Prosiect Calon Iach / Healthy Heart Project Ceredigion ... · makers and funders within Local Authorities and the NHS via presentations to the Local Health Board Executive, Health

Inequalities in Health Fund

Prosiect Calon Iach / Healthy Heart Project Ceredigion 2002 -2008

Final Project Report

This project was supported by the

Welsh Assembly Government’s Inequalities in Health Fund

[31.3.08] IIH/2001/079

Inequalities in Health Fund Final Report Healthy Heart Project Ceredigion Project Ref IIH/2001/079

ACKNOWLEDGEMENTS The following deserve special mention and thanks because without them the project would have been either not possible or very much more difficult to perform: The lead organisations: • Ceredigion Public Health Team (National Public Health Service) • Ymlaen Ceredigion.

Professional support: • Ceredigion Association of Voluntary Organisations (CAVO) • Ceredigion County Council • Ceredigion Health Alliance • Ceredigion Local Health Board • Communities First, Aberystwyth • Inequalities in Health Steering Group members • Opinion Research Services, Swansea • University of Wales, Aberystwyth • Wales Smoking Cessation Service • Welsh Assembly Government (also main funder) • Welsh Institute for Health and Social Care Involved in project delivery: • Aberystwyth Mind • Age Concern, Ceredigion • Antur Teifi • Aqua Serena Leisure Club, Penyparc • Area 43 (Youth support and information centre) • Camau Bach (Welsh medium pre school), Aberystwyth • Canolfan Padarn (Day Centre), Aberystwyth • Cardi Cardiacs (support group), Cardigan • Cardigan after schools Club • Cardigan Toy Library, Maesglas, Cardigan • Careers Wales • Ceredigion Care Society • Ceredigion Healthy Schools Scheme • Ceredigion Local Agenda 21 • Ceredigion Pupil Referral Unit • Ceredigion Social Services / Youth Offending Team • Ceredigion Training • Ceredigion WI • Coleg Ceredigion • Crymych Leisure Centre • Finch Square Café, Cardigan Cont…

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• Flying Start • Homestart • Jigso – Family drop-in centre, Cardigan • LINCS (young people - social inclusion) • Nant yr Eos Woodland Group • Penparcau Co-op, Aberystwyth • Penparcau Family Centre, Aberystwyth • Penparcau Youth Club, Aberystwyth • Plascrug Leisure Centre, Aberystwyth • Residents of Golwg y Castell and Ridgeway, Cardigan • Small World Theatre, Cardigan • Stepping Stones (pre school), Aberystwyth • Surestart • Wallich Clifford, Aberystwyth • Womens Aid, Aberystwyth • Ysgol Feithrin Penyparc • Ystwyth Primary Care Centre, Aberystwyth

Contacts:

Healthy Heart Project Officers: Rhian West, Alan Whittick, Health Promotion Officer, Community Development Officer, National Public Health Service, Ymlaen Ceredigion, Y Bryn, 15-17 Portland Road, North Road, Aberystwyth Lampeter SA48 7HA SY23 2NL 01570.424105 01970.633395

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CONTENTS

Pages 1. Executive Summary 5-9 2. Project Delivery

2.1 General Introduction and Background 10 2.2 Project Aims and Objectives 11-15 2.3 Delivery and Approach 16-22

3. Project Evaluation 3.1 Evaluation Aims and Objectives 22 3.2 Evaluation Methodology 23-24 3.3 Analysis and Results (CASE STUDIES p.24, MATRIX p.36)

24-42

4. Conclusions and Recommendations

4.1 Discussion and Interpretation of Outcomes 43-44 4.2 Summary 44-45 4.3 Core Elements of Project 45 4.4 Key Recommendations 45-47

Appendices 48-51 TOTAL 51 pages

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1. EXECUTIVE SUMMARY Between 2002 and 2008, the “Healthy Heart Project” deployed two part-time workers, one with expertise in health promotion, the other in community development, to help improve the health and well-being of those facing inequalities in Aberystwyth and Cardigan. The project used a “community development” methodology which resulted in over 30 community organisations hosting 55 wide-ranging initiatives (see matrix p.36) which were supported by an operational budget and involved over 5,000 members of the target group. The annual budget was circa £80,000.

A. Overall summary of project – key aspects

• The project has worked in partnership with the voluntary sector and other community based organisations that have access to the target group, to promote and support people to take responsibility for their own health. The project has focused on healthy eating, physical activity, stopping smoking and stress.

• The use of community organisations as an existing structure has proved to be an efficient and effective platform from which to promote healthy lifestyles and has brought about positive change in policy, practice and provision within the participating organisations, many of whom confirmed that they “would not have taken up the health agenda without the encouragement and support of the programme”.

• Community organisations have welcomed the opportunity to promote the health and well-being of their members. The programme, with its emphasis on participation and the provision of opportunities to experience change, has increased social engagement and overall attendance.

• The use of a community development, “bottom up” methodology has allowed the organisations to design and implement their own responses to the health and well-being agenda and has given members ownership of the programme, thus enhancing the sustainability of the changes made.

• The production of the “Healthy Communities Toolkit” has provided a resource for other organisation to promote healthy lifestyles and the training of Health Visitors to support the methodology used, have provided a means for the programme to be sustained in the future throughout the county.

“We will focus on health and wellbeing, not illness, by using every avenue to promote healthy communities (and by) empowering individuals to take responsibility for their own health.” Designed for Life, May 2005

B. Evaluation results Impact on health inequalities • The Healthy Heart project has enabled community organisations working with

disadvantaged people to promote healthy lifestyles in an informal and practical

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way, providing the opportunity for members to make informed choices and begin to take responsibility for their own health.

• The project has encouraged organisations to develop their own responses to the promotion of healthy lifestyles, based on the needs and knowledge of its staff and members. This has given the group ownership of the initiative, and ensured that the programme is needs led.

