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HEARTY LIVES CRAIGAVON PROJECT

FINAL EVALUATION REPORT

January 2013 – February 2016

February 2016

HEARTY LIVES Craigavon

28448 SHSCT Hearty Lives Craigavon Project Report Books.indd 1 26/02/2016 08:00

2

HEARTY LIVES CRAIGAVON PROJECT FINAL EVALUATION REPORT

Contents Introduction to Hearty Lives Craigavon 3 Context 5 Evaluation Strategy and Methodology 8 Project Development and Delivery 12

Hearty Lives Craigavon Partnership 16

Case Studies

Hearty Lives Craigavon: Health Assessments 18

Hearty Lives Craigavon in the Workplace 32

Engaging with the Irish Traveller’s Community 37

Engaging with BME Community Groups 47

Community Development and Community Planning 55

Appendix

Hearty Lives Craigavon Steering Group Members 63

References 63

Jane Turnbull Education and Development February 2016

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INTRODUCTION TO HEARTY LIVES CRAIGAVON The Project Partnership The Hearty Lives Craigavon Project was funded for three years by the British Heart Foundation (BHF) and managed by the Southern Health and Social Care Trust (SHSCT). The Hearty Lives Craigavon project aims to improve heart health for Black Minority Ethnic (BME) and Irish Traveller Communities. The Project commenced in January 2013 and the existing funding stream ceased in March 2016. The Hearty Lives Craigavon Project was led by the Southern Health and Social Care Trust, developed in partnership with Armagh City, Banbridge, and Craigavon Borough Council (the Council), Craigavon Traveller Support Committee, Community Intercultural Programme, and the Public Health Agency; and was funded by the British Heart Foundation. In addition to the formal cross-sectoral Steering Group partnership, the basis of Hearty Lives Craigavon was that this would be a Project delivered in partnership at all levels. Operationally partnerships have been built with community and voluntary organisations, workplaces, education, GP Surgeries, and Pharmacies. The Project The BHF funding was used to appoint a part time Hearty Lives Coordinator (30 hours a week) to coordinate and deliver the Hearty Lives Craigavon initiative with the Irish Traveller and BME populations within the Craigavon area. The Project Coordinator has a nursing background. There were eight core objectives for the Hearty Lives Craigavon Project: 1. To increase awareness of Heart Health within the Traveller and BME communities

through health improvement approaches; 2. Awareness-raising and brief intervention training for workplace managers, GPs,

community workers and local healthcare professionals; 3. To plan, co-ordinate and deliver assessment services for CVD risk factors to BME and

Traveller communities; 4. Liaison with community leaders, health professionals and employers for the effective

implementation of this service; 5. To develop and oversee enactment of referral pathways to ensure that Travellers and

BME community are navigated into appropriate primary or secondary care services; 6. To network with organisations and initiatives focused on reducing the risk of CVD, e.g.

community-based stop smoking services, local walking and cycling initiatives, weight management programmes, nutrition and healthy eating programmes, etc.;

7. To work with the providers of community-based health and wellbeing initiatives to ensure that these programmes can be orientated towards the specific target groups;

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8. To follow up with individuals to assess and record the impact of both the screening and treatment/intervention services in relation to health behaviour on themselves and their families where appropriate.

There were ten specific Project outcomes: 1. There will be increased knowledge and skills to support heart health within Traveller and

BME communities, support workers and organisations /employers; 2. CVD screening will have been accessed by 140 adults in the Traveller community over 3

years; 3. CVD screening will have been accessed by 600 adults in the BME/migrant communities

over 3 years; 4. 56 members of the Traveller community will have accessed primary care for

management of CVD risk factors. 180 members of BME/Migrant worker communities will have accessed primary care for management of CVD risk factors;

5. A minimum of 30 Travellers will have embedded lifestyle changes in support of heart health;

6. A further 100 Travellers including adults and children will benefit from the programme; 7. A minimum of 180 adults in BME/Migrant communities will have embedded lifestyle

changes in support of heart health; 8. Enhanced ways of working will have been developed, tested and evaluated that

demonstrate how to engage marginalised groups to improve health; 9. Local HSC professionals and GP’s knowledge and awareness about the health status of

the population groups in relation to CVD will have increased; 10. Champions will have been identified and trained within the population groups to further

develop this approach.

The Final Evaluation Report The Final Evaluation Report presents the wider context within which HeartyLives was delivered, the evaluation strategy and methodology, the Project development and delivery to meet the needs of the Irish traveller and BME communities, and the way in which the Project worked in partnership strategically and operationally. The Report also presents five Case Studies; which each include the delivery process, impact for the target groups, lessons learnt and the legacy. Each Case Study is a stand alone document; together the five Case Studies provide a comprehensive understanding of the Hearty Lives Craigavon Project.

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CONTEXT Heart Disease Hearty Lives Craigavon is part of the British Heart Foundation £12 million UK-wide Hearty Lives programme to reduce geographical inequalities in heart disease. Through this initiative, BHF works in partnership with local health and social care services and local authorities to tackle geographical inequalities in heart disease. There have been 31 Hearty Lives Projects around the UK including three in Northern Ireland (BHF funding of Hearty Lives Cookstown finished in 2014 and the Project has been sustained by funding from another source; Hearty Lives Carrickfergus is funded by the BHF until June 2016). Cardiovascular disease (CVD) is a major cause of death and disability in Northern Ireland. In 2012 more than one in four deaths (27%, 4,001 deaths) in Northern Ireland were due to diseases of the circulatory system.i As heart disease is one of the main causes of death and disease in the Craigavon Borough Council area and in an effort to address this British Heart Foundation (BHF) Northern Ireland awarded £100,000 funding for the Hearty Lives Craigavon project. The prevention of cardiovascular disease is dependent on the reduction in major risk factors such as smoking, high blood pressure, hazardous alcohol use, diabetes, cholesterol, waist-circumference and physical inactivity.ii Research conducted to investigate the reduction in coronary heart disease mortality in Northern Ireland found that 65% of this decrease was as a result of reductions in the cardiovascular risk factors of cholesterol (40%), smoking (24%) and blood pressure (40%). However, it also raised concerns about the future impact of the growing trends in diabetes, physical inactivity and obesity on the cardiovascular disease burden.iii The relationship between socio-economic disadvantage and cardiovascular disease (CVD) is well established. Cardiovascular disease remains one of the main contributors to the differential in life expectancy.iv Access to cardiovascular services may be reduced for people living in deprived areas, Irish Travellers, and BME community. Changes in cardiovascular disease (CVD) risk factors can be brought about through intervention at both an individual level in terms of behaviour change and at population level though development of appropriate policy and legislation.v As illustrated below, cardiovascular health is also influenced by other social and economic factors such as housing, employment and transport.vi

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Source: Putting a health inequalities focus on the Northern Ireland cardiovascular service framework summary report. Health impact assessment Northern Ireland cardiovascular service framework. Belfast: Public Health Agency, 2011. Local Context The Southern Health and Social Care Trust took on board evidence that Irish Travellers and BME communities, including migrant workers within the Craigavon area, are at greater risk of the risk factors associated with CVD and of developing heart disease than the rest of the population. Therefore, the purpose of the Hearty Lives Craigavon Project was to increase engagement with the Irish Traveller community, the BME community, and migrant workers in relation to preventing heart disease, early identification of risk factors, support for lifestyle change, increased uptake of treatment services and interventions. As a result of the funding a tailored and targeted approach was offered to meet the needs of these communities and overcome the difficulties they can face in accessing services. This focus can take place without removing existing opportunities from those in the resident and non-migrant communities. A scoping exercise was undertaken at the start of the Hearty Lives Craigavon Project. Those who engaged with the scoping exercise were asked to facilitate the administration of the Baseline questionnaire with 46 Irish Travellers and 69 people from BME communities, including people from Chinese, Bulgarians, Portuguese, and Polish nationalities. Key findings from the Baseline Survey showed:

Within the Irish Traveller community significant issues identified included that most felt they had a very healthy heart; despite the data showing that high numbers are smokers, have low

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Source: Putting a health inequalities focus on the Northern Ireland cardiovascular service framework summary report. Health impact assessment Northern Ireland cardiovascular service framework. Belfast: Public Health Agency, 2011. Local Context The Southern Health and Social Care Trust took on board evidence that Irish Travellers and BME communities, including migrant workers within the Craigavon area, are at greater risk of the risk factors associated with CVD and of developing heart disease than the rest of the population. Therefore, the purpose of the Hearty Lives Craigavon Project was to increase engagement with the Irish Traveller community, the BME community, and migrant workers in relation to preventing heart disease, early identification of risk factors, support for lifestyle change, increased uptake of treatment services and interventions. As a result of the funding a tailored and targeted approach was offered to meet the needs of these communities and overcome the difficulties they can face in accessing services. This focus can take place without removing existing opportunities from those in the resident and non-migrant communities. A scoping exercise was undertaken at the start of the Hearty Lives Craigavon Project. Those who engaged with the scoping exercise were asked to facilitate the administration of the Baseline questionnaire with 46 Irish Travellers and 69 people from BME communities, including people from Chinese, Bulgarians, Portuguese, and Polish nationalities. Key findings from the Baseline Survey showed:

Within the Irish Traveller community significant issues identified included that most felt they had a very healthy heart; despite the data showing that high numbers are smokers, have low


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levels of exercise, have a poor diet, lack of knowledge about the health benefits of fruit and vegetables, drink alcohol, and use non-prescription drugs.

The Chinese community reported that they had poor knowledge regarding heart disease but their health appears to be good. Significant issues included a considerable number were not registered with a GP. The group appears to have a higher rate of high blood pressure and high cholesterol than other groups. Just under a third of the respondents stated they do not exercise. Another area of concern is the use of Chinese herbal medicine and its unknown benefits.

Within the Bulgarian community significant issues were that a third were not registered with a GP, a quarter felt that there was nothing they could do to prevent heart disease, only a quarter of people recognised diabetes as a risk factor, and they had slightly higher alcohol consumption than other groups.

Within the Portuguese community (targeted through the Dom Silva Restaurant) it was highlighted that 100% of those that participated were smokers, and that the majority consume alcohol regularly on a weekly basis. Through the Hearty Lives Craigavon Project, the risk factors identified through the Baseline Health Needs Assessment Survey for these communities were addressed through health checks, the facilitation and delivery of activities and programmes, and information and support to help individuals make positive lifestyle changes to reduce their risk of CVD.

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levels of exercise, have a poor diet, lack of knowledge about the health benefits of fruit and vegetables, drink alcohol, and use non-prescription drugs.

The Chinese community reported that they had poor knowledge regarding heart disease but their health appears to be good. Significant issues included a considerable number were not registered with a GP. The group appears to have a higher rate of high blood pressure and high cholesterol than other groups. Just under a third of the respondents stated they do not exercise. Another area of concern is the use of Chinese herbal medicine and its unknown benefits.

Within the Bulgarian community significant issues were that a third were not registered with a GP, a quarter felt that there was nothing they could do to prevent heart disease, only a quarter of people recognised diabetes as a risk factor, and they had slightly higher alcohol consumption than other groups.

Within the Portuguese community (targeted through the Dom Silva Restaurant) it was highlighted that 100% of those that participated were smokers, and that the majority consume alcohol regularly on a weekly basis. Through the Hearty Lives Craigavon Project, the risk factors identified through the Baseline Health Needs Assessment Survey for these communities were addressed through health checks, the facilitation and delivery of activities and programmes, and information and support to help individuals make positive lifestyle changes to reduce their risk of CVD.


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EVALUATION STRATEGY AND METHODOLOGY Following a tendering process in summer 2014, Jane Turnbull, Education and Development, was appointed as the external evaluator of the Project. Core outputs from the evaluation were the Baseline Report, Midterm Evaluation Report, the Final Evaluation Report, and a series of case studies. The Evaluation Approach Evaluation needs to take into account the original aims, objectives, outcomes, and outputs; and to reflect and review the extent to which these have been met. On occasion it may be necessary to work with the funding body to review objectives and outcomes – due to the changing nature of the environment in which an intervention is working. Evaluation can support such discussions. Evaluation reports should feed into the review and development process of any project or programme; thus formative evaluation offers greater value to an initiative than an evaluation carried out at the end of a project (which may be seen as simply a historical document). Robust evaluation needs to work to a plan or logic model; and collect both quantitative and qualitative data. It should be a positive experience; as it offers the opportunity to reflect and review – and will report the impact of an intervention on people’s lives (at both individual and community level). A further core element of the evaluation process is to record and present added value and any unexpected outcomes (both positive and negative). Evaluation offers the opportunity for critical reflection. It should record not only what is working well; but also where things are not going as planned and challenges experienced by the project team and partners. Often more can be learned from the latter. Arguably, if everything is running perfectly well then insufficient innovation or risks are taking place. Hearty Lives Craigavon – Evaluation Objectives The overarching aim of the evaluation process is to provide a comprehensive assessment of the extent to which the Hearty Lives Craigavon project is achieving its outcomes and effecting positive change within the population groups and key stakeholders across the Craigavon Borough Council area. The Specification for the evaluation of Hearty Lives Craigavon outlines nine objectives: 1. To assess the extent to which the project has fulfilled the agreed outcomes and achieved

any unexpected/additional outcomes for health and wellbeing 2. To determine whether the Hearty Lives Craigavon project is effecting positive lifestyle

change and health improvement change with its target populations

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3. To assess the wider health improvement impact of the project with and beyond the target populations

4. To provide an analysis of the extent to which the project complements/duplicates other community-based health improvement initiatives/approaches in the Craigavon area

5. To provide an analysis of the extent to which the Hearty Lives Craigavon project enables the target groups to improve their access to and make use of community, voluntary or statutory health services

6. To determine the effectiveness of the steering group in delivering the outcomes of the Hearty Lives Craigavon project

7. To record and analyse the number and demographics of people participating in Hearty Lives Craigavon programmes as above – with particular attention paid to target groups

8. To analyse existing data and to gather and analyse new data related to the participation experience, perception of benefit and health impact of Hearty Lives Craigavon from the perspectives of participants, project staff, strategic partners and other key stakeholders

9. To assess the effectiveness of existing data-gathering mechanisms/tools currently used to measure performance against outcomes within the project and to provide additional or alternative mechanisms/tools as appropriate.

