthatmaybeinfluencingaperson’sbehaviour.However,toeffectivelytackleunhealthylifestyles,wemustgettotherootcauseoftheseissues.Thehealthtrainerservice,asacommunityresource,trustedbytheirclients,isavaluabletoolforachievingthis.

Healthtrainersaredrawnfromwithinthecommunitiestheyserveandoftenhavefirst-handexperienceoftheissuesonwhichtheyareprovidingsupport.Unlikemanyservices,theyarealsoabletooffersupportoveranextendedperiodoftime,andarethereforeideallyplacedtopromotementalwellbeingandsupportclientsonissuessuchassocialisolation,anxietyandstress.

UsingdatafromtheDataCollectionandReportingSystem,thisreporthighlightsthesuccesswithwhichhealthtrainersaredoingthis.Acrossarangeofwellbeingmeasures,healthtrainersaresupportingsubstantialimprovementsintheirclients’mentalwellbeing.Thisreporthowever,alsohighlightsthatformanyservices,mentalhealthandwellbeingisagrowingissue,withhealthtrainerssupportinganincreasingnumberofcomplexcases.

Withevermorestringentbudgetscuts,publichealthisfacingadifficulttimeahead.Itiscrucialhowever,thatwerecognisetheimportanceofpromotingmentalwellbeingandthevaluablerolethatcommunity-basedservicessuchasthehealthtrainerservicecanplayinthis.Atthesametime,itisvitalthatwerecognisetheboundariesofthehealthtrainerroleandensuretheyareprovidedwiththenecessarytrainingandsupporttocarryouttheirrolesafelyandeffectively.

Shirley Cramer CBE

ChiefExecutive RoyalSocietyforPublicHealth

There is often a tendency to look at unhealthy lifestyle choices, such as a poor diet or smoking, in isolation without considering the wider factors that may be influencing a person’s behaviour. However, to effectively tackle unhealthy lifestyles, we must get to the root cause of these issues. The health trainer service, as a community resource, trusted by their clients, is a valuable tool for achieving this.

Page 1 Minded to change The link between mental wellbeing and healthier lifestyles

Foreword

Putsimply,ourmentalhealthandmentalwellbeingisabouthowwethinkandfeel,whichaffectswhatwedoandhowwefunction.Assuch,itisfundamentaltoleadinghealthylives.

Itiswellunderstoodthatourmentalwellbeingisconnectedtoourmasteryofchoiceanddefinesourabilitytomakehealthychoices.However,thereisatendencytounderplaymentalhealthandwellbeinginapproachingphysicalhealth–viewingphysicalhealthasalinearrelationshipnotmediatedbyotherfactors.Inshort,takingaholisticapproachtobothphysicalandmentalhealthcanengendergreaterpublichealthoutcomesforall.

Healthtrainerservicesandothercommunity-basedinterventionsarearguablybestplacedtomeetthechallengesposedbymentalandphysicalhealth,andmostimportantlyhavethecapacitytomeetthesechallengeswithawider,moreholisticapproach.Orinotherwords,community-basedservicesaremoreresponsiveandconnectedtodynamiclocalneed.

Theuseofhealthtrainerservicesandothercommunity-basedservicescreatesafeedbackloop,inwhichtheserviceusercanbringabout bettermentalhealthoutcomesforthemselves,andthroughtheparticipationoftheserviceandotherslikeit,engenderwidercommunalbenefits:indirectlyaffectingthementalandphysicalhealthofthosewithinthatcommunity.

Thisreportbringsadditionalbreadthanddepthtothecurrentunderstandingsurroundinghealthtrainerservices,aswellastheefficacyofcommunity-basedserviceslikeit.Attheinitiallevel,itdemonstratesthevaluableworkofhealthtrainersinimprovingphysicalhealthoutcomes.Butalso,bringstotheforetheworkofhealthtrainersinimprovingmentalwellbeingandhowthesetwointeractwithinasingleintervention.

Thereportalsoraisesasalientchallengewithinandfacingpublichealthaboutthecurrentcapacityof‘traditional’clinicalservices,especiallythatofmentalhealthservices.Notably,howdowebalancethefinancialrealitiesoftheNHSwiththeremitandexpertiseofspecifichealthprofessionals,suchashealthtrainers?