• The target group, through participation in the programme, have undertaken training on healthy eating, undertaken accredited training and a small group have developed an enterprising activity to promote healthy eating.( see case study 1)

• Health initiatives, especially the provision of a healthy meal, have helped to break down barriers within the target group. It has encouraged those people who would not normally come into an organisation to attend thereby accessing other services and support provided by the organisation. The initiative has also allowed for increased engagement with the particularly hard to reach groups and identified further needs.

• Children attending projects with parents have shown how they are able to influence sometimes reluctant parents to make changes in their lifestyle.

• In order to reach consistently those facing inequalities, the project worked in partnership with organisations supporting young people at risk, youth offenders, those in the care of Social Services and those in alternative education, people with mental health problems, families and individuals needing additional support, people who were unemployed, on low incomes and/or in poor quality housing, people with disabilities and those in poor health, women who had experienced domestic abuse and older people.

• To engage with those who do not access community organisations, the project officers have worked with individuals directly on the social housing estates. The engagement process has shown that at times it has been necessary to address the wider determinants of health prior to addressing personal change. The response to the health agenda from this sector has been positive but requires locally based workers to provide continuous support and drive (see case study 1).

Service change and provision • The use of community organisations as an existing structure has proved to be an

efficient and effective platform from which to promote health and well-being and brought about positive change in policy, practice and provision within the participating organisations.

• These community organisations have increased the capacity within their communities for the target group to experience and participate in healthy lifestyle changes.

• Community organisations which have worked with the project have made their initiative sustainable and will therefore continue to provide their healthy lifestyle initiatives after the end of the programme.

• The project has shown that a modest investment to set up health initiatives has encouraged organisations to develop further activities.

• Working with a local arts and culture organisation has shown how the arts can be a valuable “point of entry” for those hard to reach individuals who are not members

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of community organisations. This technique has been valuable in breaking down barriers between housing estates.

• The project has delivered a health agenda outside the primary health care service. The project leaves behind a range of resources: • The provision of equipment and the facilitation of “healthy eating” training,

developed by the Ceredigion Public Health Team Food Advisors, for community organisations’ staff and members, has given them the knowledge and confidence needed to promote health lifestyles.

• The project has funded the training and employment of a smoking cessation counsellor, specifically trained to work with mental health problems. This initiative has also developed a training pack for other mental health workers and a relaxation CD to support smoking cessation clients (see case study 4).

• The “Healthy Communities Toolkit” has provided a resource to support other community organisations in the promotion of healthy lifestyles.

• Health Visitors have received training based on the toolkit to enable them to deliver healthy lifestyle initiatives within their local community organisations. They now have Performance Review targets relating to this work.

• Two of the organisations working with the project are to become Open College Network (OCN) accredited training centres on healthy eating.

• A fully accessible kitchen has been part funded by the project. This will be a community resource aimed at supporting the target group to learn about food, including how to prepare and introduce healthier food options for the family.

Partnership and joint working From the outset, the project was established under the joint leadership of the National Public Health Service (NPHS) and Ymlaen Ceredigion (a not for profit organisation concerned to promote sustainable development in the community). (a) Primary care involvement The design and implementation of the work has involved the Local Authority, the Health Alliance, Health Visitors, Primary Care, the Local Health Board and health promotion practitioners. (b) Other stakeholder involvement The project was supported by Ceredigion Association of Voluntary Organisations, Communities First and around 30 local community organisations.

Sustainability • By setting up health initiatives within established organisations, the healthy heart

programme addressed the issue of sustainability from the outset. • The use of a community development, ’bottom up’ methodology which has allowed

the organisation to design and implement their own responses to promote healthy lifestyles and given members ownership of the programme, has been key in achieving sustainability of the programmes within the organisations.

• The support for health initiatives has frequently resulted in members agreeing to take over the funding of the project to ensure its continuation.

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• Community organisations have been positive in their response to promoting healthy lifestyles. Health initiatives, especially those related to food, have encouraged participation and have benefited the organisation through increased attendance, greater social engagement with the target group and the support of members to develop further initiatives. These benefits have on occasion inspired organisations to seek alternative funding in order to sustain a health initiative.

• As stated in the previous section, the project leaves behind a variety of resources. • The project officers have taken the messages generated by this work to decision

makers and funders within Local Authorities and the NHS via presentations to the Local Health Board Executive, Health Alliance, Community Strategy, Communities First and the Chief Medical Officer. However, funding to develop or “roll out” the programme has not been identified.

C. Recommendations and best practice examples (i) Best practice examples:

1. Many community organisations not previously engaged in the health agenda have now taken policy and practice on board.

2. Organisations have responded positively to the health agenda and make effective partners to achieve the programme’s aims. Many went on to develop further initiatives of value.

3. Community Organisations are an effective platform from which to deliver healthy lifestyle activities to “hard-to reach” target groups.

4. Community arts as a “point of entry” to engage those especially hard-to-reach clients experiencing inequalities in health was especially effective, and there were notable “spin-offs” in relation to self-confidence, the braking down of barriers between estates and access to accredited learning opportunities.

5. The provision of a smoking cessation counsellor specifically for those experiencing mental health problems has shown that those especially vulnerable people have the potential and the right if supported appropriately to take positive action to improve their health (see Case Study 4).

6. Partnership working has been crucial to achieve progress in addressing the wider determinants of health and thus in implementing the promotion of health and well-being in the community amongst the target group.

(ii) Recommendations: It is proposed that:

1. The methodology of the project which ensures engagement and therefore needs-led, sustainable responses be seen as having crucial relevance for meeting the aims and objectives of Health Challenge Wales, Designed for Life, the Wanless Report, Ceredigion Health, Social Care and Well-being Strategy, Better Health Better Wales and Standard 1 of the National Service Framework implementation plan for Ceredigion. The project’s outcomes also complement the health and wellbeing objectives enshrined in: Making The Connections, The Rural Development Plan, the Community Strategy, Wales: A Better Country and the Wales Spatial Plan.