Prior to engaging the external evaluator, the Hearty Lives Craigavon Steering Group developed two Logic Models – one relating to the work and outcomes to be delivered for the BME community and one for the Irish Travellers. These are presented on the next two pages.

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Hea

rty

Live

s C

raig

avon

– L

ogic

Mod

el- T

rave

ller C

omm

unity

In

puts

Out

puts

Out

com

es -

Impa

ct

A

ctiv

ities

Pa

rtic

ipat

ion

Sh

ort T

erm

Yr

1

Med

ium

Ter

m Y

r 2

Long

Ter

m Y

r 3

Situ

atio

n

W

hat w

e in

vest

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t we

do

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we

reac

h

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t ter

m

resu

lts

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ium

term

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sults

U

ltim

ate

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ct

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elle

r co

mm

uni

ty

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er

life

expe

ctan

cy

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her

rate

s of

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VD

incl

udin

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art

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ase

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ke

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ls o

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ctor

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nds

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e

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perti

se

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ls

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log

y R

esou

rces

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ap s

ervi

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and

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tiviti

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fer t

o Tr

avel

ler p

opul

atio

n in

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ppor

t of h

eart

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entif

y ga

ps in

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vice

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ovis

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even

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tting

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milie

s in

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tion

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tyle

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eart

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lth

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aini

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ty o

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nd

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mun

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elle

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igav

on

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ose

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sk

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ers

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rs

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cies

–

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utor

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mun

ity,

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ntar

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and

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ate

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ease

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cess

to h

eart

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th

info

rmat

ion

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crea

sed

awar

enes

s of

he

art h

ealth

risk

fa

ctor

s In

crea

sed

prom

otio

n of

he

art h

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ac

tiviti

es a

nd

prog

ram

mes

In

crea

sed

acce

ss to

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reen

ing

for

CVD

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crea

sed

pers

onal

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spon

sibi

lity

for

hear

t hea

lth

Incr

ease

d us

e of

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reen

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and

serv

ices

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ilabl

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to im

prov

e he

art

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th

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ease

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rtici

patio

n in

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alth

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esty

le/

hear

t hea

lth re

late

d ac

tiviti

es a

nd

prog

ram

mes

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crea

sed

capa

city

w

ithin

or

gani

satio

ns

enga

ging

with

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avel

ler

com

mun

ity to

pr

omot

e aw

aren

ess

of

hear

t hea

lth &

up

take

ser

vice

s

Ev

iden

ce o

f re

duce

d C

VD ri

sk

fact

ors

with

in

Trav

elle

r pop

ulat

ion:

ob

esity

, sm

okin

g,

alco

hol i

ntak

e,

men

tal h

ealth

pr

oble

ms,

lack

of

phys

ical

exe

rcis

e,

diab

etes

, ch

oles

tero

l, hi

gh

bloo

d pr

essu

re

Evid

ence

of

beha

viou

r cha

nge

in

supp

ort o

f hea

rt he

alth

D

ecre

ased

gap

in

heal

th in

equa

litie

s du

e to

CVD

St

reng

then

ed

stak

ehol

der

enga

gem

ent &

in

tera

genc

y w

orki

ng

to s

uppo

rt he

art

heal

th w

ithin

A

ssum

ptio

ns

Ex

tern

al fa

ctor

s

Eval

uatio

n:

Foc

us –

col

lect

dat

a –

anal

yse

and

inte

rpre

t - re

port

Visi

on

The

Trav

elle

r co

mm

unity

hav

e in

crea

sed

know

ledg

e ab

out

hear

t hea

lth &

ac

cess

life

styl

e su

ppor

t pr

ogra

mm

es a

nd

scre

enin

g to

re

duce

risk

of

CV

D.

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11

Hea

rty

Live

s C

raig

avon

– L

ogic

Mod

el- B

ME

Com

mun

ity

In

puts

Out

puts

Out

com

es -

Impa

ct

A

ctiv

ities

Pa

rtic

ipat

ion

Sh

ort T

erm

Yr

1

Med

ium

Ter

m

Yr

Long

Ter

m Y

r 3

Situ

atio

n

W

hat w

e in

vest

Wha

t we

do

Who

we

reac

h

Shor

t ter

m

resu

lts

Med

ium

term

re

sults

U

ltim

ate

impa

ct

BM

E

com

mun

ity

Lo

wer

life

ex

pect

anc

y H

ighe

r ra

tes

of

CVD

in

som

e gr

oups

in

clud

ing

hear

t di

seas

e an

d st

roke

H

ighe

r le

vels

of

card

iova

scul

ar ri

sk

fact

ors

Hea

lth

ineq

ualit

ies

BH

F Fu

nds

and

reso

urce

s

Partn

er

Org

anis

atio

ns’

Tim

e

Advi

ce a

nd

Expe

rtise

M

ater

ials

Eq

uipm

ent

Tech

nolo

gy

Res

ourc

es

Map

ser

vice

s &

ac

tiviti

es o

n of

fer t

o B

ME

com

mun

ities

in

supp

ort o

f hea

rt he

alth

and

iden

tify

gaps

in s

ervi

ce

prov

isio

n Es

tabl

ish

prev

entio

n,

educ

atio

n an

d ris

k sc

reen

ing

serv

ices

w

ithin

com

mun

ity

setti

ng

Supp

ort a

nd

cont

ribut

e to

the

deve

lopm

ent o

f in

tegr

ated

pat

hway

s fo

r hea

rt he

alth

Fa

cilit

ate

com

mun

ity

activ

ities

for B

ME

co

mm

uniti

es i

n re

latio

n to

hea

lthy

lifes

tyle

and

Hea

rt H

ealth

scr

eeni

ng

Trai

ning

/bui

ld

capa

city

of

sta

ff

B

ME

po

pula

tion

of

Cra

igav

on

area

Th

ose

at ri

sk

of C

VD

Partn

ers

and

st

akeh

olde

rs

Agen

cies

–

Stat

utor

y,

Com

mun

ity,

Volu

ntar

y, a

nd

Priv

ate

Incr

ease

d ac

cess

to

hear

t hea

lth

info

rmat

ion

In

crea

sed

awar

enes

s of

he

art h

ealth

ris

k fa

ctor

s In

crea

sed

prom

otio

n of

he

art h

ealth

ac

tiviti

es a

nd

serv

ices

In

crea

sed

acce

ss to

sc

reen

ing

for

CVD

In

crea

sed

pers

onal

re

spon

sibi

lity

for h

eart

heal

th

Incr

ease

d us

e of

scr

eeni

ng

and

serv

ices

av

aila

ble

to

impr

ove

hear

t he

alth

In

crea

sed

parti

cipa

tion

in

heal

thy

lifes

tyle

/ hea

rt he

alth

rela

ted

activ

ities

and

pr

ogra

mm

es

Incr

ease

d ca

paci

ty w

ithin

or

gani

satio

ns

enga

ging

with

B

ME

com

mun

ities

to

prom

ote

Ev

iden

ce o

f re

duce

d C

VD ri

sk

fact

ors

with

in B

ME

com

mun

ities

: ob

esity

, sm

okin

g,

alco

hol i

ntak

e,

men

tal h

ealth

pr

oble

ms,

lack

of

phys

ical

exe

rcis

e,

diab

etes

, ch

oles

tero

l, hi

gh

bloo

d pr

essu

re

Evid

ence

of

beha

viou

r cha

nge

in s

uppo

rt of

hea

rt he

alth

D

ecre

ased

gap

in

heal

th in

equa

litie

s du

e to

CVD

St

reng

then

ed

stak

ehol

der

enga

gem

ent &

in

tera

genc

y w

orki

ng to

sup

port

hear

t hea

lth w

ithin

As

sum

ptio

ns

Ex

tern

al fa

ctor

s

Eval

uatio

n:

Foc

us –

col

lect

dat

a –

anal

yse

and

inte

rpre

t - re

port

Visi

on

BM

E

com

mun

ities

ha

ve in

crea

sed

know

ledg

e ab

out h

eart

heal

th a

nd

acce

ss li

fest

yle

supp

ort

prog

ram

mes

an

d sc

reen

ing

to re

duce

risk

of

CV

D.

11


PROJECT DEVELOPMENT AND DELIVERY TO MEET NEEDS OF THE IRISH TRAVELLER AND BME COMMUNITIES

Health Checks

The Project Coordinator carried out health checks targeting people from the Irish Traveller and BME communities. The health check included Blood Pressure, Blood Sugar, and BMI; and provided the opportunity for one-to-one conversations with individuals about lifestyle choices.

The table below presents the number of health checks undertaken, the number of individuals who have had a health check, and the number of people who have returned for a further health check between June 2013 and December 2016.

Community Total

Screenings No. of

Individuals No. of

Returners BME Community 642 564 78 Irish Travellers 181 84 42 Those outside the target groups 711 711 - Total 1534 1359 120

The data presented in the total screenings column relates to the number of health checks that the Project Coordinator has carried out; the number of individuals column presents the number of different people who have had health screenings, because – as presented in the final column – 78 from the BME Community and 42 Irish Travellers have returned to have the health check repeated on a number of occasions, and to get further advice (and support) from the Project Coordinator.

Health Check Protocols to identify those ‘at risk’

Protocols used to assess whether blood pressure and cholesterol health check results are classified as ‘high-risk’, and recommended blood glucose levels are taken from the National Institute for Health and Care Excellence (NICE) guidelines (2011). These are shown below. Further details are given about the protocols used in the Health Checks Case Study.

Individuals with high-risk health check results are referred to their GP. They are given a letter of referral, and a copy is sent to their GP. A copy of all the health screenings undertaken at workplaces were forwarded to the Occupational Health Nurse on site or Human Resources.

The table below shows the number of people from the Irish Traveller and BME communities referred to their GP for follow up categorised by health risk and target group.

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Target Community

High Blood Pressure

High Blood Sugar

BMI in excess of 30

Total

BME Community 52 19 37 108 Irish Travellers 4 2 12 18 Total 56 21 49 126

Some people were referred because they have one or more risk factors identified during the health check: 2 people had high blood pressure and high blood sugar who were not a diabetic. 2 people had high blood pressure and high BMI 3 people had high blood sugar and high BMI known diabetic but not on medication 1 person on oral medication for diabetes had high blood sugar and high BMI 1 person with high blood sugar and high BMI was an insulin dependent diabetic 1 person had high blood pressure, high blood sugar and high BMI. In total 100 people have been referred to the GP following the Hearty Lives Craigavon Health Check. 82 people who participated in the Hearty Lives Craigavon Project completed a ‘Service User Questionnaire’. There were high levels of satisfaction with the Health Checks, the information received and the service provided. Over three quarters of the respondents (76%) reported making healthy lifestyle changes. Further feedback from beneficiaries is given in the Health Checks Case Study. Registration with a GP The Project Co-ordinator identified early on that a number of people who attended for a health check said that they were not registered with a GP and others did not know who their GP was (if they become seriously ill individuals reported that they either go to Accident and Emergency or, in the case of the BME target group, return ‘home’). 27 people told the Project Coordinator that they were not registered with a GP, and others gave the name of the wrong GP (this is known because GPs sent the referral letter back to the Project stating that the individual was not registered with them). The Project Co-ordinator encouraged individuals to register with a GP, highlighting the benefits for themselves and their families. She provided individuals with information obtained from the ‘Business Services Organisation’ website. The website provides translated application forms online and what to do if they are having difficulties registering or have been refused registration with a GP surgery. 22 people have registered with a GP (12 Bulgarians, 7 Chinese, 2 Greek, and 1 Polish person); two people said they were in Northern Ireland on Holiday; and it is likely that the other three people who did not register had immigration status issues.

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Raising Community Awareness of Heart Health A total of 110 information sessions and workshops have been delivered in the community and in the workplace. 2129 people have engaged in programmes and workshops in the community or in the workplace. The table below presents the number of programmes and the total number of people attending each programme.

Summary Information

sessions Heart Start

Smoking Cessation

Total

Number of BME community programmes

46 17 4 69

Total number of people in the BME community

1285 134 24 -

Number of Irish Traveller Programmes

13 2 - 15 + 10 other programmes

Number of Irish Travellers

248 + 24 children

9 - -

Number of programmes in the workplace

30 3 3 36

Number of people in the workplace

772 39 59 -

In addition, British Heart Foundation information stands are now placed across 7 primary care and 14 community settings. The Project Coordinator has maintained the resources during the Project; and the settings will continue to do so themselves in the future through using the BHF resources website. In total, 29 different community groups working with BME communities in Craigavon and the surrounding area have requested one or more programmes or information sessions. Further information about raising awareness about heart health, programmes, and interventions is given in the Case Studies. Hearty Lives in the Workplace Initially engagement with workplaces was quite difficult, but Autumn 2014 saw a significant increased engagement with workplaces; and positive outcomes were achieved over time. Health Screenings have taken place with employees from the BME community on site at four different companies. A copy of all health check results has been forwarded to the Occupational Health Nurse, Human Resources and the individual’s GP. Delivery of Hearty Lives Craigavon in the Workplace has included:

1414

Raising Community Awareness of Heart Health A total of 110 information sessions and workshops have been delivered in the community and in the workplace. 2129 people have engaged in programmes and workshops in the community or in the workplace. The table below presents the number of programmes and the total number of people attending each programme.

Summary Information

sessions Heart Start

Smoking Cessation

Total


46 17 4 69

Total number of people in the BME community

1285 134 24 -


13 2 - 15 + 10 other programmes

Number of Irish Travellers

248 + 24 children

9 - -


30 3 3 36


772 39 59 -

In addition, British Heart Foundation information stands are now placed across 7 primary care and 14 community settings. The Project Coordinator has maintained the resources during the Project; and the settings will continue to do so themselves in the future through using the BHF resources website. In total, 29 different community groups working with BME communities in Craigavon and the surrounding area have requested one or more programmes or information sessions. Further information about raising awareness about heart health, programmes, and interventions is given in the Case Studies. Hearty Lives in the Workplace Initially engagement with workplaces was quite difficult, but Autumn 2014 saw a significant increased engagement with workplaces; and positive outcomes were achieved over time. Health Screenings have taken place with employees from the BME community on site at four different companies. A copy of all health check results has been forwarded to the Occupational Health Nurse, Human Resources and the individual’s GP. Delivery of Hearty Lives Craigavon in the Workplace has included:


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30 information sessions involving 772 employees 3 Heartstart Training Programmes involving 39 employees 3 Smoking Cessation programmes, engaging 59 people in the workplace.

