1. Health behaviour change among users of NHS Health Trainer Services Benjamin Gardner 1, James Cane 1, Nichola Rumsey 2 & Susan Michie 1 1: University College London; 2: University of the West of England 3 rd July 2012

2. This work was undertaken as part of a BPS DHP consultancy to the Department of Health (2003-2010)

3. Evaluations of the NHS Health Trainer Service 2007-09: data from hub leads (‘hub reports’) Yearly audits of workforce and clients –Who are the HTs? –Is the workforce growing? –Who is using the HT service? (Wilkinson et al, 2007; D Smith et al, 2008) 2009: DCRS data Evaluation of service effectiveness Does behaviour change among users of the HT service?

4. Questions 1)Who uses the HT service? - Are we reaching ‘hard to reach’ clients? 2)Does (diet and activity) behaviour change following use of HT service? 3)Do all clients benefit equally?

5. Data Drawn from DCRS –Period: 1 st April 2008 – 31 st March 2009 –Data extracted from DCRS v2.4 by BPCSSA Final extraction for DCRS report: December 2009 Final extraction for paper mid-2010 –Data recording on DCRS then non-compulsory At start of time period, estimated from hub report that 62% of HTSs entered data into DCRS Paper accepted for publication in Dec 2011

6. Data availability

7. Drop-out bias? Setting PHPs: –White clients (35%) and Asian clients (30%) more likely to set PHPs than Black clients (25%) –More PHPs set in least deprived quintile (42%) than others (~36%) Pre-post HTS data availability: –White clients (35%) more likely to have pre-post than Asian (30%) or Black clients (27%) –More data available in least deprived quintile (45%) than others (~29%)

8. Measures Pre- and post-HTS - Baseline demographics - Pre- and post-HTS: Behaviour measures –BMI (height, weight) –Self-reported behaviour (diet [snacks, fruit & veg], activity [moderate/intensive sessions])

9. Results 1) Who uses the HTS? 3503 female (79%) (UK population, 2001 = 51% female) Typical age 36-45 years (22.4%) (UK 2001 = 19%) Deprivation: –Q1 (most deprived):1836 (43.2%) –Q21093 (25.7%) –Q3688 (16.2%) –Q4405 (9.5%) –Q5 (least deprived)230 (5.4%)

10. Results 1) Who uses the HTS? Ethnicity: (UK 2001 = 93% White) –White 3647 (83.2%) –Asian 485 (11.1%) –Black 175 (4.0%) –Mixed or other 79 (1.8%)

11. Results 1) Who uses the HTS – and for what purpose? Weight status: –Obese2717 (72.3%) –Overweight824 (22.4%) –Normalweight218 (5.8%) PHP focus: –Diet3346 (75.7%) –Physical activity1072 (24.3%)

12. Results 2) Diet change following diet PHP achievement OutcomeNumber of clients Pre-HTS mean Post-HTS mean % change Daily fruit & veg (portions) 23763.085.23 70% increase No. of daily fried snacks 18691.990.79 60% decrease BMI316434.3332.45 6% decrease

13. Results 2) Activity change following activity PHP achievement OutcomeNPre-HTS mean Post-HTS mean % change Weekly moderate sessions 9213.064.77 56% increase Weekly intensive sessions 6370.631.71 171% increase BMI59532.4631.24 4% decrease

14. 3) Do all clients benefit equally? Ethnicity or deprivation differences? –All clients Deprivation & BMI: –Less BMI reduction in most deprived quintile vs all others (0.28 BMI points) –Diet: Deprivation & BMI: –Less BMI reduction in most deprived quintile vs all others (0.24 BMI points) Ethnicity & BMI: –Less BMI reduction in Asian versus White clients (0.55 BMI points)

15. Conclusions HTS is reaching disadvantaged clients and changing behaviour Effects similar across demographic groups –But more PHPs set and more data recorded in less deprived groups

16. Challenges and recommendations Missing data problematic –Pre- and post-HTS behaviour data essential Reliance on self-report –May overestimate behaviour change –Ideally need objective measures, e.g. biochemical verification, objectively measured weight Whether data self-report or objective should be recorded

17. Challenges and recommendations Need to ensure continued fidelity to HTS as originally devised Qualitative data needed –Quantitative data allows for ‘birds eye view’ group-level analyses –Qualitative data engages with contextualised individual experiences –Would reveal ‘real-life’ benefits of HTS

18. Challenges and recommendations Qualitative data needed –Brief interviews with clients/feedback from clients? How do clients feel they have benefitted? –Written case studies? Description of individual client’s journey –Need a DCRS repository for qualitative evidence storage

19. Acknowledgements: Janet Andelin and Rachel Carse, Dept of Health Jan Smith, CORE, UCL Ertan Fidan & David Hopkinson, Birmingham Primary Care Shared Services Agency For a copy of the published paper, contact me at b.gardner@ucl.ac.uk Thank you