Tony Coggins HeadofMentalHealthPromotionSouthLondonandMaudsleyNHSFoundationTrust

Health trainer services and other community-based interventions are arguably best placed to meet the challenges posed by mental and physical health, and most importantly have the capacity to meet these challenges with a wider, more holistic approach. Or in other words, community-based services are more responsive and connected to dynamic local need.

Page 2Minded to change The link between mental wellbeing and healthier lifestyles

Executive summary

• Introducedin2004,thehealthtrainerserviceseekstosupportthemostdeprivedinsocietytolead healthierlives,withthecoregoalsofreducingavoidableillnessandaddressinghealthinequalities.

• Healthtrainersarerecruitedfromwithincommunitiestoprovide‘supportfromnextdoor’intheformof informationonhealthylifestyles,thesettingofgoalsinpersonalhealthplans(PHPs)andsignpostingto localgroupsandservices.

• InFebruary,wepublishedareport,Indicators of change,thefirstinaseriesofsix,whichdemonstrated thatthehealthtrainerservicehasmovedbeyonditsoriginaldesignaslaidoutintheWhitePaper, ChoosingHealth:MakingHealthyChoicesEasier.Theserviceisnowbasedinawiderangeofsettings, withhealthtrainerssupportingclientsonavastarrayofissuesfromlong-termhealthconditions, financialandhousingissuestoissuesaroundmentalhealthandwellbeing.

• Thisreportbuildsonthesepreviousfindingsbyseekingtounderstandthetypesofmentalhealthissues facedbyclients,theimpactoflowermentalwellbeingontheirsuccessandthechallengesfaced byservices.

• UsingdatafromtheDataCollectionandReportingSystem(DCRS),thisreportdemonstratesthesuccess ofhealthtrainerservicesinsupportingclients,regardlessofdeprivationquintile,toachievesubstantial improvementsacrossarangeofwellbeingmeasures.

• Ourresearchalsohighlightsthedetrimentalimpactthatlowermentalwellbeingcanhaveonthesuccess ofclients,thussupportingthecaseforgreatertraininginthisarea.Thedataindicatesthatclientswhodo notfullyachievetheirPHPbehavioralgoalshavealoweraveragementalwellbeingscoreatthestartof theintervention.

• Moreover,thedataalsoindicatesthat,whilstachievingsubstantialimprovements,clientswhostart withlowermentalwellbeingscoresonaveragedonotachievethesamelevelofbehaviorchange successinmeasuressuchasconsumptionoffruitandvegetablesasthosewithhigherstartingmental wellbeingscores.

• Foralotofservices,mentalhealthisagrowingissue.Throughtheuseofsemi-structuredinterviews, wefoundmanyservicesareseeinganincreasingnumberofindividualswithmentalhealthissues andfeeltheyareoftena‘dumpingground’formorecomplexcases,partlyduetoalackof alternativeservices.

• Healthtrainersoffertimeandsupportprovidedbynootherservice.Itiscrucialhowever,thatwe recognisetheboundariesofthisrole.Toensurethathealthtrainersareabletoworksafelyandeffectively, thereisaclearcaseforgreatertraininginmentalhealthawarenessandalso,aneedforgreatersupport fromotherservices.Withmoreintegratedworking,thereisrealpotentialforhealthtrainerstoactasa bridgeforthosestrugglingwithmentalhealthissuesintomorespecialistservices.


Introduction


MentalillhealthisthemaincauseofdisabilityintheUK,withanestimatedoneinfouradultsandoneinfivechildrenexperiencingamentalhealthproblemeachyear.1Thisincidencerate,equatingtoroughly16.7millionindividuals,2ishigherthanthatforconditionssuchascancerandcardiovasculardisease.1

Mentalillhealthencompassesawiderangeofconditions,rangingfromsocialisolation,anxietyandstressthroughtomoresevereconditions,suchasbi-polardisorderandschizophrenia.Themostcommonofwhichisdepressionwithsufferersaccountingforbetween8-12%ofthepopulation.3

Physicalhealthandmentalhealthareinextricablylinked,withpoormentalhealthbeingbothadeterminantandconsequenceofpoorphysicalhealth.Researchhasshownthatindividualssufferingfromdepressionforexample,havea65%increasedriskofdiabetes,andcorrespondingly,individualswithdiabetesaretwotofivetimesmorelikelytohavedepression.4