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These findings should therefore be of interest to NHS Trusts, LHB’s, GP’s, Health Alliances, County Councils, Communities First, community organisations and the voluntary sector in general. 2. The voluntary sector and community based organisations should be seen as a

means of delivering the health and well-being agenda and a structure put in place to provide the support, training and resources necessary to implement such a programme. A “Healthy Communities Scheme” could complement the “Healthy Schools Scheme” with existing organisations such as the NPHS, Communities First, Local Authorities, the HSCWB partnership, CAVO, as the possible host organisation/s.

3. There is also a need to identify funding to employ community based workers to increase capacity for community engagement with the health and well-being agenda to reach and support the target group. This is particularly important in the light of the challenges posed by obesity and the current cost incurred by the provision of medication.

4. Consideration should be given to funding low cost, simple interventions in the community sector.

5. Health Visitors adopt the methodology and practice as part of their public health role.

6. Recognition is given to qualitative data and to the fact that evaluation relating to promoting healthy lifestyles in the community belongs in a community development, rather than a clinical/ medical culture. At present, there is a lack of qualitative research in this field. Funders and practitioners of this “community development” approach need to agree acceptable evaluation methodology based on qualitative assessment.

(iii) Summary View from the Project Officers: The Project Officers recognise the financial challenges currently facing decision makers in the NHS and Local Authorities and the fierce competition for resources, exacerbated by an ageing population. Nevertheless, work which engages the target group within their community, as this project has done, and supports them to change to healthier lifestyle choices, needs to complement the identification of existing risk and the treatment of illness. This intervention is needed before the door of the GP’s surgery, not least to avoid unsustainable costs at a later stage. This approach will be especially important if the health threat posed by obesity is to be tackled effectively within the priority group. This project offers a low cost, effective and efficient way to undertake such community based work, provided that attention is paid to ensuring that there is the capacity to respond at grass roots level. By using the methodology of this project and taking on board the learning from the experience of this work, the project officers estimate that a programme of this nature could be run throughout Ceredigion on a budget of ….

£50,000 per annum

Cost of Cardio Vascular System medication in Ceredigion (2006/07) £5,179,207 per annum

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2. PROJECT DELIVERY 2.1 General Introduction and Background 2.1.1 Funding This project was funded through the Inequalities in Health Fund supported by the Welsh Assembly Government. Funding of around £80,000 per annum was allocated to the Ceredigion initiative to work in Cardigan and Aberystwyth. This allowed for the employment of 2 part-time (60%) workers, one health promotion and one community development specialist, supported by an operational budget for healthy lifestyle initiatives. The project was managed by Ceredigion Public Health Team (National Public Health Service) and Ymlaen Ceredigion, a not for profit organisation promoting sustainable development, who were the project lead organisations. 2.1.2 The Inequalities in Health Fund The fund was established in 2001 to stimulate and support new local action to address inequalities in health and the factors that contribute to it, including inequities in access to health services. The Fund’s priority is coronary heart disease (CHD) and action that contributes to the implementation of the National Service Framework (NSF) for Coronary Heart Disease. This project is one of 67 that were funded, with Ceredigion receiving around £80,000 per annum over the six year period. The Fund, operating to a budget of around £5 million per annum, demonstrates the Assembly’s commitment to tackle inequalities in health that exist between some of our communities. Over and above the money available to support action on coronary heart disease a further £1 million per year was allocated to the Inequalities in Health Fund to address inequalities in dental and oral health. This element of the Fund has been deployed separately. 2.1.3 The National Service Framework for Coronary Heart Disease The National Service Framework for Coronary Heart Disease in Wales 2001, sets out five standards. The standards, which are about to be revised, are: Standard 1 - Health Promotion - Action to decrease risk factors for Coronary Heart Disease. Standard 2 - High-risk patient - Patient care action to identify those at risk for assessment/treatment. Standard 3 - Acute Coronary Symptoms - High quality care for everyone with an acute episode of Coronary Heart Disease. Standard 4 - Heart Failure - Identification and treatment of those with heart failure. Standard 5 - Atrial fibrillation - Identification and treatment of those with atrial fibrillation. All projects supported by the Inequalities in Health Fund fall under one or more of the above headings. This project contributes to Standard 1. Standard 1 (CHD National Service Framework –currently under revision): “Health Authorities, through their local health groups and in partnership with Local Authorities and their Local Health Alliances should develop, implement and monitor evidence based programmes to address the impact of tobacco use, diet and physical activity, targeted at the most disadvantaged communities in Wales.”

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2.2 Project Aims and Objectives 2.2.1 Main Aim The project aimed to address inequalities in health relating to Coronary Heart Disease (CHD) in Aberystwyth and Cardigan, in the county of Ceredigion. By using community development methods, it provided a stimulus to encourage health and well-being, helping to remove those barriers which prevented positive change by the target group. The programme was subject to continuous review (Action Research) and as lessons were learned, the aim and methodology were adapted as follows:

a) Community organisations were used to engage with the target group as ad hoc groups proved difficult to identify and sustain.

b) The programme focussed on promoting healthy lifestyles, principles later to be articulated via Health Challenge Wales, as the health benefit of the work was relevant not only for CHD but also for other major threats such as diabetes, obesity and some cancers.

c) Particular emphasis was placed on achieving sustainable health outcomes.

INSERT MAP OF CEREDIGION Include population of each community.

2.2.2 Objectives The project’s objectives were to: • Engage with residents in 2 deprived communities (Aberystwyth and Cardigan), as

defined by the Welsh Index of Multiple Deprivation. • Enable them to identify CHD issues and to take action on those related concerns

which they prioritised. • Give the target group opportunities to experience the benefits of balanced diets,

increased physical activity, controlling stress, stopping smoking.

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• Develop local capacity to ensure that the above occurred effectively and to ensure sustainability after funding ended.

• Develop an action research protocol for monitoring and reviewing the project's progress.

• Develop local action plans to address these inequalities using existing networks within the community.

• Inform other relevant services about the needs and aspirations of the targeted group.

