The Power of Peers

As anyone living with, or involved in the care of someone with, a chronic condition will know - self-management is critical. We also know that knowledge, skills and confidence are core prerequisites for effective self-care management.

 

Peer support can help with the daily management of living with a chronic condition and help build the necessary knowledge, skills and confidence.  Peer supporters may have a role in helping with range of things including:

• Identifying local resources e.g. where to buy healthy foods, good locations for exercise
• Helping people cope with social or emotional barriers
• Helping to keep people motivated to reach their health goals.
• Identifying when it is necessary to seek medical assistance.

 Sounds a bit like the role of a Community Health Champion – right? (we are actually  piloting some work involving GPs, Health Trainers and Health Champions in supporting diabetes management in two areas of the Yorkshire region at the moment).

In Canada, there are a number of Community Health Centre’s delivering self-management programmes. Many of these use the Stanford Programme  as a model of delivery – and a number of them focus on diabetes management.

 Here are just a couple of examples for starters….

 

North Hamilton Community Health Centre runs the Stanford programme of peer support - a chronic disease self-management programme run by volunteers. The training is delivered over 6 weeks with a 2 ½ hour session each week with a focus is on diet, exercise, goal setting, and leadership training and takes a ‘train the trainers’ approach. There are around 15 people in each class and recruitment is usually from community groups. Expenses are paid.

 

The programme co-ordinator, Peter, explained that, as lay leaders, the volunteers are asked to ‘guide from the side’ and told there is no ‘sage on the stage’. This helps to put responsibility on client and to encourage small changes and develop confidence.

Evaluation uses the self-efficacy measures as set by the Stanford Programme (including confidence to perform self-management behaviors, confidence to manage condition in general, confidence to achieve outcomes). Participants are also asked to write a letter to Stanford at the end of the programme to say what they have learnt. Peter told me that these letters were often very powerful and told of the benefits people had gained in terms of taking control over their health and improving their ability to self-manage - and also the benefits of meeting others with the same issues and having increased social networks. More evidence of social capital building!

 

Black Creek CHC Diabetes Program: Live, Learn and Share

In Toronto, I had lunch with Michelle (Diabetes Manager), Spencer (Community Development Worker) and Sandra (Peer Educator), who are involved in a self-management programme around diabetes care in Black Creek.



Spencer, Michelle and Sandra from
Black Creek CHC



The programme is called. “Live, Learn and Share” and their materials on peer support sum up the value of peer support pretty well;

 “Peer relationships promotes respect, trust, warmth and helps empower the individual to make changes and decisions that enhance their lives”

Michelle explained how the programme was developed to meet an identified need. She told me how local people with diabetes, ”wanted to meet others with diabetes, to share experience, break isolation, learn about management strategies and form connections.” – so, as well as improving self management, it’s also about building social capital and connecting people. Community members have been heavily involved in the development of the programme and the training materials, so the training guide is based on, and informed by, individual lived experience and expertise.

Sandra, who has had diabetes for 6 years but only felt able to speak openly about her condition a year ago (as result of her involvement in the peer support programme) – now runs a peer support group for others. She told me how the Peer support programme and training she received gave her, “the knowledge to help other people…and I feel good about that.”

Spencer (who trains the trainers and supports the support groups) explained how the programme uses a strength based approach, “focusing on the wisdom, capacities and expertise of community members.” So - about identifying assets in communities to improve outcomes. Sounding familiar…?

Training for Peer Educators, delivered over 3 x 2.5 hour sessions, focuses on self-management, healthy eating and physical activity – very much like some of the training for Health Champions being delivered by some Altogether Better Projects.

The training for people wanting to set up peer support groups is delivered over 7 x 2 hour workshops and focuses on the role of peer support and the practical skills needed to set up, deliver and evaluate a peer support group.

Spencer shared how the effectiveness of peer support in improving self-management had been shown through research. An RCT (Heisler et al 2010) looked at the efficacy of two alternative approaches helping patients with diabetes develop self-care management efficacy:

• one-on-one telephone conversations between two patients (of similar age )with diabetes
• telephonic nurse care management

The findings show that a simple weekly phone call with a peer facing the same self-management challenges, helped diabetes patients manage their condition and improve their blood sugar levels better than those who used traditional nurse care management services alone. The study also showed that women with uncontrolled diabetes reduced their A1c levels after 6 months in the program.