Mentalhealthproblemscanbehugelydetrimentaltothelivesofsufferers,aswellasthatoftheirfamilyandfriends.Poormentalhealthcanmakeeverydaydecisionsandroutines,includinghealthylifestylechoices,farmoreofachallenge.ItalsoplacessubstantialcostsontheNHS,welfaresystemandemployers,estimatedatanincredible£123.8billionperyear.4

ToreducetheburdenontheNHS,reduceavoidableillnessandultimately,tacklehealthinequalities,itiscrucialthatservicesandcommunitiesalikearefocusedonpromotingandsupportingmentalwellbeing.Definedas‘adynamicstateinwhichtheindividualisabletodeveloptheirpotential,workproductivelyandcreatively,buildstrongandpositiverelationshipswithothersandcontributetotheircommunity’,5 mental wellbeingisthefoundationuponwhichhealthylifestylechoicesarebased.Thehealthtrainerservice,comprisedofindividualsdrawnfromwithincommunitiestoprovide‘supportfromnextdoor’,6 are an integral partofthisandideallyplacedtotacklethe‘environmental’factorsimpactingourmentalhealthandwellbeing.

Earlierthisyear,wepublishedthefirstinaseriesofsixreportsproducedalongsidetheDataCollection andReportingSystem(DCRS)ateamtoevaluatethehealthtrainerservice.Thisreportdemonstratedthattheroleofthehealthtrainerhasexpandedconsiderably,withhealthtrainersnowsupportingclientsonawidevarietyofissues,includingpromotingmentalwellbeingandsupportingclientswithlowlevelmentalhealthissues,suchassocialisolationandanxiety.BuildingonourpreviousDCRSreport,thisnextinstalmentseekstodigabitdeepertounderstandthementalhealthissuesfacedbyclients,examinetheimpactoflowermentalwellbeingontheirsuccessandunderstandthegrowingchallengesfacedbyservicesinaclimate ofbudgetcuts.

a.TheDCRSisacentralisednationaldatabase,usedbyroughly60%ofservices,whichenableshealthtrainersandhealthtrainerservicestoreportandrecordthedataoftheirclients,atallstagesofanintervention.Whilstsimultaneouslyfacilitatingtheself-assessmentofservices’operationalandcomparativeperformancewithinspecificclientmetrics.

Methodology

TheresearchforthisreportincorporatedbothquantitativeanalysisusingdatacollectedintheDCRSandalso,qualitativeresearchintheformofsemi-structuredinterviewswithhealthtrainersandserviceleads.

WeanalysedtheDCRSdatacollectedoverathreeyearperiodfromJuly2012toJuly2015.Wealsoconducted31interviewsthroughoutAugustandSeptember2015,14withserviceleadsand17withhealthtrainers.Thiswasaself-selectedsample.Forinformationonwhichhealthtrainerservicestookpart,pleaseseethelistofcontributors.


What is a health trainer?

Theintroductionofthehealthtrainerserviceinthe2004WhitePaper,ChoosingHealth:MakingHealthyChoicesEasier,markedaturningpointinpublichealth.Previouspublichealthinitiativeshadfocusedonapaternalisticapproach,seekingtoencouragebehaviourchangethroughtheprovisionof‘advicefromonhigh’.6Thehealthtrainerservicewasinsteadtobeaworkforcedrawnfromwithincommunities,providingindividualisedsupporttoclientsfromapositionofunderstanding.

Basedonapsycho-socialmodel,7healthtrainersworkwiththeirclientsoverthecourseofgenerally6-8sessions,settingbehaviourchangegoalsinpersonalhealthplans(PHPs),providinginformationonhealthylifestylesandsignpostingtootherservices.Healthtrainersfocusontheholisticviewofhealth,seekingtounderstandandsupportclientsonawiderangeoffactorsthatmaybeimpactingtheirhealthandwellbeing,beitfinancialconcernsoremotionalwellbeing.

Sincetheservicewasrolledoutin2006,theroleofthehealthtrainerhasdevelopedconsiderably,expandingbeyonditsoriginalremitofphysicalactivity,diet,smokingandalcoholintonewareassuchasprovidinghealthchecksandofferingsupportaroundspecificconditions,includingdiabetesandchronicpain.Theserviceisalsonowbasedwithinadiverserangeofsettings,includingprisonandprobation,GPsurgeriesaswellascommunitylocationssuchaslibrariesandcommunitycentres.Despitethisadaptation,thecoregoalsoftheserviceremain,whicharetoreachthemostdeprivedindividualsinsociety,whosufferdisproportionatelypoorhealthoutcomes,andempowerthemtoleadhealthierandhappierlives.