• Allocate resources at a local level to ensure implementation of these plans.

2.2.3 Project Relevance The project forms part of Standard 1 of the CHD Implementation Plan for Ceredigion. The purpose and methodology of this work respond very closely to the principles of illness prevention which are a key theme of “Designed for Life” and the Wanless report. More generally, the findings will be of interest to those involved in:

• strategic planning and funding of services relating to primary prevention • the empowerment of individuals to take responsibility for their own health • encouraging and supporting the engagement of the target group in improving

their situation • tackling inequalities • constructive partnership with the voluntary sector • sustainability

This will include NHS Trusts, LHB’s, GP’s, Health Alliances, County Councils, Communities First, community organisations and the voluntary sector in general. The methodology of the project and its emphasis on a healthy lifestyle which leads to an improvement in people’s quality of life has crucial relevance for meeting the aims and objectives of:

• Health Challenge Wales, • Designed for Life, • the Wanless Report, • Ceredigion Health, Social Care and Well-being Strategy, • Better Health Better Wales. • Making The Connections, • The Rural Development Plan, • the Community Strategy, • Wales: A Better Country, • Wales Spatial Plan, • Standard 1 of the National Service Framework implementation plan for

Ceredigion. 2.2.4 Background • The Ceredigion “Healthy Heart Project” set out specifically to address the primary

prevention agenda in the community. The project targeted deprived areas in

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Aberystwyth, especially the Communities First area within this town, and Cardigan. Originally a three year programme, it was later extended to five and subsequently six years.

• The two towns in Ceredigion were chosen because the Welsh Index of Deprivation 2000 identified Aberystwyth (especially Aberystwyth South) as being in the highest quintiles for income deprivation, child poverty and housing deprivation and in the second highest quintiles for multiple deprivation, employment, health and disability. Cardigan, though not a Communities First area, was suffering economic deprivation and its primary schools had a significantly high percentage of children receiving free school meals when compared to other areas in the county.

• Hospital admissions for CHD from the Aberystwyth area are 50% higher than for Ceredigion as a whole (10% higher in Cardigan) and in two wards the rates are double those of the county as a whole.

• In 2003 – 2004, 47.3% of the adult population of Ceredigion were overweight or obese. Wales Centre for Health: Pictures of Health in Wales, 2006.

• The project targeted vulnerable groups and areas of social housing.

Cycling in the woods and hills near Aberystwyth.

Plascrug Leisure Centre programme.

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Steering group composition: The project officers found the steering group extremely supportive and especially useful for general advice and for contact with key agencies, in particular health visitors, the County Council and the NPHS.

HEALTHY HEART PROJECT – STEERING GROUP Note: Two GP’s and two practice representatives were invited to become members but were unable to attend any meetings .Chair alternated between Ymlaen Ceredigion and Ceredigion Public Health Team. Function: The Steering Group were given Terms of Reference which stated the aim of the group as: To provide strategic and co-ordinated support and direction to the Inequalities in Health Fund programme. Meeting quarterly, they performed the following role: • Monitoring, reviewing, supporting and advising on the programme, including:

o Allocation of funding for community organisations delivering the programme

HSCWB Strategy Manager

Healthy Heart Project Officers

Ymlaen Ceredigion

Co-ordinator

2 Health Visitors –

(management roles)

Communities First Co-ordinator

Local Health Board rep.

Ceredigion Association of

Vol. Orgs

Director of Public Health

NPHS Principal

Health Promotion Specialist

Healthy Heart Project

Steering Group

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o Professional issues o Evaluation

• Feeding back to their organisations and respond to the work of the programme as relevant to their own work

• Lobbying for support, resources and sustainability The Project Officers were members of the Communities First ‘Health and Wellbeing sub-group’ for the Aberystwyth Communities First area. 2.2.5 Evidence base for project

(a) Inequalities: Evidence has consistently shown that those people facing inequalities experience worse health than average. The project focused on the need to work with this target group to increase their physical activity levels, improve their diet, reduce their stress levels and give up smoking. The definition of “Inequality” followed the Welsh Index of Multiple Deprivation (WIMD), a holistic definition as used for example to identify Communities First areas. Clients were targeted if they were experiencing one or more of the following: low income, poor housing, poor health, disability, inadequate education, training or skills, unsuitable or no employment. (b) Health Improvement:

The project relied on the established evidence which now forms the basis of Health Challenge Wales. People’s health will benefit from eating a balanced diet, including not less than 5 portions of fruit and vegetables a day. In Wales, only 36% of men and 23% of women meet the minimum levels for healthy activity (Welsh Health Survey 2004/05). In Ceredigion in 2003/04, 25.4% of the population smoked. (Wales Centre for Health, Community Health Profiles 2006. An informal survey conducted with 200 people from the Penparcau estate in Aberystwyth showed that 92% of those interviewed had one or more risk factors which could be alleviated by positive lifestyle changes. (Ymlaen Ceredigion / Communities First 2007.) The rationale for the more costly intensive programmes, often residential, with young people at significant risk or demonstrating challenging behaviour, as well as being entrenched in effective youth work practice, can be based on references found in the work of Resnick, M.D. et al 1997 “Protecting Adolescents from Harm” Journal of the American Medical Association.

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2.3 Delivery and Approach 2.3.1 Methodology

• Following health needs analysis in the two communities and the distribution of promotional material produced in-house, the project officers held a range of meetings with individuals on the targeted social housing estates and with established community groups working with people at risk.

• Support and advice was given to community groups, agencies and individuals by the Project Officers to encourage appropriate responses to the programme’s objectives. These responses aimed to give participants the chance to experience positive change, rather than just receive information. They also allowed for sustainability and policy change to be built in for the future.

• As a result of these discussions with the Project Officers, the proposed action was sometimes modified by mutual negotiation to ensure the programme’s targets were met effectively. Officers made judgements about the effectiveness of certain organisations and their leaders in reaching and working with the target group.