The impact of Project delivery in the workplace, as reported by the Company champions included: • Raised awareness within the workplace regarding cardiovascular health. • Smoking cessation services were made available in the workplace; with good numbers

attending on a regular basis. • Employees engaged well with the health screenings and anecdotal feedback suggested

that they felt empowered to take more control of their own health. Case Study 2 focuses on the delivery, impact, lessons learned and legacy from the delivery of Hearty Lives Craigavon in the Workplace. Summary of the Hearty Lives Project Interventions

1359 people have had a Hearty Lives Craigavon health check in the community: 564

from the BME community, 84 from the Irish Travellers community, and 711people who do not fall within the two core target groups

The Project has developed good working relationships with 8 workplaces. 464 people have had a Hearty Lives Craigavon health check in the workplace

110 people have been referred to their GP following the health check with an ‘at risk’ result; including abnormal blood sugar 18, high blood pressure 43 and high BMI 49. Some people were referred because they had two at-risk results.

120 people have sought follow-up health checks and on-going advice from the Project Coordinator

256 people have engaged in programmes and workshops 24 Traveller children attended a Heart Health workshop delivered by the Project

Coordinator 21 people have been assisted to register with a GP Programmes or workshops have been delivered to 9 community organisations Total beneficiaries: 6441

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PARTNERSHIP

The Hearty Lives Craigavon Steering Group is cross-sectoral, with representatives from statutory, voluntary, and community sectors (see Appendix One). The Evaluation Questionnaire to inform the Final Evaluation Report was sent to all members of the Steering Group. Seven members completed and returned the Questionnaire. The partners were unanimous that partnership working has been key to the success of the Project.

Members of the Steering Group identified three core elements that contributed towards the success of the Hearty Lives Craigavon Project partnership model: shared resources and experience, a shared vision, and building strong relationships.

Shared Resources and experience • The Project Coordinator effectively utilised her links with the wider Promoting Wellbeing

team, Council Inequality staff and Community and voluntary sector agencies to support delivery of the programme and activities for the project participants. • Working in partnership has added value through the sharing of information and resources,

which improved outcomes for service users. • By working in partnership with the Trust and Public Health Agency the Hearty Lives

Coordinator has been able to gain access to facilitator training for various health and wellbeing programmes such as Weigh to Health, Smoking Cessation, Cook-it and Heartstart. • One organisation alone cannot meet all the needs of Irish Travellers and BME

Communities. Partnership working allows different organisations to pool resources and build capacity for the purpose of meeting the needs of those they deliver services to. • Working in partnership sets an example of how best to share funds and resources but still

meet the objectives and the needs.

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A shared vision • All partners working together for the same outcomes. • Working in partnership with the Council has also permitted the Hearty Lives Coordinator to

become an active member of the Craigavon Heart Town Steering Group and enabled joint delivery of the Heartstart programme which allows for increased numbers onto Heartstart programmes which in turn improves the rolling out of CPR training in the community. • Irish Traveller – working in partnership with CTSG meant that the existing links they had

with the Irish Travellers could be the vehicle to assess need, plan activities and deliver services which hopefully as part of the legacy will be maintained when the funding ceases. • Working in partnership with BME organisations provided an open door to share and jointly

meet objectives of the BME organisation and that of the project. Building strong relationships • Open, honest and transparency sharing ideas ensuring that everyone has a voice. • Working with workplaces was an important partnership approach to engaging with the

BME working community. • Face to face contact allowing time to build trusting relationships with the individuals

in these target communities. • Working in partnership has provided various in roads for the Hearty Lives Coordinator

gaining access to the BME Community and Irish Travelling Community. For example through Craigavon Travellers Support Committee, Wah Hep and Richmount. • Partnership working is not easy, commitment from partners is also difficult especially when

there are competing priorities. Having the ability to look at each operational partner’s strategic plans/objectives would be useful, this would give the opportunity to review and highlight how the partnership would be beneficial in helping meet these.

Partnership Case Story: The Heartstart Training Programme The British Heart Foundation set up the Heartstart programme in 1996. BHF’s aim is to create a Nation of Lifesavers through the Heartstart Programme and their Call, Push, Rescue model of training. To date over 3.5 million people have attended a Heartstart course across the UK. There are over 3,800 Heartstart schemes across the UK supported by the BHF. Heartstart courses are free and last approximately two hours. Topics covered include dealing with an unconscious person, the signs and symptoms of a heart attack, recognising a cardiac arrest and performing CPR, choking, and serious bleeding. The Project Coordinator and the lead partner from the Council (Investing for Health officer) completed the BHF Heartstart Train the Trainers course. This enabled them to deliver the training to the target audiences through the Hearty Lives Project. They delivered the first Hearty Lives Craigavon Heartstart Programme in March 2014 and since then have delivered 22 Heartstart Programmes in partnership to 182 people in community groups and workplaces.

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CASE STUDY HEARTY LIVES CRAIGAVON: HEALTH CHECKS

Context: Hearty Lives Craigavon

The Hearty Lives Craigavon Project, funded by the British Heart Foundation (BHF), aimed to tackle Heart Health of the Irish Traveller Community and Black Minority Ethnic (BME) communities within the area previously covered by Craigavon Council, by increasing awareness of the risk factors contributing to cardiovascular disease (CVD) and encouraging positive lifestyle changes. 80% of heart disease, stroke and Type 2 Diabetes could be prevented through lifestyle changes; including healthy diet, regular physical activity and avoidance of tobacco.

The development and implementation of the Hearty Lives Craigavon Project has included: Awareness-raising of CVD risk factors and awareness raising events with workplaces,

community groups and community workers and local healthcare professionals. Planning, co-ordinating and delivering health assessment services for CVD risk factors

to Irish Travellers and BME communities. Liaising with community leaders, health professionals and employers for the effective

implementation of this service. Developing and overseeing enactment of referral pathways to ensure that Irish

Travellers and people from the BME communities are navigated into appropriate health improvement, primary or secondary care services.

Networking with organisations and co-ordinating delivery of initiatives focused on reducing the risk of CVD; for example community-based stop smoking services, local walking and cycling initiatives, weight management programmes, nutrition and healthy eating programmes, etc.

Working with the providers of community-based initiatives to ensure that these programmes can be tailored towards the health needs of each specific target group.

Following up with individuals to review and record the impact of both the Health Check results and treatment/intervention services in relation to health behaviour on themselves and their families where appropriate.

The Hearty Lives Craigavon Project has been delivered in partnership; partners include the Southern Health and Social Care Trust (who manage the Project), Armagh City, Banbridge and Craigavon Borough Council, the BHF, and the Public Health Agency. The Project employed a Health Coordinator (30 hours a week).

Evidence undertaken prior to the start of the Hearty Lives Craigavon Project suggested that both the BME and Irish Traveller communities do not routinely access the opportunity for health checks. Anecdotally this is for a number of reasons including a lack of awareness of primary care services, fear of statutory agencies, lack of communication or language skills, people not being registered with a GP, and a lack of health prevention awareness.

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Context: The Irish Traveller Community

The All Ireland Traveller Health Study1 states that there are 3905 travellers in Northern Ireland. Approximately sixty families, 12% of the NI Irish Traveller total, live in the Craigavon area. The Southern Trust Action Plan (2005)2 reports that the health and wellbeing of travellers is worse than that of the most disadvantaged people in the settled population. As a result of health inequalities the Irish Traveller community was identified as having a higher risk of developing cardiovascular disease, and therefore were a target group within the Hearty Lives Craigavon project.

Health inequalities experienced by the Irish Travellers community include: Only 10% of the community live beyond 40 years of age and only 1% beyond 60years of

age They are more likely to experience ill health due to poor living conditions, low educational

attainment, limited employment opportunities and social exclusion. Literacy levels exacerbate health inequalities; less than half the community have basic reading and writing skills.

Obesity due in part to a lack of awareness in relation to healthy eating, preparing and cooking food

A tendency for inappropriate approaches to weight management within the community (including starving, vomiting, and using laxatives and slimming pills).

The Manager of the Craigavon Traveller Support Committee has been an active partner within the Hearty Lives Craigavon Project and a member of the Project Steering Group. An added advantage is that the Craigavon Traveller Support Committee is located within the same building as the Hearty Lives Health Coordinator.

Context: The Black and Ethnic Minority Community

People from a wide range of countries and communities are represented within the BME community in the Craigavon, Lurgan and Portadown area. Many people from these communities suffer health inequalities due to poor levels of access to available services; language and cultural barriers; poor housing; and low income. In March 2012, the Southern Health and Social Care Trust reported the top ten requested language translations were Polish, Lithuanian, Portuguese, Tetum, Russian, Latvian, Slovak, Chinese-Cantonese, Hungarian, and Chinese-Mandarin.

At the start of the Project, feedback from the Cardiac Rehabilitation Services at Craigavon Area Hospital indicated lower levels of uptake of secondary care services indicating that only six individuals from the BME community have attended the Cardiac Rehabilitation Phase 3

1 All Ireland Traveller Health Study – Our Geels. Summary of Findings, All Ireland Health Study Team, University College Dublin, 2010 2 2 Promoting Wellbeing Strategic Action Plan, Southern Health and Social Care Trust, 2005

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Context: The Irish Traveller Community

The All Ireland Traveller Health Study1 states that there are 3905 travellers in Northern Ireland. Approximately sixty families, 12% of the NI Irish Traveller total, live in the Craigavon area. The Southern Trust Action Plan (2005)2 reports that the health and wellbeing of travellers is worse than that of the most disadvantaged people in the settled population. As a result of health inequalities the Irish Traveller community was identified as having a higher risk of developing cardiovascular disease, and therefore were a target group within the Hearty Lives Craigavon project.

Health inequalities experienced by the Irish Travellers community include: Only 10% of the community live beyond 40 years of age and only 1% beyond 60years of





The Manager of the Craigavon Traveller Support Committee has been an active partner within the Hearty Lives Craigavon Project and a member of the Project Steering Group. An added advantage is that the Craigavon Traveller Support Committee is located within the same building as the Hearty Lives Health Coordinator.

Context: The Black and Ethnic Minority Community

People from a wide range of countries and communities are represented within the BME community in the Craigavon, Lurgan and Portadown area. Many people from these communities suffer health inequalities due to poor levels of access to available services; language and cultural barriers; poor housing; and low income. In March 2012, the Southern Health and Social Care Trust reported the top ten requested language translations were Polish, Lithuanian, Portuguese, Tetum, Russian, Latvian, Slovak, Chinese-Cantonese, Hungarian, and Chinese-Mandarin.

At the start of the Project, feedback from the Cardiac Rehabilitation Services at Craigavon Area Hospital indicated lower levels of uptake of secondary care services indicating that only six individuals from the BME community have attended the Cardiac Rehabilitation Phase 3

1 All Ireland Traveller Health Study – Our Geels. Summary of Findings, All Ireland Health Study Team, University College Dublin, 2010 2 2 Promoting Wellbeing Strategic Action Plan, Southern Health and Social Care Trust, 2005


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programme and accessed available services. Feedback also suggested that there is a tendency within the BME community to delay seeking intervention from health professionals until individuals are very unwell. Primary prevention and early intervention in relation to cardiovascular disease and promoting wellbeing, prior to illness, was identified as a priority.

A report published by the Northern Ireland Council for Ethnic Minorities (June 2013) presents feedback about the experiences of BME women in Northern Ireland. 13.6% said access to health services was poor, and 15.8% said they had had a poor experience. Those who were dissatisfied with their health and social care experience felt they had not got the medical treatment they needed, that they were discriminated against, no interpreter was available, there was no cultural sensitivity and they experienced long waiting times.

The vision for the future for BME Communities, through the delivery of the Hearty Lives Craigavon Project, was to increase individual and community knowledge of heart health, facilitating access to lifestyle change support programmes, and delivering health checks to reduce the risk of Cardiovascular Disease. Across the Craigavon area there are a number of organisations that work with the BME community. Partnership opportunities within the Hearty Lives Craigavon Project were been explored, and the Project developed working relationships with a range of community organisations.

Process

The Project Co-ordinator carries out health checks which included the following:: smoking status, alcohol intake, Blood Pressure, Blood Sugar, and BMI.

The Project Coordinator completed a form in triplicate for all health checks, one was retained by the Project, a copy was given to the client, and a copy was forwarded to the GP. Additionally, a copy of all the health check results undertaken at the work place was sent to the Occupational Health Nurse or Human Resources on site.

Protocols used to assess whether blood pressure results are classified as ‘high-risk’, and recommended blood glucose sugar levels are based on the National Institute for Health and Care Excellence (NICE) guidelines and the British Heart Foundation guidance. These are shown in Appendix One. Individuals with high-risk health check results are referred to their GP. They are given verbal advice to attend their GP with a copy of their health screening, and a copy of the health screening results is also sent to their GP.

Project Implementation

During Hearty Lives Craigavon health checks have taken place across a range of settings including group environments, out in the community, and in local workplaces.

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The table below shows the number of health checks that have taken place and the range of different groups and organisations in the community that have engaged with the Hearty Lives Craigavon Project.

Organisation Health Checks

Irish Travellers 181 health checks, 84 individuals Community Intercultural Programme 152 Wah Hep 134 Splash Surestart / Chrysalis 111 Richmount 91 Seagoe Polish Saturday School 69 Portuguese Restaurant 35 Lismore Comprehensive 27 Midnight Soccer 25 Southern Regional College Lurgan 24 Polish Shop 15 Rushmere 14 Southern Regional College Portadown 14 Brazilian Restaurant 11 BME Deaf Group 9 Ameera 8 Total number of health checks: 920

The table below shows the number of health checks that have taken place with companies who have engaged with the Hearty Lives Craigavon Project; promoting the health checks to employees (predominantly from the BME communities) in the workplace.

Company Health Checks

Moy Park 241 Interface 92 APB Meats 69 Huhtamaki 46 BHF Shop Portadown 7 Almac 7 Tesco Craigavon 2 Total number of people: 464

“It was great to have a nurse talking to us as a lot of people will not go to the doctor. The Project had a big impact on the whole community. It is good because it is local and the Nurse [Project coordinator] comes to the site.”