Promoting mental health and wellbeing

Thecentralgoalofthehealthtrainerservice,asarticulatedintheChoosingHealthWhitePaper,istoreducehealthinequalitiesbyreachingouttocommunitiestypicallyseenas‘hardtoengage’,particularlythosefromthemostdeprivedareas.TheDCRSdatademonstratesthatalmosttenyearslatertheserviceremainssuccessfulindoingso;from2012to2015,overtwo-thirdsofclientswerefromthetwomostdeprivedquintiles,43.88%fromquintileoneand23.61%fromquintiletwo(quintileonebeingthemostdeprivedandquintilefivebeingtheleastdeprived).


Asaresultofthisfocus,healthtrainersoftenworkwithclientsexperiencingarangeofcomplexissues,includingphysicalhealthissues,problemsrelatingtothewiderdeterminantsofhealth,suchasfinancial,housingandemploymentconcernsandalso,mentalhealthissues.

Throughourinterviews,almostallofthehealthtrainersandserviceleadsfeltthatmentalhealthformedamajorpartoftheirwork,withmanystatingthatthemajorityoftheirclientssufferfromsuchissues.Onehealthtrainer,forexample,statedthat‘almost in all cases, with all clients, there is a mental health issue alongside it’.

Thehealthtrainerserviceisanexampleofhumanisticpsychology,aservicefocusedonsupporting,motivatingandultimately,empoweringtheirclients.Throughthismethod,healthtrainersareeffectiveinboostingtheconfidenceoftheirclients,helpingthemtofeelmoreengagedandsupportingthemtocopemoreeffectivelywiththestressesofdailylife.Thisaspectofthehealthtrainerroleisimportantinitselfforimprovingmentalwellbeing,andisalsocrucialfortheirsuccessinsupportinghealthybehaviorchange.Improvingclients’mentalresilienceandself-beliefisavitalfirststeptosupportinghealthierlifestylechoices.Oneserviceleadfeltthatjusttheprocessoftheinterventioncanbebeneficialformentalwellbeing,“people don’t always need specific specialist help – it’s part of this social prescribing agenda – people need a purpose to get up and go out. Basic interactions would help a lot of people we see”.

However,despitethisprevalence,formanyclientsthisisnottheprimaryreasontheyaccesstheservice.TheDCRSdataindicatesthatdiet(55.95%)andexercise(21.84%)arethemostpopularreasons,withalmostthree-quartersofclientsenteringtheserviceforsupportintheseareas.Conversely,mentalhealthandwellbeingaccountsforlessthan5%ofrecordedprimaryissues.Thismayindicatethatformanyclientsmentalhealthisanunderlyingissue.

Healthtrainersareuniqueinthetimeandtypeofsupporttheyoffer,oftenhavingfirst-handexperienceoftheissuesonwhichtheyareprovidingsupportandbeingdrawnfromwithinthecommunitiesthemselves.Theyaretherefore,ideallyplacedtodiscussmentalwellbeingwiththeirclients.Oneserviceleadstatedthat“health trainers have an ability to instigate conversations and to listen... clients feel at greater ease talking about those issues”.Similarly,anotherserviceleadfeltthat“when you’ve spent a long time with somebody, people are saying things they wouldn’t necessarily say to a GP... health trainers are more likely to understand those difficult or more complex issues, and are able to effectively signpost”.

TheefficacyofthehealthtrainerserviceforpromotingmentalwellbeingissupportedbyawealthofdataintheDCRS.Asthetablesbelowdemonstrate,acrossarangeofwellbeingmeasures,thehealthtrainersaresupportingsubstantialimprovements.Wehavechosentofocusontwomentalwellbeingmeasures,theWHO-5andWEMWBS,theself-efficacymeasure(theextenttowhichanindividualbelievestheycanachieve)andthegeneralhealthmeasure.


WHO-5 The WHO-5 Wellbeing Index is a tool for measuring mental wellbeing that looks at the following five areas; the extent to which individuals are feeling cheerful, calm and relaxed, active and vigorous, fresh and rested when waking up, and interested in daily activities.