It seems there is clear role (and financial incentive from a service point of view) for the use of Peer Support in terms of improving self-management and thereby empowering people to take more control of their condition (and their lives) and reducing demand on health services.

In the UK, Community Health Champions and Health Trainers are playing a partial role in some areas – but this is by no means any sort of universal provision and many people with chronic conditions continue to struggle with self management issues.  So – why aren’t peer support systems a more integral part of the wider health care system? Seems a no-brainer to me…

Sources:

The Black Creek Diabetes Programme Training Manual can be found here.  

The ‘Self-help Provincial Network’ has many materials for individuals interested in self-help / peer support www.selfhelp.on.ca

References:

Heisler, et al.  Diabetes Control With Reciprocal Peer Support Versus Nurse Care Management – A Randomized Trial. Annals of Internal Medicine. 2010;153:507-515.

Dale, J. et al.  Peer support telephone calls for improving health. The Cochrane Library. 2009, Issue 3.

The journey so far...

I am meeting so many people (the business cards below represent a large number but there have been many more!). And those people introduce me to other people or organisations who have an interest or experience in the subject of my fellowship. It is a true snowballing effect! I just wish there were more hours in the day and more energy in my bones to be able to take full advantage....

So - I am coming to the end of week three of the fellowship and have spent time in Toronto, Ottawa and Montreal so far. All great cities for different reasons (and am not sure I'm allowed to have a favourite anyway...).

I have attended 4 different conferences, visited 11 organisations and spent time in communities where services are targeted. I have also had countless conversations with people about Community Health Champions, the Altogether Better programme and  our work in the UK. Some conversations - as you might expect - were at conferences and events but others were more random - like whilst eating a Beaver Tail in Ottawa, over Moules Mariniere and at the Bixi Bike stand in Montreal! Seems Canadians like to chat...which is great!

There's too much to report the details but to give you a flavour - here are a couple of highlights from my time in Toronto...

My visit to Health Nexus in Toronto provoked some interesting thoughts about the social determinants, of health and health equity. Health Nexus 'view health broadly' (as their strapline says) and have been enabling communities to promote health for the past 25 years. They assist organizations and individuals  to develop and implement prevention and health promotion strategies that aim to enhance well-being and reduce demand on the health care and social service systems. Community Health Champions could be one such strategy and I was able to share our evidence reviews and resources. Thanks to Peg, Barb, Subha and Suzanne for the stimulating discussion (and tasty lunch!). 

Visit to Health Nexus, Toronto

The Wellesley Institute  is a non-profit research and policy institute with  a focus on developing research and community-based policy solutions to the problems of urban health and health disparities. We spent a useful  afternoon sharing information about our respective areas of work.  Of particular interest was their work around Peer Health Ambassadors - (more on that later) and a participatory action research project on how neighbourhoods affect well-being in one densely populated area of Toronto (St James Town). You can read more about the St James Town  initiative here. 

Tomorrow I leave for Nova Scotia, a weekend in Halifax and then onto the Coady Institute in Antigionish (which I have now learnt how to pronounce correctly... or so I am informed when I pull a quizzical face). After Nova Scotia I head west to Vancouver (via the Rockies...very excited) for some much needed R 'n' R before heading south to Seattle to complete this part of the journey.

Phew.

Better get packing....

Community Health Centres: An empowering and holistic approach to well-being

Whilst in Toronto, I attended the Ontario Association of Health Centre’s Conference – along with a few hundred others from across Canada and further afield. I was also fortunate enough to get the opportunity to visit a couple of Centres to see what goes on there.

Community Health Centres (CHCs) seek to provide services to those whose circumstances mean they may be vulnerable to poor health or face obstacles accessing the care they need  - they also aim to give people a voice and a choice about how their health care is delivered. An empowering idea of an approach if ever I heard one…but what’s the reality?

There are 1,500 Community Health Centres (CHCs) across North America but only 300 in Canada (most are in the States). Only 4% of the population of Ontario have access to a CHC and it is estimated that around 18% need access, so provision is lacking for many communities.