Irish Traveller

21

Coordinator] comes to the


23

The table below presents the number of health checks undertaken, the number of individuals who have had a health check, and the number of people who have returned for a further health check between June 2013 and December 2016.

Community Total Health

Checks No. of

Individuals No. of

Returners BME Community 642 564 78 Irish Travellers 181 84 42 Those outside the target groups 711 711 - Total 1534 1359 120

The data presented in the total health checks column relates to the number of health checks that the Project Coordinator has carried out; the number of individuals column presents the number of different people who have had health screenings, because – as presented in the final column – 78 from the BME Community and 42 Irish Travellers have returned to have the health check repeated on a number of occasions, and to get further advice (and support) from the Project Coordinator.

“This was a very useful project. All information sessions were well attended. There is scope for the screening to be continued. This is by nature a migrant community with people coming and going all the time. If the screening does not continue the long term impact will be reduced”.

Community Worker with the BME Community 22


24

Those identified as being high-risk


Target

Community High Blood Pressure

High Blood Sugar

BMI in excess of 30

Total


Some people were referred because they have one or more risk factors identified during the health check: 2 people had high blood pressure and high blood sugar who were not a diabetic. 2 people had high blood pressure and high BMI 3 people had high blood sugar and high BMI known diabetic but not on medication 1 person on oral medication for diabetes had high blood sugar and high BMI 1 person with high blood sugar and high BMI was an insulin dependent diabetic 1 person had high blood pressure, high blood sugar and high BMI.

In total 100 people have been referred to the GP following the Hearty Lives Craigavon Health Check.

Impact

82 people who participated in the Hearty Lives Craigavon Project completed a ‘Service User Questionnaire’. Half the respondents were from the workplace, and half from the community. Appendix Two presents the data in full.

“Many people have been targeted from all generations, each generation brings new behaviours and new problems. Hearty Lives has assisted Craigavon Travellers, children have been involved, and there has been a big impact.”

Irish Traveller

Everyone who responded had a health check undertaken with the Project Coordinator, over one third had sought further information; and over a quarter took part in the Heartstart training programme. There were high levels of satisfaction with the information received and the service provided.

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24

Those identified as being high-risk


Target

Community High Blood Pressure

High Blood Sugar

BMI in excess of 30

Total


Some people were referred because they have one or more risk factors identified during the health check: 2 people had high blood pressure and high blood sugar who were not a diabetic. 2 people had high blood pressure and high BMI 3 people had high blood sugar and high BMI known diabetic but not on medication 1 person on oral medication for diabetes had high blood sugar and high BMI 1 person with high blood sugar and high BMI was an insulin dependent diabetic 1 person had high blood pressure, high blood sugar and high BMI.

In total 100 people have been referred to the GP following the Hearty Lives Craigavon Health Check.

Impact

82 people who participated in the Hearty Lives Craigavon Project completed a ‘Service User Questionnaire’. Half the respondents were from the workplace, and half from the community. Appendix Two presents the data in full.

“Many people have been targeted from all generations, each generation brings new behaviours and new problems. Hearty Lives has assisted Craigavon Travellers, children have been involved, and there has been a big impact.”

Irish Traveller

Everyone who responded had a health check undertaken with the Project Coordinator, over one third had sought further information; and over a quarter took part in the Heartstart training programme. There were high levels of satisfaction with the information received and the service provided.


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“We have found the Coordinator to be very engaging with our clients and always demonstrated a strong sense of empathy and cultural competence in providing practical solutions to issues which clients presented. At an organisational level it was extremely beneficial to have someone who, brought a high degree of expertise to the role, an understanding of our service provision and had a flexible approach to delivering an essential service in a pleasant, unassuming manner”.

Community Worker

Over three quarters of the respondents (76%) reported making healthy lifestyle changes. The most frequently mentioned changes were doing more exercise and eating more healthy meals (including for example; less take away food, reduction in food consumption in general, and reduction in the intake of sugar, biscuits and crisps).

“I’m doing more exercise during the week and having more attention with cooking food and choosing the meal”.

Portuguese respondent

Summary of the Hearty Lives Project Interventions

1359 people have had a Hearty Lives Craigavon health check in the community: 564 from the BME community, 84 from the Irish Travellers community, and 711people who do not fall within the two core target groups

The Project has developed good working relationships with 8 workplaces. 464 people have had a Hearty Lives Craigavon health check in the workplace

110 people have been referred to their GP following the health check with an ‘at risk’ result; including abnormal blood sugar 18, high blood pressure 43 and high BMI 49. Some people were referred because they had two at-risk results.

120 people have sought follow-up health checks and on-going advice from the Project Coordinator

256 people have engaged in programmes and workshops 24 Traveller children attended a Heart Health workshop delivered by the Project

Coordinator 21 people have been assisted to register with GP Programmes or workshops have been delivered to 9 community organisations Total beneficiaries: 6441

Raising Community Awareness of Heart Health

A total of 110 information sessions and workshops have been delivered in the community and in the workplace. 2129 people have engaged in programmes and workshops in the

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community or in the workplace. The table below presents the number of programmes and the total number of people attending each programme.

Summary Information

sessions Heartstart Smoking

Cessation Total


46 17 4 69

Total number of people in the BME communities

1285 134 24 -


13 2 - 15 + 10 other

programmes Number of Irish Travellers

248 + 24 children

9 - -


30 3 3 36


772 39 59 -

In addition, British Heart Foundation information stands are now placed across 7 primary care and 14 community settings. The Project Coordinator has maintained the resources during the Project; and the settings will continue to do so themselves in the future through using the BHF resources website.

Lessons Learnt from the Hearty Lives Health Assessment (Health Check) Model

• Face to face contact supports the building of trusting relationships. • Health checks were completed by a qualified Nurse; this was a good way for this project to

engage with these communities, sometimes referred to as ‘hard to reach groups’. The Nurse instilled confidence in the beneficiaries. • Outreach and out of office hours work was carried out as required; meeting the needs of

the target groups (ie 9 to 5 hours are not suitable or accessible for everyone). • The number of people identified as not registered with a GP in the BME population was

concerning and highlights the need for an ongoing service to ensure those new to the country are registered with a GP. • The need for referral to primary care was not as high as anticipated. • The good working relationship with CTSC supported follow-up work with Irish Travellers.

Those who had at-risk health check results after the initial appointment, continued to meet with the Project Coordinator. During these meetings individuals received additional lifestyle information, gained a greater understanding about their prescribed medications and advice they were given from the GP, engaged in Healthy Lives Programmes, and had further health checks to record improvements. Conversely, little is known about the outcomes of many of the BME community who had at-risk results and were referred to their GP. This

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not only highlights the benefit of close partnership working; but also points to the need for resources to be allocated to implement follow-up protocols, such that a better understanding of the impact and outcomes can be recorded and measured.

Legacy The number of Health Checks carried out has surpassed the targets

originally set out in the application. Health trainers have been identified within some community /voluntary

sector groups, who will continue to deliver programmes promoting a healthier lifestyle.

The contacts made across workplaces and community groups engaging with the Traveller and BME population can be built upon in the delivery of future services.

Processes and resources have been developed in relation to health checks, supporting people to register with a GP and can be shared with other service providers.

The newly commissioned NI New Entrants Service (NINES) will support GP registration, and early screening for health risk factors by qualified staff. This service should build on the models of good practice developed within Hearty Lives.

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CASE STUDY 1: APPENDIX ONE PROTOCOLS USED FOR HEALTH CHECKS Blood Pressure Protocol: NICE Guidelines 2011 Protocol for Cholesterol: NICE Guidelines 2011

Normal Range – ie for individuals who are not Diabetics, have not been diagnosed with Heart Disease, and where there is no family history of Angina or Heart Attack before the age of sixty: the total cholesterol should be: < 5 mmols

For individuals who are Diabetics, have been diagnosed Heart Disease, or where there is a family history of Angina or Heart Attack before the age of sixty: the total cholesterol should be: < 4.0 If the Cholesterol reading is greater than normal range the individual is referred to their GP. In addition the Project Coordinator provides advice and leaflets about diet and healthy lifestyle choices. The Project Coordinator did not carry out Cholesterol checks (which is considerably more expensive to carry out than the other health checks). However, she has liaised with a local Pharmacist who has the approved equipment, and has screened ten members of the Chinese community alongside the Project Coordinator. She also recommends that individuals with two or more high-risk health screening results ask their GP for a cholesterol check. BMI Protocol: British Heart Foundation protocols (2009)

Irish Travellers and Caucasian: BMI≥ 30: Refer to GP for Weight Management

Black African, Caribbean, South Asian, Chinese, Middle Eastern or Mixed Family Origin: BMI≥27.5: Refer to GP for Weight management

Recommended target blood glucose level ranges

BP ≥ 140/90

Take second BP reading

If BP remains ≥ 140/90

provide lifestyle advice

Refer to GP

BP ≥ 180/110

Symptoms of Retinal haemorrhage, headache, feeling unwell, palpitations

or pallor

Refer to GP – same day or if out of hours refer to out of hours GP

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CASE STUDY: APPENDIX ONE


29

Individual’s Health History

Recommended target blood glucose level ranges

Non-diabetic 4.0 to 5.9 mmol/L Non-diabetic Type 2 diabetes 4 to 7 mmol/L Type 2 diabetes Type 1 diabetes 4 to 7 mmol/L Type 1 diabetes Children w/ type 1 diabetes 4 to 8 mmol/L Children w/ type 1

diabetes

CASE STUDY: APPENDIX SERVICE USER FEEDBACK

Respondent Profile

18 to 30 years old 31 to 60 years old Over 60 years old Male 8 24 1 Female 12 36 1

Yes No Registered with a Doctor or Health Centre 80 0 0 Registered with a Dentist 76 2 2

What is your nationality? Nationality No. of responses

British 43 Polish 12 Irish Traveller 6 Lithuanian 4 Latvian 3 Chinese 2 Czech 2 Irish 2 Portuguese 1 Norwegian 1 Unknown 1

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Not Sure


30

How did you first hear about the Hearty Lives Craigavon Project?

Nationality No. of responses Work 42 Wah Hep 11 CIP Women’s World 6 During this interview 5 CIP 4 Craigavon Heart Town 4 Support Committee 3 Not sure 3 Sure Start 2 British Heat Foundation Website 1 Support at Moylinn 1

The Hearty Lives Craigavon Project

Question Yes No Did you have a health check done by the Project Coordinator?

81 1

Did you understand what the Hearty Lives Coordinator told you about the Project, her role and what the project can offer you?

80

Were you satisfied with the verbal heart health information given to you about healthy lifestyle changes?

80

Were you satisfied with the written information about heart health given to you about healthy lifestyle changes?

77

Overall were you satisfied with the service provided by the Hearty Lives project?

75 5 1

Have you made any lifestyle changes after your health check or other Hearty Lives activity?

62 6 4

Have you taken part in any other Hearty Lives Activities? If so please tick the box

Heartstart Walking Group Getting more advice No. of responses 25 4 31

29

Not Sure


31

Please briefly say what lifestyle changes you have made (for example more physical exercise, changes to what you eat, stopped or reduced smoking cigarettes:

Lifestyle Changes No. of responses

Eating healthy meals / Better diet* 24 Doing more exercise 20 Healthier lifestyle 4 Joined a Walking Group 2 Cut down on smoking 2 Visiting the doctor more quickly 2 Cycling 1 Stopped smoking 1 Started taking medication 1 Walking 1

* Examples mentioned included: less take away food, reduction in food consumption in general, reduction in the intake of sugar, biscuits and crisps.

Would you like to take part in another Hearty Lives Activity?

Yes Maybe No No. of responses 34 1 1

If you said ‘yes’ or ‘maybe’, please tick the box to show what you would like to do:

Heartstart 22 Getting more advice 18 Cook it! 12 Walking Group 11 Zumba 10 Smoking Cessation 10 Weigh to Health 6 Mental Health Management 5 Weight Management 4 Help with sleeping 1 Cycling 1 Teenagers 1

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Do you have any suggestions about ways in which Hearty Lives Craigavon could help you further with your heart health?

Suggestions about ways in which Hearty Lives Craigavon

could help further with your heart health No. of responses

More Health Screenings 22 Joint Walking 3 CPR course 3 Healthy food 2 More Health Info 2 Mental health awareness 2 Help getting Registered 2 Continue as it is 2 Less form filling 1 More group gatherings 1 Smoking Cessation 1 Working Together 1 Healthier at Work 1 Collaboration and Networking 1 Stuff for Kids/Teens 1 Tummy exercises 1 Cooking course 1 Alcohol and Drug awareness 1 Weight Management 1

Why were you satisfied with the service provided by the Hearty Lives project?

Reasons for Satisfaction No. of responses Very useful 3 Helpful 2 Friendly service 2 Liked to see the changes due to physical activity 1 Orientation to healthier lifestyle 1 I can check my own health / self-management 1 Confidential 1 Health Start was a useful training programme 1

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CASE STUDY HEARTY LIVES CRAIGAVON IN THE WORKPLACE Context: Hearty Lives Craigavon The Hearty Lives Craigavon Project, funded by the British Heart Foundation (BHF), aimed to tackle Heart Health of the Irish Traveller Community and Black Minority Ethnic (BME) communities within the area previously covered by Craigavon Council, by increasing awareness of the risk factors contributing to cardiovascular disease (CVD) and encouraging positive lifestyle changes. The World Health Organisation research shows that 80% of heart disease, stroke and Type 2 Diabetes could be prevented through lifestyle changes; including healthy diet, regular physical activity and avoidance of tobacco. People from a wide range of countries and communities are represented within the BME community in the Craigavon, Lurgan and Portadown area. Many people from these communities work locally. Many individuals across the BME community suffer health inequalities due to poor levels of access to available services. Through engaging people from the BME community within the Hearty Lives Craigavon Project, the vision was to increase individual and community knowledge of heart health, facilitating access to lifestyle change support programmes, and delivering health screening to reduce the risk of Cardiovascular Disease. Context: Health Awareness in Workplace Settings

The World Health Organisation (WHO) recognises the importance of the workplace as a setting to promote healthy lifestyle practices such as healthy eating, physical activity, and avoiding smoking and alcohol abuse. The WHO definition of a healthy workforce is ‘one in which workers and managers collaborate to use a continual improvement process to protect and promote the health, safety and wellbeing of all workers and the sustainability of the workplace by considering the following: health and safety concerns in the physical work environment; health, safety and wellbeing concerns in the psychosocial work environment, including

organisation of work and workplace culture; personal health and resources in the workplace; ways of participating in the community to improve the health of workers, their families

and other members of the community.’3

In 2013 the Public Health Agency launched Health and Wellbeing at Work: a resource guide. The Resource presents the case for healthy workplaces, suggesting that “effective workplace health programmes can make a real difference to the health and wellbeing of

3 Burton J. WHO healthy workplace framework and model: Background and supporting literature and practice. Geneva: World Health Organization, 2010

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employees, businesses and the communities in which people live and work”. Research shows that promoting health in the workplace improves the working environment and is beneficial to organisations and employees in different ways, including: Reduction in illness-related absence Reduced ineffectiveness when going into work when ill Increased retention of staff and reduced staff turnover Increased motivation among staff Improved working atmosphere, resulting in greater flexibility, better communications and

improved use of resources Measurable increases in the quality of products and services, more innovation and

creativity, and a rise in productivity. Prestige for the organisation, which improves public image and makes the company

more attractive for staff and potential employees.