WEMWBS The Warwick-Edinburgh Mental Wellbeing Scale is a tool for measuring mental wellbeing that looks at twelve areas, including for example, the extent to which individuals feel useful, relaxed, confident and optimistic for the future.


A. Pre and post general health score for all health trainer clients, July 2012 – July 2015


General health Before After Change

53.08 66.84 +25.92%

B. Pre and post WHO-5 scores for all health trainer clients, July 2012 – July 2015

WHO-5 Before After Change

44.56 59.03 +32.47%

C. Pre and post WEMWBS for all health trainer clients, July 2012 – July 2015

WEMWBS Before After Change

58.91 69.14 +17.37%

D. Pre and post self-efficacy scores for all health trainer clients, July 2012 – July 2015

Self-efficacy Before After Change

65.88 73.09 +10.94%

Whenthesemeasuresarebrokendownaccordingtothedeprivationquintilesofclients(tablesbelow),thisfurtherdemonstratesthesuccessoftheservice.Despitehavingalowerstartingpoint,healthtrainersareabletosupportclientsinthemostdeprivedquintilestoachieveroughlythesameWHO-5andgeneralhealthscoresasclientsfromthehigherquintiles.Giventhissuccessandtheabilityofhealthtrainerstoreachthe‘hardtoengage’,thisdemonstratestheirpotentialtopositivelyimpacthealthinequalities.



E. Pre and post general health scores by deprivation quintile, July 2012 – July 2015

Quintile Before After Change

52.04 66.79 +28.34%Q1 – Most deprived

52.92 66.83 +26.28%Q2

53.28 66.84 +25.45%Q3

55.09 66.93 +21.49%Q4

55.85 66.91 +19.80%Q5 – Least deprived

F. Pre and post WHO-5 score by deprivation quintile, July 2012 – July 2015


43.58 58.69 +34.67%Q1 – Most deprived

44.53 58.90 +32.27%Q2

45.15 59.39 +31.54%Q3

46.67 59.82 +28.18%Q4

47.43 60.19 +26.90%Q5 – Least deprived

G. Pre and post WEMWBS scores by deprivation quintile, July 2012 – July 2015


59.83 69.09 +15.48%Q1 – Most deprived

56.20 66.57 +18.45%Q2

51.97 64.16 +23.46%Q3

58.52 66.58 +13.77%Q4

70.34 77.04 +9.53%Q5 – Least deprived

H. Pre and post self-efficacy scores by deprivation quintile, July 2012 – July 2015


66.81 73.76 +10.40%Q1 – Most deprived

64.97 72.91 +12.22%Q2

64.95 72.35 +11.39%Q3

66.14 72.35 +9.39%Q4

65.90 72.43 +9.91%Q5 – Least deprived

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Connection between mental and physical health

Inresponsetothementalhealthneedsofclients,manyservicesnowprovidetheirhealthtrainerswithadditionaltrainingonmentalhealthawarenessandtechniquessuchasmotivationalinterviewingandcognitivebehaviouraltherapy.However,severalintervieweesfeltthatthispartofthehealthtrainerroleisnotalwaysrecognisedandinsomeareas,thetrainingisinsufficientfortheirwork,bothintermsofthetypeoftrainingofferedandtheimmediacywithwhichitisprovided.

Oneserviceleadfeltthatthecomplexityoftheirworkisnotalwaysunderstood,statingthat“there are a lot of services out there that still don’t quite get what the health trainers do... There is a perception that the majority of the work is signposting and making referrals and ‘getting the next one in’. The reality is far removed from this’’. Similarly,anotherserviceleadfeltthat“where it is recognised, commissioners have got the impression we just see people who are depressed. Depression isn’t a straight forward illness and they don’t bare the complexity in mind”.

Whilstmanyoftheintervieweesstressedthattheywantedtoprotectthehealthtrainerroleanddidnot wanttobecomedefactocounsellors,theyalsorecognisedtheimportanceofhavingagreaterunderstandingofmentalhealthandcalledformoretraining.Oneserviceleadfeltthatwithoutadditionaltraining“when they (health trainers) get a difficult client, they just become stumped - additional training could boost the confidence of the health trainer’’.