CHC’s provide primary care (and other services) to those with limited financial resources and focus on meeting the basic health care needs of their individual communities. They provide services to a range of groups living in poverty with who may otherwise face barriers to services e.g. homeless, residents of public housing, migrant workers, refugees, Aboriginal peoples. Centre's have an open-door policy, providing treatment regardless of an individual’s income or insurance cover.  They provide comprehensive care, including physical, mental and dental care.

As the opening speaker at the conference stated, CHCs;

“were born out of the struggle to create more equitable health and have a crucial role to play as catalysts of change”.

CHCs;

 “take a bottom up approach to serving communities….and recognise there is a circle of care that extends beyond clinical health.” 

 The Canadian model of CHCs has been heavily informed by the USA model where, it is claimed, the provision of CHCs has resulted in between 25 – 35% costs saved to the health care system (according to the National Association of CHCs - Centres save the US national health care system between $9.9 billion and $17.6 billion a year by helping patients avoid emergency rooms and making better use of preventive services).

The Community Health Centre model of care focuses on five service areas:

·         Primary care

·         Illness prevention

·         Health promotion

·         Community capacity building

·         Service integration

So - what are these Centres like....? I popped along to a couple to investigate...

North Hamilton Community Health Centre

I visited the North Hamilton Community Health Centre (NHCHC) about an hour from Toronto. Earlier this year, the centre moved to an environmentally friendly and very smart new building. The Centre is described as the “anchor” in the heart of the community it serves and is a place for community members, partners and staff to share together and work towards health and well-being - for present and future generations.

North Hamilton Community Health Centre

NHCHC uses a holistic approach to improving health of individuals and families and communities.  Elizabeth Beader,  Executive Director, shared with me their vision of, “No obstacles to health” and mission, “to enable health through healing, hope and wellness.”. So it’s not just about providing GP services (although primary care provision is based here too)…

NHCHC has around 180 visits per day and provides a wide range of services and facilities including:

1.       Community room

2.       Community kitchen

3.       Primary care services

4.       Children’s programs

5.       Pathways to education programme – encourages and incentivizes Grade 8 students at risk of ‘dropping out’ to stay in school by working with pupils and parents.

6.       Health Wellness Gymnasium – a smart new facility which is free to access. Helping address financial barriers to accessing private gym facilities for some community members.

7.       Health promotion

8.       Foot care

9.       Diabetes programs – including an outreach programme visiting shelters and  helping homeless people to manage their diabetes. Delivered using a partnership approach with Shelter Health Network and community centres.

10.   ‘Drop in day’ for seniors – to learn about services available, enjoy a healthy lunch and socialize with other older adults in the community

11.   Dietitians service

12.   Occupational Therapy

13.   Physiotherapy

14.   Client support services / counselling / social care

NHCHC also helps facilitate community outreach events with over 30 programs offered. Seen as essential for promoting the CHC programs and services available, these include:

·         Volunteer appreciation dinner – an annual event to thank the 200+ volunteers who lend skills and time to assist clients.

·         Community Health Day – which included an open house focused around healthy food (with a healthy lunch) and a discussion on the social determinants of health where the community were invited to share their thoughts on what could be done to create positive change around each determinant.

They also run a volunteer led Peer Support programme for people with chronic illness, which had some similarities with our Community Health Champion approach. The approach is based on the Stanford Programme and I’ve discovered this programme (or adaptations of it) are run by a number of CHCs…so will write a separate post on this later.

Access Alliance - Toronto

I also visited Access Alliance - a Community Health Centre based to the east of Toronto in an area with an extremely diverse community including many new immigrants and refugees. Their Vision statement reflects this – “Toronto’s diverse communities achieve health with dignity.” They seek to, “improve health outcomes for the most vulnerable immigrants, refugees, and their communities by facilitating access to services and addressing systemic inequities”.

The centre is based on a series of beliefs which inform their approach and strongly reflect the community driven, empowering approach to reducing health inequities:

·         All people should have access to the resources and supports they need.

·         Anti-oppression principles strengthen our work.