Health at Work is the British Heart Foundation’s programme to inspire and support health and wellbeing in the workplace4. The BHF website notes that sickness absence costs UK businesses £14billion a year “so a healthy workforce makes good business sense”. Join our fight and help keep the nation’s hearts working. Workplaces can support employee’s through encouraging physical activity, providing healthy eating options, supporting employees to access smoking cessation opportunities, and recognising symptoms of stress. BHF has a number of resources to promote and support health in the workplace. Hearty Lives Craigavon in the Workplace The Hearty Lives Craigavon Project Coordinator made contact with workplaces in a number of different ways. Some initial approaches were made because the company was known to have a high number of employees from the BME community, two contacts came through the British Heart Foundation, and one company directly contacted the Project (they were made aware of the Project by the Health Trainer working for The Verve Project; who put the company in touch with the Project Co-ordinator). Health checks have taken place in seven companies. These have taken place over a number of sessions; and companies have tried to make access to the Project Coordinator as accessible as possible through planning health screenings during breaks, and locating the Project Coordinator in a room that is easy for employees to access. A copy of all health check results has been forwarded to the Occupational Health Nurse or Human Resources, and when a referral is made a further copy is forwarded to the individual’s GP. A small number of health checks have also taken place in two other companies.

4 https://www.bhf.org.uk/health-at-work

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“Hearty Lives Craigavon was an excellent partner in helping to deliver part of our health and wellbeing strategy by providing training and support through the Project. The employees found the Project Coordinator really easy to talk to and she really made a difference to them. I would definitely recommend the Hearty Lives project to all employers”.

Occupational Health Nurse, Moy Park

The Project Coordinator has supported the delivery of smoking cessation programmes on site, delivered by the Southern Trust Smoking Cessation Specialist. The Project Coordinator has delivered health information sessions, and facilitated Heartstart training in companies. The table below shows the activity across the companies that engaged with Hearty Lives Craigavon.

Organisation Information Sessions

Heartstart Training

Smoking Cessation

Health Checks

Asda 87 - - - BHF Shop Portadown 7 - - 7 Tesco Craigavon 4 sessions

123 attended 16 - 2

Tesco Portadown 56 - - - Tesco Lurgan 23 7 - - McKeagneys Chemist - 16 - - Moy Park 9 sessions

258 attended - - 241

Huhtamaki 4 sessions 46 attended

- - 46

Interface 3 sessions 94 attended

- 45 92

APB Meats 5 sessions 71 attended

- 13 69

Almac 7 - 1 7 Total number of people: 772 39 59 464 The British Heart Foundation has a partnership with Tesco stores, who fundraise for BHF. All the Heartstart training at Tescos was delivered to staff in the stores. The majority of the health checks undertaken at Tesco were with staff, whilst a minority were with customers to the stores.

“The Project Coordinator is so helpful and always goes out of her way to provide information and support to our employees. She communicates well with people and it is a pleasure having her here when she comes to our company”.

Human Resources Officer, Interface

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Delivery of the Hearty Lives Craigavon Project in the workplace was initially challenging, and a number of lessons were learnt, which may be taken on board by projects in the future. These included: • Initially it was hard to engage with workplaces: management may restrict the times that

employees can be released to attend health related activities within working hours and individuals may not be able to commit to time outside of work. • The Project worked closely with one workplace in the first instance; the learning from this

initial work included ensuring commitment from the workplace that they will support the organization required to offer health checks; once one workplace engaged it was easier to demonstrate the benefits to others. • In order to engage with the BME employees it was necessary to offer a whole workplace

approach. • There is a need to identify a health champion within the company; this may be the

Occupational Health Nurse or someone within Human Resources. • Timing and persistence is important. • Take on board the need for ‘buy-in’ from the company Senior Management Team. • Once engaged employers, employees and the Project all benefited.

Outcomes and Impact Initially engagement with workplaces was quite difficult, but Autumn 2014 saw a significant increased engagement with workplaces; and positive outcomes were achieved over time. This suggests the need for projects to build credibility; and also to link in with other workplace initiatives.

“Working with the workplaces appeared challenging, initially getting them onboard and then having someone within the workplaces willing to be a point of contact to review results of Health Checks and follow up referrals”.

Member of the Hearty Lives Craigavon Steering Group The Hearty Lives Craigavon Project model of offering outreach clinics in workplace settings to engage people in health checks and health education was very successful, with a total of 464 people having a health check, and 59 individuals engaging in smoking cessation programmes. The impact for people from BME communities of delivering Project services in the workplace include: • 464 employees took the opportunity to have a health check, with signposting to the GP,

smoking cessation programmes, or other services as appropriate. • 772 employees attended health information sessions. • 59 employees participated in Smoking Cessation programmes.

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• 39 employees participated in the Heartstart training. • Raised awareness within the workplace regarding cardiovascular health. • Smoking cessation services were made available in the workplace; with good numbers

attending on a regular basis. • Employees engaged well with the health screenings and anecdotal feedback suggested

that they felt empowered to take more control of their own health.

Legacy Smoking cessation programmes for employees commenced and continue. Some employees have undertaken training to deliver programmes in relation to

cardiovascular health and healthier lifestyles. Knowledge about heart health and risk factors to heart health has increased across

the BME employees population groups and those recruiting people from the BME community.

There is a greater understanding of the health needs of the BME community within the companies that employ them.

A database of local contacts has been developed and can be shared with other services such as the Northern Ireland New Entrants Service

Links have been made with the BHF Health at Work programme and with the PHA health in the workplace initiatives; this Case Study will be shared with both organisations.

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CASE STUDY HEARTY LIVES CRAIGAVON ENGAGING WITH THE IRISH TRAVELLER’S COMMUNITY Context: Irish Travellers Support and Health Inequalities There is a lot of evidence about the health inequalities of Irish Travellers, especially in relation to heart health inequalities. Health inequalities experienced by the Irish Travellers community presented in the All Ireland Traveller Health Study include: Only 10% of the community live beyond 40 years of age and only 1% beyond 60 years of





Barriers to heart health and other health issues for Irish Travellers include: Families with high levels of nomadism Traditionally barriers to GP registration, although this is reducing to some extent Very little preventative health care Tendency to present to Accident and Emergency or a GP when there is a health crisis,

rather than seek early intervention. Many Irish Travellers who come from the South of Ireland will wait until they are back in

Ireland to see a GP, rather than see a GP in the North, when they may mistakenly be charged. [There are agreements in North and South Ireland that Travellers do not have to pay for prescription costs or GP appointments].

Misuse of prescription drugs Lack of continuity Limited access to rehabilitation programmes. Low level of take up for health screenings.

The All Ireland Traveller Health Study highlighted that Irish Travellers are more likely to die earlier than the population average; and there is a growing recognition amongst the community that something has to change. Hearty Lives Craigavon was ‘timely’; Irish Travellers are becoming more social and media aware and through this they become more aware of what is happening.

Context: Craigavon Travellers Support Committee The Craigavon Travellers Support Committee (CTSC) works with about seventy families at any one time, representing approximately 300 individuals living within the Craigavon area.

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About 40% are housed (ie Travellers living in Craigavon) and 60% are nomadic. The small team of six staff deliver in five key areas: Early years and youth work Education and Development Advice, advocacy and support Health Community Development The overarching aim of CTSC is to improve the quality of life of Irish Travellers in the Craigavon area by achieving the following:

Adopting a community development approach which will enable Travellers to articulate their needs and to support them to ensure those needs are met Engaging the range of statutory and voluntary bodies in order to ensure provision of

appropriate and culturally sensitive services Highlighting the problems arising from lack of recognition / acceptance of Travellers as

an ethnic group and the consequences of this in terms of experiencing racism at an individual and institutional level

Building relationships between the Traveller and settled communities To assist in alleviating prejudice and misunderstanding. Craigavon Travellers Support Committee provide the following Health services: Assistance in accessing GPs, Mid Wives, and Health Visitors Support for families in relation to doctors appointments, hospital appointments, and social services appointments Heath and wellbeing programmes for adults Work with local Statutory agencies to promote healthy living and lifestyles.

The Craigavon Travellers Support Committee felt that the Hearty Lives Craigavon approach from the outset was user focused which suited this target group. The Manager and Community Development worker were involved in the initial discussions about the Project, and sitting on the Hearty Lives Craigavon Steering Group helped to maintain the continuity. Consultation with the Irish Travellers At the outset of the Hearty Lives Craigavon Project, 46 Irish Travellers completed the Baseline Health Assessment. This data analysis showed that high numbers of Irish Travellers are smokers, have low levels of exercise, have a poor diet, lack of knowledge about the health benefits of fruit and vegetables, drink alcohol, and use non-prescription drugs. An additional barrier to heart health are low literacy levels, and that the Irish Travellers find it hard to talk to their GP. A recommendation within the Midterm Evaluation Report was to call a meeting with representatives from the Irish Travelling community with which the Project currently works, (and also those who may be interested in becoming involved). The aim of the workshop was to seek feedback about what was working well, and benefits and impact of Hearty Lives Craigavon for groups and individuals. Suggestions for additional activity from the project to

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further the promotion of healthy lifestyles and to support maintaining lifestyle changes were also discussed, along with the option to support community heart health champions within the Irish Traveller community. The discussions highlighted a number of issues that the Irish Travelling community need more information and understanding about: Alcohol intake Smoking Poor nutritional intake, lack of cooking skills and “Take Aways” as main food source Isolation Domestic violence Family planning, Pregnancy, Post Natal Care and Child Care Mental health Diabetes.

There is also a need for heart health awareness to be delivered as simple messages, with resources made available in simple language supported by pictures. The consultation also noted that the Project has gained a lot of credibility and confidence amongst the Irish Traveller community; and that there is an on-going need in the community to increase health awareness and facilitate access to health professionals and healthcare services. Bringing Hearty Lives Craigavon to the Irish Travellers community The Health Checks The main resource that CTSC offered Hearty Lives Craigavon was their own time; and a commitment to introducing the families to the Project Coordinator. The Project Coordinator met the Irish Travellers within the CTSC setting; and met individuals in a private room at Moylinn House (the same building in which the CTSC is located). The health check included Blood Pressure, Blood Sugar, and BMI; and provided the opportunity for one-to-one conversations with individuals about lifestyle choices. Having the separate space in which the health checks and advice took place emphasised the confidentiality and privacy; and gave a respect for the clinical elements of the Project.

“There was a close dynamic between the CTSC workers and the Hearty Lives Project Coordinator. Being based in the same building was a great advantage, but having the separate office for the health checks helped to remove some of the dependency that some Travellers have with CTSC staff. Initially we were a bit worried that the men wouldn’t engage because the project Coordinator was a woman – but in practice this was not an issue. The Project Coordinator understood the Irish Traveller community culture, and the Travellers respected and liked her”.

Manager CTSC 39


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Initially the intention was to identify those most at risk and refer them to the Hearty Lives project. However, it was evident very soon that almost every adult within the Irish Traveller fell within the high risk category; presenting with one or more risk factors associated with heart disease. These included: High levels of smoking Alcohol abuse and misuse Family and hereditary heart related conditions Lifestyle choices.

Of the 84 Irish Travellers who had an appointment with the Project Coordinator for a health check, a total of 18 people (21%) were referred to their GP due to at risk health check results. The most frequent reason for the referral was a high BMI result (in excess of 30), with 12 people being referred for this reason. 4 people were referred to the GP because of high blood pressure, and 2 were referred due to at risk blood sugar results. After the initial health check some families accessed further support and information by telephoning the Hearty Lives Craigavon Project Coordinator. Others came in to see the project Coordinator regularly for ongoing advice; and some individuals were highlighted and referred to the Project Co-ordinator when they came to see the CTSC staff about other non-related issues. 84 Irish Travellers had a health check; and 42 (50%) chose to return for additional health checks and advice. In total 181 health screenings were carried out. Case Story 1 One of the Irish Travellers, John, had put on a lot of weight. He had been in denial about his weight until he had a health screening with the Project Coordinator. After a number of conversations and discussions John started walking regularly and making more healthy meal choices; he has lost a lot of weight. Programmes delivered to the Irish Travellers 248 Travellers attended information sessions over the duration of the Project. In addition, a range of programmes were offered to the Irish Travellers through the Hearty Lives Craigavon Project. These included: Two Cook It! programmes, one for adults and one for young people: 27 people Heartstart Training with young people and adults: 9 people Zumba sessions: 24 people Walking Group: 3 people Fit Zone: 6 people Early Movers: 3 children with their mothers One member of the Irish Traveller community attended and completed the Health

Champion Training. 40


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“The Project Coordinator is a great girl, she has kept me right with all my new scripts [prescriptions] and has gave me great words on how to lose this weight”.

64 year old Man

In addition a Women’s Group met regularly to discuss a wide range of physical and mental health issues. Between 6 and 24 women attended each session; and 24 women attended the Irish Traveller Exhibition of crafts. A number of the women also took part in a breast screening session. A further consequence of this session was that one man had received an appointment for bowel cancer screening in the post; he had thrown it away; but his wife persuaded him to go after she learnt more about screening for breast cancer. The CTSC is currently applying for funding from the Big Lottery to support the continuation of the Women’s Group.