TheDCRSdatasupportsthiscallforadditionaltraining.Acrossanumberofmentalwellbeingmeasures(seetablesbelow),itseemsthatthosewhodonotachieveoronlypartachievetheirgoalstendtohavelowerstartingscoresthanthosewhofullyachievetheirPHP.Thismayindicatethatclientswithlowermentalwellbeingmayneedadditionalsupportanditistherefore,importantforhealthtrainerstohavegreaterawarenessoftheseissues.ThereisalsoanotabledeclineintheWEMWBSscoreandself-efficacyofthosewhodonotachieve,furtherdemonstratingthisimportance.




I. Pre and post general health scores of clients that achieve, part achieve and do not achieve their PHP goals, July 2012 – July 2015

Plan Outcome Before After Change

53.67 69 +28.56%Achieved

51.18 52.99 +3.54%Not Achieved

50.68 60.58 +19.53%Part Achieved

J. Pre and post WHO-5 scores of clients that achieve, part achieve and do not achieve their PHP goals, July 2012 – July 2015


45.44 61.61 +35.59%Achieved

39.26 40.06 +2.04%Not Achieved

41.25 50.16 +21.60%Part Achieved

K. Pre and post WEMWBS scores of clients that achieve, part achieve and do not achieve their PHP goals, July 2012 – July 2015


59.58 70.69 +18.65%Achieved

57.39 53.21 -7.28%Not Achieved

54.73 61.92 +13.14%Part Achieved

L. Pre and post self-efficacy scores of clients that achieve, part achieve and do not achieve their PHP goals, July 2012 – July 2015


66.04 74.56 +12.90%Achieved

60.76 57.8 -4.87%Not Achieved

65.58 67.87 +3.49%Part Achieved


TheDCRSdataalsohighlightsthecomplexissuesfacedbysomehealthtrainerclients.Thosewhoentertheservicewithalowerstartingmentalwellbeingscorealsoseemtohavepoorerstartingscoresinvariousphysicalhealthmeasuresaswell.ThedataindicatesthatasthestartingWHO-5scoreofclientsdecreases,theaveragelevelofmoderatephysicalactivityandconsumptionoffruitandvegetablesalsodecreases,(groupedintofourcategoriesinthetablesbelow),whilstaverageBMIincreases.

Thesetables,whilstdemonstratingsubstantialimprovementsforthosewithlowerstartingWHO-5scores,alsodemonstratethattheseclientsstilldonotachievethelevelsofthosewithgreatermentalwellbeing.Thismayindicatethatpoorermentalwellbeingisactingasabarriertosuccessandtherefore,supportstheneedforhealthtrainerstohaveagreaterunderstandingandawarenessofmentalhealth.Thiswasaconcernsharedbymanyofthepeopleweinterviewed,oneforexample,statedthat“If a client’s depressed or anxious they aren’t going to be thinking ‘I must eat my 5 portions of fruit and veg’ – their personal health is hindered”.


M. Pre and post moderate exercise (30 mins per week) grouped by WHO-5 starting scores, July 2012 – July 2015

Starting WHO-5 scores Before After Change

3.68 5.18 +40.76%75–100 (High)

2.67 4.5 +68.54%50–74

2.29 4.21 +83.84%25–49

1.81 3.93 +117.13%0–24 (Low)

N. Pre and post BMI score grouped by WHO-5 starting scores, July 2012 – July 2015


33.09 31.93 +3.51%75–100 (High)

34 32.74 +3.71%50–74

34.83 33.59 +3.54%25–49

35.1 33.85 +3.56%0–24 (Low)

O. Pre and post consumption of fruit and vegetables score grouped by WHO-5 starting scores, July 2012 – July 2015


3.99 5.35 +34.09%75–100 (High)

3.34 4.93 +47.60%50–74

2.84 4.56 +60.56%25–49

2.43 4.15 +70.78%0–24 (Low)



Therearesimilarfindingswhenexaminingpreandpostmentalwellbeingscores.Asthetablesbelowdemonstrate,thosewhostartwithlowerwellbeingscores,whilstachievingsubstantialimprovements,donotreachthesamelevelasthosewithhigherstartingpoints.Thismayindicatethathealthtrainerscanonlysupportclientstoacertainpointandthatgreatertimeordifferenttypesofsupportwouldberequiredtofullyaddressthementalwellbeingissuesoftheseclients.