·         The strength and resilience of immigrants and refugees enriches our City.

·         Innovation thrives in a diverse environment.

·         Diverse sources of knowledge inform our practice.

·         Collaboration broadens our impact.

·         We are accountable for the provision of high quality services and programs.

Access Alliance CHC, Toronto

As we walked around the centre, in addition to the well equipped and pristine clinical and examination  rooms  - we were also shown the roof top community garden, the basement 'den' for young people to connect with each other in a safe environment, the Internet 'cafe' area where community members can access information and meet with each other and the range of art work on the walls which had been produced by community members and gave a real sense of ownership. All in all a great facility reaching and providing services to some of those in greatest need.

Some of the art work produced by local young people
 at Access Alliance.

The Access Alliance model of care can be found here.

Going Global!

I spent the last 2 days discussing community health workers and community empowerment with a group of people from all over the world. I joined delegates from India, Iran, Bangladesh, Pakistan, Brazil, Ecuador, Kenya, South Africa, the Congo, Canada*, Australia* and New Zealand* - and was also lucky enough to meet with some of the people I will meet in South Africa in October for part 2 of my fellowship.

Just some of our International grouping!

The focus of the two day event was on Comprehensive Primary Health Care (CPHC) and it marked the end of a 4 year international study co-ordinated by Ron Labonte at the University of Ottawa and David Sanders at the University of the Western Cape in South Africa. The project - ‘Revitalising Health Care for All’ - involved 20 projects in 20 different countries and more than 60 researchers.

The projects had identified a number of key themes - many of which were of interest and relevance to my fellowship including: 

1.  Community Health Workers  (CHWs)
2. Community Empowerment
3.  Inter-sectoral working

We know that models and roles of Community Health Workers (CHWs) across the world vary. As just two of many examples, in northern India the ASHA (Accredited Social Health Activists) are volunteers whose role is focused around child and maternal health whilst in Iran the 'Behvarz' are paid, permanent employees of the health system who receive 2 years training to prepare them for their role which is focused on helping to build community capacity and mobilising community members. 

Despite these differences - learning from the experience of other countries where health needs, resources and policies may be very  different to the UK, was extremely helpful in terms of offering an alternative perspective - though it seems many issues are the same the world over.

We were reminded that the original rationale for CHWs in the developing world was to address the fact that poor families were less likely attend or access state health care facilities, and that CHWs could have a role in increasing access to services.   The findings from the project also demonstrated a number of other potential roles undertaken by CHWs:

1.      Health care provider

2.      Advocate for community

3.      Agent of social change

4.      Facilitating inter sectoral / partnership work

Some research gaps in relation to CHWs were identified which reflect some of the outstanding questions have about Community Health Champions in the UK:

1.      What are the communities views on CHWs?

2.      What factors constrain or facilitate CHWs in operating as agents of change?

3.      What factors and polices could improve recruitment and retention of CHWs?

4.      Which roles should CHWs undertake?

5.      What are the possible negative effects of CHW programmes?

6.      What payment and support systems are needed?

There was also much discussion about the wider social determinants of health (e.g. housing, education, poverty) and the role of community health workers in helping to address these. This quote clearly illustrates the need to not just tackle ‘health’ as an issue – but also those factors that impact on health:

“what good will it do to treat people’s illnesses…and then send them back to the conditions that make them sick?”

Community participation and empowerment processes were also recognised as effective in improving population health and increasing levels of social capital.  We talked about mobilising communities as part of the wider CPHC agenda - and how CHWs may have a role in identifying and mobilising community assets.

There were questions raised around the somewhat sticky issue of how we define and measure community empowerment - and how we demonstrate empowerment in a way that speaks to funders and policy makers, so that they take it seriously. Seems this isn't an issue unique to the UK...but just how do you convince funders to pay for empowerment activities when they are so often hooked on tangible, measurable health outcomes such as smoking cessation or reduced hospital admissions? Whilst we have developed some ideas around this linked to our work on demonstrating social capital and our Altogether Better Evidence Reviews on empowerment and well-being (both of which I was able to 'plug'!) it remains a challenge.