• Needs identification, evaluation, outcomes and targets were agreed at the

outset and contained in a Service Level Agreement for each project.

• The proposals for funding also needed to show that potential beneficiaries had had a say in their planning and implementation.

• Operational funding, reducing from £50,000 per annum in years one to three, to

£23,000 in years four to six, was then allocated subject to approval by the Inequalities in Health Steering Group. The balance of the £80,000 per annum was used to employ two part-time staff, a community development officer and a health promotion officer.

• The partnership with community organisations initially resulted in 55 initiatives

being hosted by over 30 organisations and involving over 5,000 beneficiaries. The activities included:

training (for both staff and target group), production of resources such as food maps, calorie map, exercise video

and community gardens, provision of healthier food and menu options, physical activity sessions, classes and equipment, awareness raising discussions and events, personal mentoring, residentials and intensive programmes promoting healthier lifestyles for

young people at risk

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environmental improvement (chosen as the first task by the housing estate residents) to engage with potential participants and build up trust.

• Following the 2005 evaluation, in line with the principle of Action Research, it

was decided that the second phase would not establish new initiatives but rather build on success, strengthen certain initiatives and concentrate on issues of sustainability. This also followed WAG guidelines which in general advised against starting new initiatives.

Support was given by the Steering Group and by the University of Swansea and

subsequently by Opinion Research Services of Swansea. Up until 2004, support was also received from Powys / Ceredigion Health Promotion. The programme was enhanced by the different disciplines of the lead agencies: Ceredigion Public Health Team (NPHS) and Ymlaen Ceredigion.

Nature of the 55 projects.

Training and awareness

raising for staff and target

group Environmental improvement

Toolkit, calorie map,

exercise video, community

gardens

Residentials promoting healthier lifestyles

Physical activity

sessions, classes and equipment

Personal mentoring

Healthy Heart Project

generating…. Promoting and experiencing healthier food

options

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2.3.2 Justification of Method

The programme’s “community development approach”, holistic and client-centred, is a crucial component because it explicitly encourages community and, in particular, beneficiary ownership of the action taken, an element which in itself promotes sustainability. The principles of Community Development are:

Social justice Self determination Working together Participation Reflective practice Sustainability

Many WAG policies and programmes are underpinned by 3 themes central to community development: social justice, equality of opportunity and sustainable development. These and other principles were reflected throughout the programme:

Social justice and Equality of Opportunity: The focus of the programme was to address health inequalities and reach the most vulnerable members of society. Self determination and participation: It was a part of the Service Level Agreement and of the culture of community organisations that beneficiaries were consulted and involved at all times, an essential feature since their participation was at all times voluntary. Working together: The programme operated through comprehensive partnership and groups were encouraged to share and learn from other initiatives. Sustainability: Again, this was a concern and a requirement from the outset, with an emphasis on mainstreaming good practice and on training. The reasons for using Community Development methodology to deliver the health agenda:

It encourages decisions to be made by the people affected. These decisions are often more realistic and sustainable than those made by others on their behalf.

The community participates in defining and addressing the problem with appropriate help from professionals (doing with, not for) – again making the action more likely to be sustainable.

It increases awareness of health issues, develops participants’ skills and helps people make realistic and informed choices.

It meets the World Health Organisation’s definition of health as being a state of complete physical, social and mental well-being and not merely the absence of ill health.

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It accepts that people hold experience of their own health and enables them to voice their own needs in a way which is relevant and acceptable for them.

The reason for using Community Organisations: Community Organisations offer:

A safe and trusted environment that accesses some of the most vulnerable members of the community.

Such an environment is favourable to influencing change. A relationship with the client group that allows for open discussion which is

non-judgemental. This environment and relationship provide a unique platform that can

significantly influence changes in lifestyle issues. A wealth of local knowledge and insight about their members and their

community which can help the depth of engagement necessary to bring about long term change.

The opportunity to bring about change, not simply by telling and informing but by allowing the client group to experience change, through seeing, doing, or tasting something new.

Again, such experiences can significantly influence change in the long term.

Jigso - Cardigan family centre - members and staff, preparing to go for a walk…

2.3.2 Project Timetable The following illustrates the key stages in the development of the project. Milestones: Date: Action: Research November 2002 Needs analysis produced and

background information assimilated by December ‘ 02.

Devise and produce bilingual info/ promotion pack, hold Action Group training Days for organisations and individuals

April –August 2003 400 packs produced and distributed April – June ‘03. Two Action Days for recruitment with identified community groups and individuals, using the information pack. 30 meetings held with community group leaders. 26

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community groups initially involved. Range of appropriate ideas generated and implemented.

Community Projects (phase 1):

June 2003 to March 2005

Range of 52 new projects commenced and supported via community orgs. and ad hoc groups.

Extension Spring 2004 Extension from 2005 – 2007 announced

Community Projects (phase 2):

2005 - 2008 Continuation and consolidation of successful initiatives with a view to enhanced sustainability and increased capacity to deliver on healthy lifestyles.

Extension February 2006 Extension from 2007 – 2008 announced

Production of Toolkit and training programme. Influence on decision makers to adopt good practice from the programme. Seek alternative funding for programme.

2007 - 2008 Health visitors and youth service staff trained. Presentations to decision makers and funders (Health Alliance, Communities First, LHB Executive, Director of Public Health, Chef Medical Officer). Bid to Health Challenge Wales Voluntary Sector Grants Scheme.

2.3.3 Resources Developed The following resources were developed as a result of the “Healthy Heart Project”. Other local resources included a Welsh language exercise video and community gardens.

Resource 1: Healthy Communities Toolkit Description: Toolkit based on the experience of the Healthy Heart programme. Contains straightforward information and practical ideas as to how community groups can help their members live healthy lifestyles. The Toolkit clarifies the meaning of health, identifies the potential of community organisations to influence healthy lifestyles and the benefits to members and the organisation itself. It also provides information on healthy lifestyle messages, resources and support networks at a local and national level. Function: To promote the programme’s sustainability, by providing a resource to support community organisations to integrate the healthy lifestyle message into their work. Provides a basis for the training of health visitors and for example youth service staff, to enable them to take healthy lifestyle messages and practice to those experiencing inequalities.