P. Pre and post WHO-5 score grouped by WHO-5 starting scores, July 2012 – July 2015


81.95 79.1 –3.48%76–100 (High)

60.97 68.72 +12.71%51–75

38.12 56.89 +49.24%26–50

14.48 34.55 +138.60%0–25 (Low)

Q. Pre and post self-efficacy score grouped by WHO-5 starting scores, July 2012 – July 2015


79.1 81.57 +3.12%76–100 (High)

73.09 77.43 +5.94%51–75

64.07 72.97 +13.89%26–50

53.25 63.78 +19.77%0–25 (Low)

R. Pre and post general health score grouped by WHO-5 starting scores, July 2012 – July 2015


68.79 77.11 +12.09%76–100 (High)

60.07 71.48 +18.99%51–75

49.73 65.75 +32.21%26–50

38.47 56.95 +48.04%0–25 (Low)

A growing challenge


Anintegralpartofthehealthtrainerroleispromotingemotionalwellbeingandsupportingclientswithlowlevelmentalhealthissues,suchassocialisolation,anxietyandstress.However,aclearthemethatemergedfromourinterviewsisthatformanyhealthtrainers,thisisagrowingissue.Whilstthishasalwaysbeenafeatureoftheirwork,healthtrainersareseeinganincreasingnumberofindividualswithmentalhealthissues.Oneserviceleadstatedthat“the nature of the society we live in means that mental health is much more prominent. Welfare changes mean that people are much more stressed, anxious and worried”.

Alongsidethis,however,severalhealthtrainersraisedconcernsthattheyarealsoseeinganincreaseinclientswithmoreseverementalhealthproblems,suchassuicidalthoughts,severedepressionandschizophrenia.Onehealthtrainerstatedthat“I have clients who have psychosis, schizophrenia, self-harmed... sometimes I don’t know what their diagnosis is”.

Theinterviewsindicatedthatthisisinpartduetoinappropriatereferralsfromotherprofessionalsresultingfromalackoffamiliaritywiththehealthtrainerroleandtheremitoftheservice.However,severalofourintervieweesalsostatedthatthisisduetoservicecutsmeaningthattheyarebecominga‘dumpingground’forclientsthatotherprofessionalsdonotknowwhattodowith.

Oneservicemanagerstatedthat“clients are being referred to them (health trainers), because other services don’t know what to do with them – they’ve fallen through the net” and felt that “unless the client is going to make a dangerous decision, there isn’t the support there for them”.Theseconcernsweresharedbyanotherserviceleadwhostatedthat“because of cuts and the reduction of services, without the support of the health trainers there is nowhere for these people to go”.

Forserviceswithgoodlinkstospecialistmentalhealthteams,theirhealthtrainersareabletoreferclientsandworkwiththemalongsidemorespecialistsupport.However,inotherservices,severalofourintervieweesfeltthatalackofintegrationbetweenthehealthtrainerserviceandmentalhealthteamswasamajorchallenge.Thereseemstoberealpotentialforhealthtrainerstoactasabridgefor‘hardtoengage’clientsintomentalhealthservices;onehealthtrainerstatedthat“I often feel it would be better to refer those with mental health issues out to services, because there’s still a stigma attached to mental health and most clients don’t want to go back to their GP and admit they have an issue”.

TheDCRSdataclearlydemonstratestheeffectivenessoftheserviceforpromotingmentalwellbeing.However,supportingindividualswithmoreseverementalhealthproblemsgoesbeyondthehealthtrainerremitandmaynotbeappropriatesupportforthoseclientssufferingfrommentalhealthissues.Onehealthtrainerexpressedconcernthat“when we’re talking about people with the most severe mental health problems: is the health trainer service really meeting their needs? It can help them for a while, but it isn’t behaviour they can necessarily sustain” and stressed that “the health trainer concept is meant to be empowering people, and not creating a dependency. But the people with the most severe mental health problems are looking for something consistent in their life”.

Conclusion

Page 14

TheDCRSoffersawealthofdata,providingalmostanationalpictureofthehealthtrainerservice.UsingtheDCRSdata,thisreport,alongsidepreviouseditions,hasclearlydemonstratedtheeffectivenessofthehealthtrainermodelforsupportingvastimprovementsinmentalwellbeing,aswellaspositivebehaviourchangeamongstclients.