Ron Labonte (Project Grantholder) and Sara (Iran),
Sara (Canada) and Sarah (UK)!

There was lots of interest in our work in the UK and  - all in all - it was a great forum with a great bunch of people -  all passionate about improving health equity and health outcomes for all and I was very glad to be part of it.

The ’Revitalising Health for All’ project has database of articles on CPHC from each of the participating countries.



* most delegates were working in low to middle income countries. Those people from Australia, New Zealand and Canada were representing Indigenous communities within those countries who still face many barriers to health care and are considered low/middle income countries within wealthier nations.

Health as a ‘hook’ for engagement

Today I went to Pembroke (Ontario) to meet with some of the volunteers who have been involved in the CHAP programme in Ontario. CHAP (the Cardiovascular Health Awareness Program) is a community-based program that brings together GPs, pharmacists, other health professionals, volunteers, and health and social service organizations to work together to promote and actively participate in the prevention and management of heart disease and stroke. Volunteers are trained to take blood pressure checks from those aged over 65 in pharmacies and other community settings (including Walmart stores). A volunteer ‘greeter’ would meet people on arrival and explain the process – another volunteer would take the BP check and collect other lifestyle information.

The programme was developed in partnership with McMaster University and has been piloted in 20 communities with impressive results – a 9% reduction in hospital admissions for cardiovascular disease for those aged over 65. (Read the full study in the BMJ).

Whilst this reduction in hospital admissions is an impressive result and will be sure to make health care commissioners take interest  – I also learnt today about some of the other ‘softer’ outcomes of the programme and how it had a potential role in increasing social capital for participants.



CHAP volunteers Gary and Laura
and Co-ordinator Holly.



Volunteers Gary, Laura and Delores told me how the main problem for most of the people who came for BP checks was not physical, “they are people who face barriers to getting out and socialising…who want to talk and tell their story”.

They went on to explain how they would see the same people at each session and how the BP check and the sessions themselves, “became a ‘hook’ to get people involved, provided a place to meet and a way to connect people”. In some cases the volunteers developed a ‘peer mentor’ role, offering advice on issues such as portion size and telling people about other services they could access - all activities which further enable people to feel more empowered to make decisions about their own health and well-being and,  potentially, increase social capital.

Read more about the CHAP programme here.

Sport: More than just a hockey game...

Another day – another interesting connection made.

I spent of couple of enjoyable hours today with Christina Parsons of the True Sport Foundation  - learning about their efforts to work with asset based approaches in four communities across Canada.

True Sport is not just about sport. It is a national social movement and enabler for sport AND for community. Its core mission is;

“to be a catalyst to help sport live up to its full potential as a public asset for Canada and Canadian society – making a significant contribution to the development of youth, the well-being of individuals, and quality of life in our communities.”

As Christina says, "sport is an asset  where people come together to integrate, to communicate and to make new connections", and sport can also be, "a tool to help build more resilient communities".

So – it’s not just about playing hockey (though I understand - for many Canadians - that’s very important too….).

As their information leaflet states; at the heart of True Sport is the simple idea that “good sport can make a great difference.” True Sport believe that sport embodies a range of principles which are applicable way beyond the playing field - and  are neatly summed up in this short film.

·         Go for it – Always rise to the challenge.

·         Play fair – Play honestly and obey the rules.

·         Respect others - respect teammates, competitors and officials both on and off the field

·         Keep it fun – Have a good time.

·         Stay healthy – respect your body, stay in shape.

·         Give back – do something that helps your community

Through working with communities via Community Foundations in the four pilot areas, True Sport has funded a range of activities aimed at increasing accessibility and inclusivity in ‘sport’ – in its broadest sense (from increased recreation and use of parks and green spaces to more structured, traditional  ‘sporting activities’).

The criteria for funding applications states that all projects should involve sport (obviously) but should also:

• Enhance a sense of belonging to the community
• Allow neighborhood residents to give back to the community (e.g. through volunteering)
• Build skills, knowledge and ability to continue to strengthen the community in the future

So the programmes are not just about sport – they are about identifying and mobilizing community assets, about embedding and promoting the principles of good community engagement – and about building social capital.

Read more about True Sport and ABCD approaches here