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Resource 2: Training for staff and community members Description: Staff in regular contact with target group trained in aspects of healthy lifestyles. (Health Visitors, youth service, Mind, family centres etc.) In addition: Open College Network (OCN) accredited centres offering healthy eating courses to staff and the target group within the community have been established at Small World Theatre and Area 43. Function: To disseminate learning and good practice from the work of the “Healthy Heart Project” and contribute to the project’s sustainability.

Resource 3: Community Kitchen

(See Case Study 1) Description: Part funded kitchen facilities to be used by the community (including full disabled access), in the new Small World Theatre premises in Cardigan. Function: To teach cooking and related skills and give participants a chance to experience healthy food. Host organisation now operating OCN accredited training for staff and members of the community.

Resource 4: A smoking cessation counsellor specialising in mental health

(See Case Study 4) Description: Specialist training for a member of staff working with clients with mental health problems to support smoking cessation amongst this group. The training involved the recognised smoking cessation service training. Additional training needed to be sought which related specifically to mental health and which incorporated motivational training and clinical issues. Counsellor has produced a training pack for other mental health workers and a relaxation CD. Function: To support those with mental health problems to give up smoking.

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Resource 5: Calorie and Step Map Description: Developed in partnership with the University of Wales, Aberystwyth and Ridgeway (Cardigan) residents. Map of Cardigan town showing steps taken and calories burned off when walking around town. Delivered to every household and 2,000 additional copies funded by Ceredigion Health Alliance. Launched through Jigso family centre and subsequently distributed through the Age Concern office. Function: To relate accessible physical activity to everyday life for people living in and around Cardigan.

Cardigan calorie and step map (produced bilingually)

3. PROJECT EVALUATION

3.1 Evaluation Aims and Objectives 3.1.1 Evaluation Aim Evaluation was intended to ascertain whether working through community organisations represented an effective and sustainable method of reaching the target group.

3.1.2 Evaluation Objectives The objective of the programme’s evaluation was to ascertain the following:

• How have community organisations responded to the promotion of healthy Lifestyles within their organisation?

• How has the initiative been supported by staff and members? • What have been the benefits to the organisation?

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• How has the initiative helped the members of the target group? • Have the initiatives engaged with the target group and therefore impacted on

health inequalities ? • What developments have occurred within the organisation following the

projects initial investment? • Has the programme increased the local capacity to promote healthy life styles

to the target group? • Has the programme brought about positive change in service provision for the

area? • How sustainable is the initiative? • How many people were involved? • What was the feed back? • Were there any spin offs?

3.2 Evaluation Methodology

• Each project was subject to a Service Level Agreement (SLA) specifying particular objectives for that organisation, monitored by continuous assessment and adapted if necessary through the process of Action Research. See appendix 4 for an example. SLA’s contain the agreed purpose and method of the initiative, evaluation required, funding level, timing and organisational responsibility. They are also designed to assess levels of sustainability. They are signed by the organisation and the local Director of Public Health (NPHS).

• The programme uses an Action Research model. This is a continuous process

which analyses how the programme is implemented and the services and/or changes which are delivered. The methodology and action of the programme are then reviewed and revised regularly as the results are fed back.

• In 2005, the 52 community based projects were assessed by face to face

interviews conducted by the programme officers with an agreed script. These interviews sought to confirm outcomes, check expenditure, identify spin-offs, receive feedback, including quotes from participants / beneficiaries and staff and also to assess the level of sustainability and the future in general.

• Following this 2005 evaluation, it was decided that the second phase would not

establish new initiatives but rather build on success, strengthen certain initiatives and concentrate on issues of sustainability. These projects included smoking cessation in the field of mental health, cooking skills, community arts to promote healthy lifestyles, influencing the curriculum of community organisations, a range of physical activity initiatives, and working in partnership work with the NPHS food team “train the trainer” programme. This response also followed WAG guidelines which in general advised against starting new initiatives.

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• In 2007, as part of the final evaluation for the programme, a case study pro forma was sent to organisations so that a selection of appropriate case studies could be included in the report. See appendix 6.

3.2.2 Professional Assistance for Evaluation

• Assistance was received from the University of Swansea, though the officers found it difficult to apply this model - perhaps more suited to the collation and analysis of clinical data - to a community development context. Subsequently, support was given by ORS of Swansea whose assistance proved for the most part to be relevant, constructive and accessible.

• The programme also benefited from the active support and advice of a Steering Group which includes representation from health visitors, the NPHS, Ymlaen Ceredigion, the HSCWB Alliance, LHB and Ceredigion Association of Voluntary Organisations.

• The Project Officers used the Community Development Cymru publication “Evaluating Your Community Development Activities” to inform their evaluation methods and are grateful to CDC for this excellent support material.

Growing fruit and vegetables in the back garden (Ridgeway, Cardigan) 3.3 Analysis and Results The following case studies illustrate many of the principal features of the projects, as identified in each opening paragraph. ALL (BLUE) SHADED TEXT IS TAKEN DIRECTLY FROM THE EVALUATION PRO FORMAS FILLED IN BY PARTICIPATING ORGANISATIONS IN RESPONSE TO THE QUESTIONS POSED. For clarity, these questions are repeated in the case studies.