Thisreporthowever,hasgoneonestepfurtherbyseekingtounderstandtheimpactofmentalwellbeingonthesuccessofclients.ThedataindicatesthatthosewithlowermentalwellbeingarelesslikelytofullyachievetheirPHPgoals.Theyarealso,whilstachievingsubstantialimprovementsinhealthandwellbeing,unabletoreachthesamehighscoresacrossarangeofmeasuresasthosewithgreatermentalwellbeing.Thisdemonstratesthatmentalhealthmayactabarriertosuccessforsomeclientsandstronglysupportsthecaseforhealthtrainerstobegivengreatertraininginmentalwellbeingandunderstandingmental healthconditions.

Throughourinterviewswithhealthtrainersandserviceleads,wehavealsouncoveredamoreconcerningtrendofhealthtrainersincreasinglysupportingclientswithmoreseverementalhealthproblemsandinsomeareas,becominga‘dumpingground’formorecomplexcases.Healthtrainersprovidetimeandsupportofferedbynootherservice,theyareatrustedcommunityresourceandasshownbytheDCRSdata,hugelysuccessfulinreachingthosetypicallyseenas‘hardtoengage’.Wemustensurethattheroleofhealthtrainerisprotectedandfullyunderstoodbyotherprofessionalstoavoidinappropriatereferrals.Itisalsovitalthatwherehealthtrainersaresupportingthosewithmentalhealthissues,theyareprovidedwiththenecessarytrainingandsupportfromotherservicesthroughmoreintegratedworking.


Appendix

A. Deprivation quintiles of clients, July 2012 – July 2015

Deprivation Quintiles

No fixed abode

Q1 – Most Deprived

Q2

Q3

Q4

Q5 – Least Deprived

Total

Count Percent

813 0.30%

119841 43.88%

64483 23.61%

39660 14.52%

28886 10.58%

19413 7.11%

273096 100.00%


Appendix

F. Personal health plan achievement, part achievement and non-achievement rates for all clients, July 2012 – July 2015

PHP outcome

Achieved

Not Achieved

Part Achieved

Total

Count Percent

63666 62.47%

7281 7.14%

21148 20.75%

101920 100.00%

B. BMI change for all clients, July 2012 – July 2015

BMI Before After Change

34.14 33.01 –3.31%

C. Weight (Kg) change for all clients, July 2012 – July 2015

Weight (Kg) Before After Change

93.61 90.55 -3.27%

D. Moderate exercise (30 mins per week) change for all clients, July 2012 – July 2015

Moderate exercise Before After Change

2.59 4.47 +72.59%

E. Consumption of fruit and vegetables per day change for all clients, July 2012 – July 2015

Consumption of fruit and vegetables per day

Before After Change

3.01 4.56 +51.50%

Outcome Unknown 9825 9.64%

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1.NHSEngland.Acalltoaction:achievingparityofesteem;transformativeideasforcommissioners.Redditch:NHSEngland,2014

2.BMJ.Tacklingmentalhealthwillbecentraltowhitepaperonpublichealth.Availableonlineat:http://www.bmj.com/rapid-response/2011/11/03/economic-burden-mental-illness-cannot-be-tackled-without-research-investme%20(2010,lastaccessed12thSeptember2015)

3.MentalHealthFoundation.Mentalhealthstatistics:themostcommonhealthproblems.Availableonlineat:http://www.mentalhealth.org.uk/help-information/mental-health-statistics/common-mental-health-problems/(lastaccessed12thSeptember2015)

4.MentalHealthFoundation.Economicburdenofmentalillnesscannotbetackledwithoutresearchinvestment.London:MentalHealthFoundation,2010

5.GovernmentOfficeforScience.Mentalcapitalandwellbeing:makingthemostofourselvesinthe21stcentury.London:GovernmentOfficeforScience,2008

6.HealthTrainersEngland.Abouthealthtrainers.Availableonlineat:http://www.healthtrainersengland.com/(Lastaccessed3rdApril2014)

7.BagnallAM,TrigwellJ,WhiteJ.Healthtrainersendofyearreview1stApril2013–31stMarch2014.Availableonlineat:http://www.leedsbeckett.ac.uk/healthtogether/health-trainers-report.pdf(2014,lastaccessed12thSeptember2015)

References


For more information, please contact Emma Lloyd, [email protected] Society for Public HealthJohn Snow House, 59 Mansell Street, London E1 8ANwww.rsph.org.uk

© RSPH 2015 Charity Registration Number 1125949

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