“Its great having a nurse you can talk to. I be afraid I’m keeping the doctors back, but there’s times I don’t understand what he’s telling me. The nurse goes over stuff with me so I know what I need to do”

27 year old Woman 24 children attended workshops delivered by the Project Coordinator after school. The content of the workshops reinforced a range of health elements, including cleanliness, sunscreen, and dental care. The role of Nurses and other health professionals was also talked about with the children during these workshops. These workshops provided a positive experience of a health care provider; the children knew the Project Coordinator was a nurse, and felt comfortable talking with her. This positive interaction in formative years will count a lot for future interventions that these children (as young people and adults) will have with health care professionals.

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Case Story 2 One of the Irish Travellers, Mary, is a young mum who had a lot of issues with self-esteem and lack of identity. Furthermore, over half her family have died before the age of fifty due to heart health issues. Mary also had a high BMI and did not have the confidence or motivation to follow a weight management programme. She talked with the project Coordinator, who gained Mary’s trust; and the young woman sought advice and support from her. Mary joined Fit Zone, a local community based charity offering healthy programmes. Mary regularly attended Fit Zone, and also met with the Project Coordinator once a week to get weighed and discuss other health issues. Mary has lost weight consistently, and feels more self-confident and able to deal with her own life. Outcomes and Impact A number of the Project outcomes identified from the outset link directly to the Irish Travellers community. The table below shows the relevant Project Outcomes and how these have been achieved.

Project Outcomes Comment There will be increased knowledge and skills to support heart health within Traveller communities, support workers and organisations / employers

This has been achieved through the Health Checks, one-to-one advice, workshops and programmes. A greater number of people in the Irish Traveller community have a greater understanding of cardiovascular disease and associated risk factors.

CVD screening will have been accessed by 140 adults in the Traveller community over 3 years

181 heart health checks have taken place with adults in the Traveller community

56 members of the Traveller community will have accessed primary care for management of CVD risk factors.

18 Irish Travellers have been referred to the GP following the health check for management of CVD risk factors. The CTSC Manager reports that Irish Travellers will attend their GP at an earlier stage now before they actually become very unwell (ie accessing early intervention).

A minimum of 30 Travellers will have embedded lifestyle changes in support of heart health

The Project Coordinator reported that 132 Irish Travellers have embedded lifestyle change activities; the CTSC Manager confirms that individuals and families have made lifestyle changes following engagement in the Hearty Lives Craigavon Project. Irish Travellers are more able to cook healthier meals and participate in exercise programmes.

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Project Outcomes Comment A further 100 Travellers including adults and children will benefit from the programme

141 Travellers have participated in Information sessions, Zumba, Cook It or Walking Programmes delivered through Hearty Lives Craigavon. 24 Traveller children have attended healthy lifestyle workshops delivered by the Project Coordinator.

Enhanced ways of working will have been developed tested and evaluated that demonstrate how to engage marginalised groups to improve health

A variety of innovative ways have been utilised to engage with the Irish Travellers. The success of the Project model of offering outreach clinics in the same setting where the Traveller Support organisation is based built trust with the Traveller community and enabled them to engage in health check and health education. This has resulted in a change in how Craigavon Traveller Support Committee as well as Irish Traveller Community approach health related issues.

Local HSC professionals and GP’s knowledge and awareness about the health status of the population groups in relation to CVD will have increased

All 15 GP practices in the area have been made aware of the Hearty Lives Craigavon Project through email, telephone and face to face engagement. The relevant GP practice receives a copy of health check results. 5 practices have BHF information display units.

Champions will have been identified and trained within the population groups to further develop this approach.

Within the CTSC staff have received training in the delivery of health information and advice. One of the Irish Travellers has completed the Community Health Champions programme.

Case Story 3 One of the Irish Travellers, an older man called James, was living rough and had a history of heart health issues, and alcohol misuse. James was being assessed for dementia, but he wasn’t engaging with health care professionals. After the initial Health Check James came in once a month to see the Hearty Lives Project Coordinator. He felt comfortable talking to her and was able to ask questions about his illness and the prescriptions he was given by the GP, for example ‘should I take this prescription the GP gave me’, ‘what is it doing for me’. James was not comfortable in the GP setting, so he would forget to ask the questions he wanted answers to, and as a consequence would come away with half the story. James has made a number of lifestyle changes; he has joined Alcoholics Anonymous, walks in and out of town, and has cut down on fried meals.

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Impact identified by the Irish Travellers during the Consultation Event in 2015 Increased realisation of heart health risk factors through the health checks – not just a

‘check’ but information given and an opportunity for individuals to discuss heart health General increase in levels of information and learning about heart health, which in turn

has increased individual’s confidence Increased awareness of heart health risk factors through lifestyle programmes People referred to their GP due to risk factors following the health check that they were

previously unaware of – whilst it is not easy to quantify the impact, it is likely that for some people early intervention has had a positive impact on individual health, and may also have saved some people from hospital admission

Health is higher on the Irish Travelling community agenda Greater involvement of the Irish Traveller community sector, and anecdotal evidence of

better use of existing services Big impact on the whole Irish Traveller community in the area widely known and

information spread from family to family.

Case Story 3 Type 2 diabetes develops when the body cannot produce enough insulin, or when the insulin that is produced doesn't work properly. Type 2 diabetes accounts for between 85 and 95 per cent of all people with diabetes, and is treated with a healthy diet and increased physical activity. Annie, a 46 year old female, had a health check in the early stages of the Hearty Lives Project, when a high blood sugar reading was recorded. Annie said that there was a family history of diabetes; and she was advised to attend her GP for further tests and fasting blood glucose. Annie told the CTSC staff that she had attended the GP and had been diagnosed as a non-insulin dependent diabetic on oral medication. Unfortunately Annie did not believe her diagnosis and was non-compliant with her diabetic diet and medication. Further advice was given to her by CTSC staff and the Hearty Lives Project Coordinator. The case was discussed with the GP Practice Nurse who stated that Annie had had many DNAs with the GP and herself in relation to her diabetes. Through working together in partnership to promote Annie’s health and wellbeing, lifestyle changes began to take place. Annie was reviewed, and her blood sugar was within the normal range. Lessons Learned • The benefits of working in close partnership – statutory and community partners working

towards the same vision and looking at innovative ways to engage with Irish Travellers.

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The partnership approach extended to building an excellent working relationship between the CTSC team and the Project Coordinator; with good two-way communication. • The need for ‘the right person’ to work with ‘hard to reach’ communities. The Project Co-

ordinator worked well with the Irish Travellers; and took on board the male dominance within the Irish Traveller culture. Respect was given by the Project Coordinator for the culture, and at the same time she was able to challenge misperceptions and non healthy approaches. • Flexibility in the organization and delivery of stakeholder consultation events; the informal

style (with no PowerPoint presentations) worked very well with the Irish Travellers, who engaged and gave feedback that could be used to further develop heart health programmes to meet interest and need. • Geographical placement of the Project Coordinator and venue for the health checks was

very convenient for the Irish Travellers, facilitating ease of access within an environment that they feel safe. • Open door policy, no appointments necessary for health checks or discussion about health

issues. • Face to face trusting relationships built between the Project Coordinator and the Irish

Travellers. • Having a trained Nurse employed as the Project Coordinator built trust and gained respect

and credibility from the Irish Travellers. • The use of visual pictorial information, and relevant BHF resources. • The need for a balance between integration and a service that Irish Travellers will access. • The positive engagement from the Traveller’s community because they recognised that the

individual was at the centre and steps were designed to overcome barriers to engaging with the Hearty Lives service and programmes. • The model highlighted the need for a level playing field to get to integration – CTSC will

fight to secure resources to replicate this approach.

“There was a lot of benefit from ‘two-way reinforcement’; someone would be talking to us and we might say that a certain behaviour or food choice wasn’t such a good idea, and that they should use their common sense more. The response was often ‘well, I’ll just go and check that with the Nurse [the Project Coordinator]’. A few minutes later the person would be back and tell us that yes, we were right and the Nurse said that it was better do this or do that. We were also able to seek guidance from the Project Coordinator about health related programmes and projects that would be meaningful to the Irish Traveller community, and raise awareness about health for individuals and families”.

Manager CTSC

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Legacy • CTSC staff have been trained to deliver heart health Programmes. • Changed the mind-set of how health related programmes can be delivered and the depth

of issues that can be addressed. • Travellers involved in Cook It and the Heartstart Emergency Life Support training

sessions have passed new skills and knowledge onto other family members. • Commitment to trying to offer tailored health related services to Irish Travellers. • Irish Travellers are being encouraged and supported to complete a Health Trainer course

(one person has already completed the programme) • The Traveller Support Organisation has increased knowledge and access to resources to

support health and wellbeing with the Irish traveller community. • Local Irish Travellers have developed skills in Emergency Life support including CPR

through the Heartstart training sessions and participated in programmes enabling them to make lifestyle behavior changes • A Health Visitor has been appointed to work with the Irish Traveller Community and she

will use the Hearty Lives Clinical room in Moylinn House for some of her work. • Activities and services provided could be embedded into other programmes and services

provided; for example Cook It → PHA, Health Check → New Entrants programme, Heartstart training → Armagh City, Banbridge, and Craigavon Borough Council.

•

“There is a ‘fun legacy’ as all the health work has been done with a laugh and great craic. Initially there was such fear and so many excuses to not participate – but this model worked, not least because the Project Coordinator was the right person. She worked so well with the Irish Travellers; and managed the male dominance within the Traveller’s culture. She gave respect to the Irish Traveller culture as a whole, but was able to challenge misperceptions and non-healthy approaches. People listened to the Project Coordinator, went to her for advice, and encouraged other members of their family and community to get involved as well”

Manager, CTSC

“When I’m grown I’m going to be a nurse”. 9 year old Girl

The names in the case stories have been changed to maintain anonymity.

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“There is a ‘fun legacy’ as all the health work has been done with a laugh and great craic. Initially there was such fear and so manyexcuses to not participate – but this model worked, not least because the Project Coordinator was the right person. She worked so well with the Irish Travellers; and managed the male dominance within theTraveller’s culture. She gave respect to the Irish Traveller culture as a whole, but was able to challenge misperceptions and non-healthy approaches. People listened to the Project Coordinator, went to her for advice, and encouraged other members of their family and community to get involved as well”

Manager, CTSC

“When I’m grown I’m going to be a nurse”.9 year old Girl

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Legacy • CTSC staff have been trained to deliver heart health Programmes. • Changed the mind-set of how health related programmes can be delivered and the depth

of issues that can be addressed. • Travellers involved in Cook It and the Heartstart Emergency Life Support training

sessions have passed new skills and knowledge onto other family members. • Commitment to trying to offer tailored health related services to Irish Travellers. • Irish Travellers are being encouraged and supported to complete a Health Trainer course

(one person has already completed the programme) • The Traveller Support Organisation has increased knowledge and access to resources to

support health and wellbeing with the Irish traveller community. • Local Irish Travellers have developed skills in Emergency Life support including CPR

through the Heartstart training sessions and participated in programmes enabling them to make lifestyle behavior changes • A Health Visitor has been appointed to work with the Irish Traveller Community and she

will use the Hearty Lives Clinical room in Moylinn House for some of her work. • Activities and services provided could be embedded into other programmes and services

provided; for example Cook It → PHA, Health Check → New Entrants programme, Heartstart training → Armagh City, Banbridge, and Craigavon Borough Council.

•

“There is a ‘fun legacy’ as all the health work has been done with a laugh and great craic. Initially there was such fear and so many excuses to not participate – but this model worked, not least because the Project Coordinator was the right person. She worked so well with the Irish Travellers; and managed the male dominance within the Traveller’s culture. She gave respect to the Irish Traveller culture as a whole, but was able to challenge misperceptions and non-healthy approaches. People listened to the Project Coordinator, went to her for advice, and encouraged other members of their family and community to get involved as well”

Manager, CTSC

“When I’m grown I’m going to be a nurse”. 9 year old Girl

The names in the case stories have been changed to maintain anonymity.


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CASE STUDY HEARTY LIVES CRAIGAVON ENGAGING WITH BME COMMUNITY GROUPS Context People from a wide range of countries and communities are represented within the BME community in the Craigavon, Lurgan and Portadown area. This includes people from China, Bulgaria, Ukraine, Hungary, Lithuania, Poland, Russia, Latvia, Slovakia, East Timor, Portugal, Pakistan, and Bangladesh, and those from Muslim communities. Many people from these communities suffer health inequalities due to poor levels of access to available services; language and cultural barriers; poor housing; and low income. Reports from Cardiac Rehabilitation Services Craigavon Area Hospital reflect that six individuals from the BME community have attended the Cardiac Rehabilitation Phase 3 programme and accessed available services. They feel that the BME communities do not seek medical assistance readily, and that there is a tendency to delay intervention from health professionals until they are very unwell. Primary prevention and early intervention in relation to cardiovascular disease and promoting wellbeing, prior to illness, needs to be a priority. A report published by the Northern Ireland Council for Ethnic Minorities (June 2013) reported that hose who were dissatisfied with their health and social care experiences felt they had not got the medical treatment they needed, that they were discriminated against, no interpreter was available, there was no cultural sensitivity and they experienced long waiting times. The vision for the future for BME Communities, through the delivery of the Hearty Lives Craigavon Project, is to increase individual and community knowledge of heart health, facilitating access lifestyle change support programmes, and delivering health screening to reduce the risk of Cardiovascular Disease. The Baseline Scoping Study, completed by 69 people from BME communities (including Chinese, Bulgarian, Polish and Portuguese) highlighted: Within the Chinese community the majority stated they had poor knowledge regarding

heart disease but their health appears to be good. Significant issues included that a considerable number were not registered with a GP. The group appears to have a higher rate of high blood pressure and high cholesterol than other groups. Just under a third of the respondents stated they do not exercise. Another area of concern is the use of Chinese herbal medicine and its unknown benefits. This group showed a high level of interest in cooking; therefore the ‘Cook It’ programme may be a consideration to progress with this group.

Within the Bulgarian community significant issues were that a third were not registered with a GP, a quarter of people felt that there was nothing they could do to prevent heart disease, only a quarter of people recognised diabetes as a risk factor, and they had slightly higher alcohol consumption than other groups.