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CASE STUDY 1: Small World Theatre (SWT) This case study illustrates the important and necessary process of engagement with that section of the target group who do not access community organisations. It also shows the use of arts as a valuable point of entry to accessing people facing inequalities and promoting health. Of particular note, is the increased self-esteem reported by many of the participants and the positive training outcome for certain individuals as well as the potential for future sustainability offered by the community kitchen and the OCN accredited training. Small World Theatre is an arts and culture for development charity based in Cardigan which uses performing, digital and visual arts to work with people facing disadvantage to improve their situation. They have experience of working with community groups in Britain, the Middle East, the Far East and Africa and are about to open a new purpose built centre in the town. They were brought in to develop work with residents on the Golwg y Castell and Ridgeway estates which had been started by the PO’s and following evaluation showed the need for a consistent local presence. The initial work undertaken by the PO’s included supporting Ridgeway residents to clear their estate of 17 tons of rubbish and numerous house visits, resulting in the setting up of a fruit and vegetable co-op and “grow-your-own” in their gardens. SWT worked closely with residents of all ages, using craft materials to make puppets and models on the theme of healthy lifestyles. The residents also undertook visits to local producers, participated in organising a community feast and food festival, prepared and cooked food and helped run a bicycle—powered smoothie making machine. Some have now undertaken accredited training and residents of the two adjacent estates are continuing to work together. 1. How do you feel the initiative has helped the members of the group?

What difference has it made? Arts work with a healthy eating theme has increased awareness of the benefits of healthy eating amongst children and adults in two disadvantaged communities. Families are actually buying and eating more fruit and vegetables, a fact that was evidenced in evaluation games and observation by SWT staff of choices made by participants about lunch and snacks during other activities (and also by the merciless teasing of project staff - who sometimes eat chips - by the participants!). A core group of mothers has become involved in running a bicycle-powered smoothie-making machine in order to promote healthy eating themselves 2. What have been the benefits to your organisation? It has enabled our organisation to develop new work based around healthy eating and encouraged us to develop a healthy eating policy. By including a communal meal of some sort in project activity days, we have created a positive cohesive atmosphere that makes all our work go more smoothly. 3. What developments have occurred within your organisation following the project’s initial investment? A new fully accessible kitchen, part funded by the HH project, is being built within SWT’s new building (Canolfan Byd Bychan). This will be a community resource aimed at teaching the target group about preparing and consuming healthy food. SWT has established links with local caterers who are willing to be trainers on OCN accredited courses. SWT is now an OCN Accreditation Centre. 4. How many people took part? 40 in direct activity and up to 250 through the bicycle powered smoothie making machine, picnics and open air cooking during Open Access Play activities

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5. Do you have feedback from your members and/or staff, eg. quotations? ”””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””” “Show us how on earth we can get our kids to eat 5 fruit and veg a day!” …exasperated mother “I’ve never tasted anything as good as this fruit kebab”… child cooking during a play day in Cardigan. “Giving and sharing of food is an important way to develop and define relationships” …staff member. ””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””” 6. Were there any spin offs i.e. unintended benefits? One participant, single mother, unemployed is now doing a full time catering course at Coleg Ceredigion and two other participants have taken food related jobs, one full and one part time. 7. How was the initiative supported by a) members. b) staff?. Staff took care not to seem critical of participants’ current lifestyles and to make the experience of change enjoyable. Children who had been thinking about these issues in school supported sometimes reluctant parents to make changes. Staff loved it, especially tasting the recipes! 8. Do you see this initiative as being sustainable? We have evidence to support applications for future funding. Staff and participants have food hygiene training. SWT is developing new work around community feasts. Some local parents are committed to doing courses to gain OCN accreditation in healthy lifestyle related subjects.

CASE STUDY 2: Area 43

This case study illustrates work with a particularly hard-to-reach group to give them personal experience of the benefits of a healthier lifestyle, especially in relation to food. Also, the provision of healthier food has benefited both clients and the organisation by allowing greater engagement which has led to increased identification of their clients’ health needs and the range of services available to them. A good level of sustainability was achieved and there were positive spin-offs. “Area 43” is an independent voluntary sector youth information and support centre based in Cardigan. It provides services for the 16 – 25 age group, many of whom face particularly complex challenges in their daily lives, including unemployment and low income. The Healthy Heart project funded a part-time post to introduce and promote healthier lifestyles amongst its members. The work aimed to increase awareness of the importance of healthy food and lifestyle, cooking skills, budgeting and planning for this “hard-to-reach” client group. 1. How do you feel the initiative has helped the members of the group?

What difference has it made? It has increased awareness around the importance of diet, developed cooking skills and the realisation that it’s not that difficult to cook well, helped participants learn about budgeting and planning and improved awareness of the longer-term benefits of healthy food and lifestyle. 2. What have been the benefits to your organisation? Running a café adds a great deal of value to Area 43 as an organisation. Providing food, whether it is free or at a modest cost, encourages those young people who would not normally come into the centre to attend and then access all the other services we provide. A large proportion of our clients are unemployed or on low incomes, so having healthy food