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Within the Polish community significant issues included that two people had multiple risk factors, high blood pressure, heart disease/angina, a family history and one had high cholesterol - both were from India.

Within the Portuguese community it was highlighted that 100% of those that participated in the Baseline survey were smokers, the majority consume alcohol regularly on a weekly basis, one male admitted previous use of cannabis.

Health Checks in the Community Health checks were carried out with members of the BME community. The Health Checks took place on-site at 15 different locations. The health check included Blood Pressure, Blood Sugar, and BMI; and provided the opportunity for one-to-one conversations with individuals about lifestyle choices. The table below presents the number of health checks undertaken with people from the BME community, the number of individuals who have had a health check, and the number of people who have returned for a further health check between June 2013 and December 2016.

Community Total Health Checks

No. of Individuals

No. of Returners

BME Community 642 564 78 The data presented in the total health checks column relates to the number of health checks that the Project Coordinator has carried out; the number of individuals column presents the number of different people who have had health screenings, because – as presented in the final column – 78 people from the BME Community have returned to have the health check repeated on a number of occasions, and to get further advice (and support) from the Project Coordinator. The table below shows the 15 different BME community organisations that have engaged with the Hearty Lives Craigavon project and facilitated health checks on-site.

Organisation Health Checks Community Intercultural Programme 152 Wah Hep 134 Splash Surestart/ chrysalis 111 Richmount 91 Seagoe Polish Saturday School 69 Portuguese Restaurant 35 Lismore Comprehensive 27 Midnight Soccer 25 Southern Regional College Lurgan 24

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Organisation Health Checks Polish Shop 15 Rushmere 14 Southern Regional College Portadown 14 Brazilian Restaurant 11 BME Deaf Group 9 Ameera 8

" This project was welcomed by the Bulgarian community. It was an indication to them that the wider society cared about their health. Their personal health was treated confidentially and the Community Association had arranged for community translators to explain the programme and the health checks. They became familiar with the nurse performing the checks and a good professional rapport was established. I also believe that it gave our health service a greater insight how the Bulgarian community regard their personal health”

Community Association Chairperson Those identified as being high-risk The table below shows the number of people from the BME community who were referred to their GP.

Target Community

High Blood Pressure

High Blood Sugar

BMI in excess of 30

Total

BME Community 52 19 37 108 Total 56 21 49 126 78 people returned to the talk with the project coordinator and have additional health checks, and were able to gain greater understanding and support in relation to the GP’s advice or prescribed medication.

“The Bulgarian population is relatively young, many have a high sugar intake. There were several cases of high blood sugar levels following the health check, where the participants were advised to contact their GP”.

Community Association Chairperson Raising Community Awareness of Heart Health In total, 41 different community groups in Craigavon and the surrounding area have requested one or more programmes or information sessions. The table below presents the

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programmes that were delivered in community groups and the number of people who engaged.

Summary Information sessions

Heartstart Training

Smoking Cessation

Total

Number of in the community programmes

46 17 4 69

Total number of people in the community

1285 134 24 1443

The table below shows the range of community organisations working with the BME community that have engaged with programmes delivered through Hearty Lives Craigavon.

Organisation Information sessions Heartstart Training

Smoking Cessation

Wah Hep 1 session 30 attended

7 -

Richmount 6 sessions 167 attended

5 -

Community Intercultural Programme

10 sessions 217 attended

12 -

Splash Surestart / Chrysalis 9 sessions 386 attended

6 2

Ameera 2 sessions 19 attended

8 -

Avondale 2 sessions 25 attended

- -

Seagoe Polish Saturday School

3 sessions 107 attended

- -

Lismore Comprehensive 31 - - Magheralin - 7 - Aghagallon - 9 - Killicomaine - 12 - Dromore Community Centre - 8 - Maghery Community Hall - 6 - Ardmore Community - 9 - Banbridge Surestart - 2 - Zero 8 Teen 17 - - Rushmere 3 sessions

40 attended - 14

Polish Shop 2 sessions 19 attended

- -

Portuguese Restaurant 15 - 7 Brazilian Restaurant 11 - -

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Organisation Information sessions Heartstart Training

Smoking Cessation

Southern Regional College Lurgan

90 - -

Southern Regional College Portadown

70 - -

Park Run Craigavon - 6 - Ashgrove Community Centre - 18 - Midnight Soccer 29 1 BME Deaf Group 12 - - Cedar Foundation - 10 - Mindwise Banbridge - 3 - Banbridge Leisure Centre - 6 -

In addition to the programmes presented in the table above, supported by Hearty Lives Craigavon, the Community Intercultural Programme established a Walking Group with 52 members.

“Many do not comprehend all the media attention given health issues, simply because they have a limited use of English. There is a steady stream of newcomers to Northern Ireland, who will not be able to avail of this programme and of the ones that did they need to be constantly reminded of the need to prevent heart disease and all the contributory conditions”.

Community Association Chairperson

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Events The Project Coordinator ‘set up shop’ at four local events (attending Brownlow Festival in 2014 and 2015). The table below shows the Events attended, and the input at each. Information

sessions Health Checks

Heartstart

Sportadown 17 8 - Brownlow Festival 55 50 7 Country comes to town 73 10 - Supporting Behaviour Change The National Institute for Health and Care Excellence (NICE) issued guidelines on behavioural changes and lifestyle choices to reduce risk factors to chronic disease. The guidelines note that behaviour change can be brought about through intervention at both an individual level and population level (NICE Guidance: Behaviour Change PH6) though the development of appropriate policy and legislation. Buck and Frosini5 suggest that there is a need to find effective ways to help people in lower socio-economic groups or vulnerable groups to reduce the number of unhealthy behaviours, which in turn will address health inequalities. They propose that behaviour change is only likely to work through an integrated, cross-sectoral holistic approach to policy and practice. The NICE Guidelines and other research into behaviour change suggest a number of ways in which breaking down barriers to healthy lifestyle options can be achieved. Four approaches, all of which have been addressed by Hearty Lives Craigavon, are shown below. 1. Creating linkages with community organisations 2. Local provision programmes meeting identified need 3. Accessible community, voluntary, and statutory health and wellbeing services 4. Enhancing connections between Primary Care and communities.

From the outset the Project consulted with community organisations and conducted a baseline survey of need, health awareness, and lifestyle choices with Irish Travellers and BME communities. These initial linkages continued to be developed, with health checks, programmes and workshops being delivered out in the community; including with community groups, at a local Polish shop, in a Portuguese restaurant, and in workplaces employing a high percentage of people from the BME community. This meant that accessible opportunities for health checks and raising health awareness was accessible to those individuals who previously experienced barriers to accessing health care support.

5 Clustering of unhealthy behaviours over time: implications for policy and practice, The Kings Fund, 2012

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In addition, through supporting and facilitation people register with a GP, increased connections were made at Primary Care level. Connections were also made following health screenings for those who had ‘at risk’ results. The Project Coordinator referred individuals to their GP, and explained how and why they would benefit from making an appointment with the GP. Outcomes and Impact • Opportunities and environments through which to engage with the ‘hard to reach’ BME

community through partnership working • Raising awareness and empowering people to take control of their own health by giving

them the information and knowledge they require at a level they understand • Signposting individuals to appropriate organisations to meet their needs. • The project has supported increased partnership working across a range of Voluntary

Organisations and supported increased knowledge, skills and capacity of staff in these organisations to support health and wellbeing. • Raised awareness of cardiovascular disease and its risk factors. • Raised awareness across the BME community in relation to the Northern Ireland health

care system and how it works • Health trainers have been identified within some community and voluntary sector groups,

who will continue to deliver programmes promoting healthy lifestyles. • The project model of offering outreach clinics in Community group settings was practical

and valued by community groups. This model enabled them to utilise their engagement with the community to support engagement in screening and health programmes.

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Lessons Learnt • Community group engagement is essential for successful outcomes, by engaging with

community groups the Project Coordinator was able to meet ‘hard to reach’ communities. Initial relationship building is essential and can take time. • The need to build trusting relationships with individuals, which may involve ‘turning up’ on

a number of occasions, being accepted, and then being able to address real issues and need. • People working with BME communities must be culturally aware. • Translated documents and leaflets in appropriate language proactively support building

health awareness. • In some situations it is necessary to have the resources to bring in interpreters. • Community groups appreciate programmes that are tailored to their needs; this can

stimulate further health and wellbeing activity through their further interventions.

Legacy Health trainers have been identified within some community and voluntary

sector groups who will continue to deliver programs promoting a healthier lifestyle

Increased partnership working with a range of Voluntary Organisations and increased knowledge and skills in staff within these organisations

The SHSCT Promoting Wellbeing team will continue to maintain links with community groups

Community groups have access to Promoting Wellbeing support The newly commissioned NINES service will support early screening in the

BME community for health risk factors by qualified staff. This service should build on the models of good practice developed within Hearty Lives.

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CASE STUDY HEARTY LIVES CRAIGAVON COMMUNITY DEVELOPMENT & COMMUNITY PLANNING Introduction The Marmot Review was published in 2010, following an independent review to propose the most effective evidence-based strategies for reducing health inequalities. Central to the content of the Review is that reducing health inequalities is “a matter of fairness and social justice”, and that health inequalities result from social inequalities. Marmot emphasised that action on health inequalities requires action across all the social determinants of health; which will only happen by empowering individuals and local communities6. Marmot suggests “tackling social inequalities in health and tackling climate change must go together” and that policy objectives need to be established and actioned to reduce health inequality. Hearty Lives Craigavon sits well within Public Health Agency policy and practice; for example Making Life Better, Corporate Strategy, and Working in Partnership: Community Development Strategy for Health and Wellbeing. There are also direct links to Transforming Your Care, the Programme for Government, and Fit and Well: Changing Lives. Hearty Lives Craigavon identified two hard to reach target groups: Irish Travellers and the Black and Ethnic Minority (BME) community. Local, regional and national research has identified health inequalities, including heart health inequality, and barriers to accessing health care for both groups. Hearty Lives Craigavon aimed to improve heart health for BME and Irish Traveller Communities. The British Heart Foundation funded Hearty Lives Craigavon for three years. The Project was managed by the Southern Health and Social Care Trust (SHSCT), and has been developed in partnership with Craigavon Borough Council, Craigavon Traveller Support Committee, Community Intercultural Programme, and the Public Health Agency, with funding from the British Heart Foundation. The wider partnership includes community group and workplace representatives. The Wider Policy Context The 10-year public health framework, Fit and Well – Changing Lives, aims to secure more coherence cross-departmentally with a focus on upstream interventions which will improve health and tackle health inequalities.7 Fit and Well recognises that health is determined by factors both within and beyond the control of individuals, families and communities and influenced by social and economic circumstances well beyond the reach of health services. It seeks to improve health and wellbeing along the life course from early to old age by

6 Fair Society, Healthy Lives: A Strategic Review of Health Inequalities in England Post-2010, February 2010

7 Fit and Well Changing Lives - 2012-2022. Belfast: Department of Health, Social Service and Public Safety (DHSSPS), 2012

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CASE STUDY HEARTY LIVES CRAIGAVON COMMUNITY DEVELOPMENT & COMMUNITY PLANNING Introduction The Marmot Review was published in 2010, following an independent review to propose the most effective evidence-based strategies for reducing health inequalities. Central to the content of the Review is that reducing health inequalities is “a matter of fairness and social justice”, and that health inequalities result from social inequalities. Marmot emphasised that action on health inequalities requires action across all the social determinants of health; which will only happen by empowering individuals and local communities6. Marmot suggests “tackling social inequalities in health and tackling climate change must go together” and that policy objectives need to be established and actioned to reduce health inequality. Hearty Lives Craigavon sits well within Public Health Agency policy and practice; for example Making Life Better, Corporate Strategy, and Working in Partnership: Community Development Strategy for Health and Wellbeing. There are also direct links to Transforming Your Care, the Programme for Government, and Fit and Well: Changing Lives. Hearty Lives Craigavon identified two hard to reach target groups: Irish Travellers and the Black and Ethnic Minority (BME) community. Local, regional and national research has identified health inequalities, including heart health inequality, and barriers to accessing health care for both groups. Hearty Lives Craigavon aimed to improve heart health for BME and Irish Traveller Communities. The British Heart Foundation funded Hearty Lives Craigavon for three years. The Project was managed by the Southern Health and Social Care Trust (SHSCT), and has been developed in partnership with Craigavon Borough Council, Craigavon Traveller Support Committee, Community Intercultural Programme, and the Public Health Agency, with funding from the British Heart Foundation. The wider partnership includes community group and workplace representatives. The Wider Policy Context The 10-year public health framework, Fit and Well – Changing Lives, aims to secure more coherence cross-departmentally with a focus on upstream interventions which will improve health and tackle health inequalities.7 Fit and Well recognises that health is determined by factors both within and beyond the control of individuals, families and communities and influenced by social and economic circumstances well beyond the reach of health services. It seeks to improve health and wellbeing along the life course from early to old age by

6 Fair Society, Healthy Lives: A Strategic Review of Health Inequalities in England Post-2010, February 2010

7 Fit and Well Changing Lives - 2012-2022. Belfast: Department of Health, Social Service and Public Safety (DHSSPS), 2012


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addressing disadvantage through and across a wide spectrum of service provision and support. Strategically, it promotes the need for public agencies, local communities and others to work in partnership. Transforming Your Care (TYC), a review of the provision of Health and Social Care Services in Northern Ireland, was published in December 2011. TYC proposed a future model for Integrated Health and Social Care designed with the individual at the centre and health and social care services built around this, providing support to promote self-care and make good health decisions. With people living longer the demand for health and social care services will increase in the future; pointing to the need for more preventative work and improved community based access. Within the TYC Report, the word ‘partnership; is used 82 times. The vision and aims of Making Life Better – A Whole System Strategic Framework for Public Health: 2013 – 2023 are to strengthen co-ordination and partnership working within a whole system approach. It builds on the former public health strategy "Investing for Health" and takes account of consultation feedback on the draft framework "Fit and Well – Changing Lives" and a number of other key reports and evidence. The Framework provides direction for policies and actions to improve the health and wellbeing of the people of Northern Ireland and reduce inequalities in health. It seeks to create the conditions for individuals and communities to take control of their own lives and move towards a vision for Northern Ireland where all people are enabled and supported in achieving their full Health and Wellbeing potential. The aims are to achieve better health and wellbeing for everyone and reduce inequalities in health. Achieving a healthier Northern Ireland will hinge largely on what is done collaboratively, through both policy and practice, to influence the wide range of factors that influence lives and choices. The framework is not just about actions and programmes at government level – it also provides direction for work at both regional and local levels with public agencies, including local government, local communities and others working in partnership. Through strengthened co-ordination and partnership working in a whole system approach, the framework seeks to create the conditions for individuals and communities to take control of their own lives, and move towards a vision for Northern Ireland where – "All people are enabled and supported in achieving their full health and wellbeing potential." Making Life Better has six overarching themes: 1. Giving every child the best start in life 2. Equipped throughout life 3. Empowering Healthy Living 4. Creating the Conditions 5. Empowering Communities 6. Developing collaboration. A Fitter Future for All: Obesity Prevention Framework for Northern Ireland 2011-2021 aims to empower the population of Northern Ireland to make healthy choices (and thereby reduce

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the level of harm related to overweight and obesity) by creating an environment that supports and promotes a physically active lifestyle and diet. The framework has two overarching objectives- to increase the percentage of people eating a healthy, nutritionally balanced diet: and to increase the percentage of the population regularly participating in physical activity. Community Development Approach The Working in Partnership: Community Development Strategy for Health and Wellbeing 2012 – 2017 (Health and Social Care Board and Public Health Agency) highlighted opportunities to deliver Transforming Your Care through a community development strategic approach. The aim of the strategy is to strengthen communities and improve health and social wellbeing through an increased emphasis on community development, prevention, and early intervention. The strategy recognises “the importance and pivotal role” that community development plays in improving health and wellbeing. The PHA seek to build “strong, resilient communities where everyone has good health and wellbeing”. The strategy highlights the benefits of people working together to improve shared conditions, community dialogue and cooperation, asset-based approaches, Personal and Public Involvement linked to community development, working at a range of levels, and working within a performance management framework. The Hearty Lives Craigavon model was based on key Community Development principles. The Project promoted and facilitated cross-sectoral working during the three years; including a multi-sectoral Steering Group, meeting regularly throughout the project. Some of the ways in which this community development model worked in practice are presented below. Promoting equality between the community and statutory sectors Promoting equality between the community and statutory sectors was achieved in practice by working with organisations that have the most contact with Irish Travellers and the BME communities that the project sought to reach. Empowering and supporting people and communities The Project focus was to empower and support people and communities to make better choices for themselves through health checks, supported by lifestyle information provided by the Project Coordinator (a registered nurse), signposting individuals to participate in local initiatives, providing health information, and developing, delivering or facilitating healthy lifestyle workshops and programmes tailored to the needs and interests of the target groups. Programmes have included Cook it!, smoking cessation, Zumba, Heartstart (in partnership with the Council), and workshops designed for Irish Traveller children and young people. Social justice Hearty Lives Craigavon worked to make health services and advice more accessible; seeking to redress inequalities by ensuring that everyone has the right to the highest

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attainable standard. The Project Co-ordinator identified early on that a number of people who attended for a health check said that they were not registered with a GP and others did not know who their GP was (if they become seriously ill individuals reported that they either go to Accident and Emergency or, in the case of the BME target group, return ‘home’). 27 people told the Project Coordinator that they were not registered with a GP, and others gave the name of the wrong GP (this is known because GPs sent the referral letter back to the Project stating that the individual was not registered with them). The Project Co-ordinator encouraged individuals to register with a GP, highlighting the benefits for themselves and their families. She provided individuals with information obtained from the ‘Business Services Organisation’ website. The website provides translated application forms online and what to do if they are having difficulties registering or have been refused registration with a GP surgery. 22 people have registered with a GP (12 Bulgarians, 7 Chinese, 2 Greek, and 1 Polish person); two people said they were in Northern Ireland on Holiday; and it is likely that the other three people who did not register had immigration status issues.

“The Bulgarian population was very keen to get involved in this programme. Generally they take little time out and overwork, which can have long term health negative implications. I was pleased to see them taking part in this programme. Many are working fifteen hours a day, seven days a week, having two jobs is not uncommon. A lot of the females work long hours in mushroom tunnels with only artificial light. This is a community, which is very individualistic so to see them coming together on a common theme was to be welcomed. There was a relatively high incidence at the start of the programme with non-registration with GPs. There had been a problem with a GP incorrectly refusing registration (This was before Bulgaria was an A2 EU member and had not been granted full EU status) and this spread through the community, so they did not register. Through the Hearty Lives Project members of the Bulgarian community were supported to register with a GP, which hopefully has broken the cycle of non-registration. ”

Community Association Chairman Working in Partnership Hearty Lives Craigavon worked with a number of community groups, carrying out health checks, health information sessions, and healthy lifestyle programmes supporting physical activity and healthy eating on-site. The Craigavon Travellers Support Committee has been the main partner organisation with whom the Project has linked to work effectively with Irish Travellers (with the added benefit of being located on the same site as the Project). The Project Coordinator has worked alongside a range of community organisations (targeting different BME groups) including: Wah Hep (the Chinese community), Richmount Community Association (working predominantly with the Bulgarian community), the Seagoe Polish Saturday School, and the Community Intercultural Programme. Other community groups with high numbers of people from the BME communities have also engaged in the Project, for example Dromore Community Centre, Maghery Community Hall, and Sure Start.

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Addressing local need The Hearty Lives Craigavon model is based on evidence of need, and addresses the priorities of the local community. Interventions were tailored to meet the unique needs of individuals, groups, and neighbourhoods. Social prescribing Social prescribing is a relatively new term used to describe the process of linking people up to activities in the community that they might benefit from. The aim is to connect people to non-medical sources of support. There is increasing evidence to support the use of social interventions for people experiencing a range of health problems8. Effective social prescribing should be a clear, coherent and collaborative process in which healthcare practitioners work with patients and service users to select and make referrals to community-based services9. Hearty Lives Craigavon has delivered social prescribing models through working with community groups to deliver non-medical approaches to improving and supporting healthy lifestyles. Supporting Behaviour Change The National Institute for Health and Care Excellence (NICE) issued guidelines on behavioural changes and lifestyle choices to reduce risk factors to chronic disease. The guidelines note that behaviour change can be brought about through intervention at both an individual level and population level (NICE Guidance: Behaviour Change PH6) though the development of appropriate policy and legislation. Buck and Frosini10 suggest that there is a need to find effective ways to help people in lower socio-economic groups or vulnerable groups to reduce the number of unhealthy behaviours, which in turn will address health inequalities. They propose that behaviour change is only likely to work through an integrated, cross-sectoral holistic approach to policy and practice. The NICE Guidelines and other research into behaviour change suggest a number of ways in which breaking down barriers to healthy lifestyle options can be achieved. Four approaches, all of which have been addressed by Hearty Lives Craigavon, are shown below. 1. Creating linkages with community organisations 2. Local provision programmes meeting identified need 3. Accessible community, voluntary, and statutory health and wellbeing services 4. Enhancing connections between Primary Care and communities. From the outset the Project consulted with community organisations and conducted a baseline survey of need, health awareness, and lifestyle choices with Irish Travellers and BME communities. These initial linkages continued to be developed, with health checks,

8 http://www.wellbeingenterprises.org.uk/what-we-do/our-work/social-prescribing/ 9 http://www.nesta.org.uk/publications/more-medicine-new-services-people-powered-health#sthash.tmhi7fbx.dpuf 10 Clustering of unhealthy behaviours over time: implications for policy and practice, The Kings Fund, 2012

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programmes and workshops being delivered out in the community; including with community groups, at a local Polish shop, in a Portuguese restaurant, and in workplaces employing a high percentage of people from the BME community. This meant that accessible opportunities for health checks and raising health awareness was accessible to those individuals who previously experienced barriers to accessing health care support. In addition, through supporting and facilitation people register with a GP, increased connections were made at Primary Care level. Connections were also made following health checks for those who had ‘at risk’ results. The Project Coordinator referred individuals to their GP, and explained how and why they would benefit from making an appointment with the GP. 120 people returned to the talk with the project coordinator and have additional health checks, and were able to gain greater understanding and support in relation to the GP’s advice or prescribed medication. Community Planning Armagh City, Banbridge and Craigavon Borough Council’s Corporate Plan defines the vision, mission, values and corporate priorities. The Council aims to “Prosper the Place, Serve the People and Strengthen our Position.” People are at the centre, where local communities and stakeholders can be actively engaged on key issues in an inclusive manner11. The Council has a statutory responsibility to lead and facilitate the community planning process. In partnership with other public service providers and through public engagement, the Council can influence how and where services are provided, allowing for a more flexible approach to meet local needs. Community planning places a duty on key departments and agencies to engage in the community planning process and to have regard for the community plan when considering how best to deliver services at a local level. The aim is that through effective community engagement and an understanding of local issues, delivery of services will be more responsive to the community needs. Community planning will provide a long-term vision aiming to create communities that are vibrant, healthy, prosperous, safe and sustainable and have the needs of citizens at their core. Health has been identified as a key outcome in the Department of the Environment’s (DOE) Community Planning Foundation Framework. The process will increase joined up working across statutory bodies, providing a more cohesive, outcome-based approach to meeting local needs. The Local Government Act defines community planning as’...a process whereby councils, statutory bodies and communities work together to develop and implement a shared vision for promoting wellbeing in an area.’ When considering well-being community plans should

11 Armagh City, Banbridge and Craigavon Borough Council, Statement of Community Involvement, http://www.armaghbanbridgecraigavon.org/wp-content/uploads/2014/11/Statement-of-Community-Involvement-SCI.pdf

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include the social, economic and environmental factors which can impact on communities and citizens. Whilst Community Planning is at an early stage, a number of agreed key priority outcomes have been identified, which partners will focus on to improve: social well-being - including promoting equality and good relations economic well-being - including tackling poverty, social exclusion and deprivation environmental well-being - including how the Council will contribute to achieving

sustainable development.

Within the Draft Statement of Community Involvement, the Council notes the need to engage with under-represented (Section 75) groups who will be invited to identify whether there are any types of planning policies that are likely to have a significant impact on the groups they represent. They will also be provided opportunity to identify any particular issues or needs that they feel the plan should address. It is noted that across the new Council area 4.28% of the population do not have English as their first language. This is higher than the Northern Ireland average of 3.14% (NINIS). The Draft Statement of Community Involvement is out for consultation (closing date 1st February 2016). Following feedback the Council expect to publish the final Statement of Community Involvement in “early 2016”. It is hoped that the Hearty Lives Baseline Report and the Final Evaluation Report will be forwarded to the Council within the Community Planning consultation. Outcomes and Impact Over the years it has been recognised that the Review of Public Administration, and implementation thereof, takes time. Community planning is a developing process and still in the early stages. Community Plans for all Councils in Northern Ireland have to be in place by April 2017. The Manager leading on Community Planning in Armagh City, Banbridge and Craigavon Borough Council participated in the Hearty Lives Craigavon showcase event in March. Hearty Lives Craigavon has been successful in engaging with 6441 beneficiaries during the lifetime of the Project (three years). Individuals have increased their knowledge and understanding about heart health issues, risk factors, and lifestyle choices. In terms of community development and community planning there have been a number of outcomes and associated impact: • The benefits of cross-sectoral and inter-agency partnership working. • Raising awareness and empowering people to take control of their own health by giving

them the information and knowledge they require at a level they understand. • Signposting people to appropriate organisations who can support them to address their

needs. • Support for increased partnership working with a range of Voluntary Organisations and

supported increased knowledge, skills and capacity of staff in these organisations to support health and wellbeing.

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• Community development is strongly embedded in the Council’s Promoting Wellbeing Team.

Legacy Groups working with Irish Travellers and the BME community have a greater

awareness of the health needs of their target groups, and opportunities that are available to promote and address healthy lifestyles.

Individuals have registered with local GPs. 100 individuals who had high risk health check results were advised to see

their GP, and many received support to make healthy lifestyle changes. Community groups have been empowered and seen positive outcomes

following consultation; this experience may encourage them to participate in future community planning.

Increased partnership working with a range of voluntary organisations and increased knowledge and skills in staff in these organisations.

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APPENDIX ONE HEARTY LIVES CRAIGAVON STEERING GROUP MEMBERS Lynne Smart (Chair) SHSCT Head of Health Improvement Cathy Devlin Craigavon Borough Council Jane Ferguson SHSCT Hearty Lives Health Coordinator Joe Garvey Richmount Association Manager Kelly Hanvey SHSCT Heart Failure Nurse Specialist Lisa Hogg Craigavon Traveller Support Committee Manager Stephanie Leckey BHF Area Development Manager Angela McComb PHA, Lead of Health Improvement Patricia McVeigh SHSCT Communication Stephen Smith Community Intercultural Programme Manager Brenda Toal SHSCT, Promoting Wellbeing Specialist Lead Cross Directorates Paul Yam Wah Hep Manager REFERENCES i Northern Ireland Statistics and Research Agency. Deaths in Northern Ireland 2012. Belfast: NISRA, 2013. ii Cardiovascular health and wellbeing in Northern Ireland Literature review. Health impact assessment Northern Ireland cardiovascular service framework. Belfast: Public Health Agency, 2011. iii Hughes J et al. Explaining the decline in coronary heart disease mortality in Northern Ireland between 1987 and 2007. Journal of Epidemiology and Community Health 2010; 64(Suppl 1).

iv NI Health & Social Care Inequalities Monitoring System. Life Expectancy Decomposition An overview of changes in Northern Ireland life expectancy 2001-03 to 2008-10. Belfast: DHSSPS, 2013. v Prevention of cardiovascular disease at population level. Public health guidance 25. London: National Institute for Health and Clinical Excellence, 2010. vi Homer J, Milstein B, Wile K, Pratibhu P, Farris R, Orenstein D. Modelling the local dynamics of cardiovascular health: risk factors, context, and capacity. Preventing Chronic Disease 2008; 5(2).

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HEARTY LIVES CRAIGAVON PROJECT

FINAL EVALUATION REPORT

January 2013 – February 2016

February 2016

HEARTY LIVES Craigavon


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