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available is a practical and important part of what our organisation has to offer. Running a kitchen also provides staff with a platform to discuss the effects of healthy eating and to deliver informal education and practical advice on how to improve clients’ diet, fitness and budgeting skills. 3. What developments have occurred within your organisation following the project’s initial investment? The most important development is that we are continuing to provide a full healthy eating agenda and that the whole project has been sustained after the funding finished. There is also a heightened awareness of food and the traditional festivals. For example, we now do pumpkin things at Hallow’een, pancakes on Shrove Tuesday, chocolate nests at Easter as well as our usual Christmas lunch. 4. How many people took part? From the daily client log we are able to provide statistics to demonstrate the effectiveness of running a café on both the physical health and fitness of our clients and their education regarding health. The number of health advice sessions given in 2006 was 2387, in 2005 it was 2,411, in 2004 it was 2,229 and in 2003 it was 2,335. These high figures illustrate the need from our clients to discuss and receive advice about their health and fitness. 5. Do you have feedback from your members and/or staff, eg. Quotations? Customer feedback has been very positive and paying for the food has also been relatively painless- especially as we now sell soup for 50p (those that say they are broke can usually rustle up 50p). ”””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””” Tracey says: “Because I’ve got kids I need to think about keeping them healthy. I’ve learned lots from here about good food. Now my kids actually like fresh vegetables and fruit. I don’t like giving them chips any more”. Miles, who often cooks for an elderly relative commented: “Chips and pizza are really bad. Now I do curries with really nice spices, and rice and good stuff like that. I learned some of that from coming here”. Joe mentioned the fact that he had been inspired to cook a stir-fry with his left overs and some veg he found in his fridge – “I would have thrown it away but since seeing what can be done with a stir-fry I thought I’d give it a go – and it was lush, no junk in it either”. ”””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””” 6. Were there any ‘spin offs’ i.e. unintended benefits? Joe got a job in a café. Some of our young people have been on catering courses and now help in the kitchen and give us tips! 7. How was the initiative supported by a) members. b) staff?. Those clients who have been engaged from the beginning are now our best ambassadors in getting the message out to other young people who have yet to take part. Therefore, those who are new to the idea of healthy eating and exercise are working alongside those who have been in the programme for up to two years. In these situations, we see peer education and mentoring working at its best. Through our informal learning programme we have encouraged ever greater participation in the Project to experiment with different ingredients, cooking methods, storage and budgeting. There is evidence of ownership and increased self esteem as Area 43 takes on board and uses ideas for menus and preparation methods etc. We have also varied and added to, the fitness and exercise programme in response to feedback received and found that our ability to respond quickly is a real bonus for the participants. As our clients belong to one of the hardest to reach groups identified, we have had to overcome their many barriers to do this work with them. Moving from ‘pot noodle’ snacks, crisps, cake and greasy pies because you’re starving, have no money and haven’t eaten for two days, to regular healthy meals which you have had a hand in the preparation is quite an

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achievement. One particular young man has taken such an interest in the Project that he is now employed for the first time in his life, in a café, and has achieved his Health & Hygiene Certificate! He is now quite passionate about good food for which we feel some responsibility, as his first experience of good food, that he really enjoyed, was through our Healthy Heart Project! 8. How do you see the sustainability of this initiative? We continue to operate the kitchen and it is very well subscribed despite our recent need to increase prices of healthy meals. All newly appointed staff receive accredited Health and Hygiene training. Lunchtimes are a busy focus in our day, and our young people look forward to coming in and enjoying talking to the staff over a cup of tea and discussing menu options and ideas and likes and dislikes (particularly around those disgusting green vegetables). Baguettes are offered at a competitive price and their partial withdrawal from the menu has been met with good-humoured resistance. As things stand at present, other options which were at first rejected are now tolerated and even welcomed. Soups now attract a considerable amount of positive feedback and the salad platter has achieved iconic status!

Area 43, Cardigan. “Healthy Heart” exhibition for the community - Theatr Mwldan

CASE STUDY 3: Aberystwyth Mind – Healthy food

This case study illustrates how the provision of healthy food can be an effective means of engaging with a particularly hard to reach group and how an organisation may use this opportunity to develop services tailored to the needs identified by their client group. Funding was given to Mind Aberystwyth to provide a healthy breakfast at their weekly drop in session and provide training on food hygiene and storage to both members and staff. 1.How do you feel the initiative has helped the members of the group? It has provided the foundation for Mind Aberystwyth to develop a comprehensive service based on health and well being. Funding for health food was first received in 2004. It started with a free healthy breakfast drop in session, once a week. Later developing to two drop-in days with a charge of £1 for a healthy buffet, this introduced an element of sustainability and encouraged members to take more responsibility. Since then Mind Aberystwyth has refurbished the ground floor into a café style drop-in which is open three times a week for healthy lunches and light snacks. Here members pay (either a waged or unwaged price on their discretion) per food or drink item. This way Mind Aberystwyth works on being

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sustainable and members learn how to take more responsibility. Mind Aberystwyth bases its whole ethos on healthy living and well-being. This helps in educating our members about healthy living and how food can affect ones mood. 2. What have been the benefits to your organisation? It has helped Mind Aberystwyth to develop a service based on health and wellbeing, without the money for the healthy breakfasts this would not have been possible. 3. What developments have occurred within your organisation following the project’s initial investment? Mind Aberystwyth now offers a range of therapeutic activities five days a week to run along side the healthy food drop- in sessions. Activities on offer include yoga, swimming, arts and crafts, creative writing and walking. We also deliver regular ‘food and mood’ courses – educating our members in how food affects mood and how one can cater for this in an affordable way. 4.How many people took part? We have up to 100 contacts per week, seeing up to 60 people per week in the healthy food drop-in sessions. 5. Do you have feedback from your members and/or staff? ‘Great food and a very friendly place to come.’ ‘It has made me more conscious about how what I eat affects how I feel. It is good to have a place I can come to that has healthy food to support my mood.’ ‘Coming to Mind Aberystwyth and having a healthy meal has given my week a positive structure.’ ‘I came here for the food and I have made nice friends in the process.’ 6. Were there any spin offs i.e. unintended benefits? “Receiving the money for the healthy food has been the foundation we have built the rest of our service on. It helped set up the original service and showed its potential when we came to bid for the Wanless funding.” (Company Secretary) 7. How was the initiative supported by a) members. b) staff? Mind Aberystwyth is a membership organisation and our members inform everything we do. The healthy lifestyle focus has been initiated by our members. Our staff love providing healthy, nourishing food and taking that as an opportunity for the education of our members and volunteers. Members have undertaken training on food hygiene and storage and help in the running of the drop in café. Staff have trained as walk leaders for organised walks. 8. Do you see this initiative as being sustainable? The food we provide in our drop-in is now fully sustainable. We charge people for their meals and drinks to cover the cost of the ingredients. We have recently received a co-operative grant to use for the food purchasing so that we can build up a contingency fund with the money coming in from sales.

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Aberystwyth Mind café – healthy options

Case Study 4 – Aberystwyth Mind – Smoking Cessation

This case study follows on from the previous initial investment in MIND Aberystwyth and illustrates how an organisation that engages with their staff and members are able to develop a service in a way that meets the needs of their client group. One of the needs, identified at MIND was that they felt excluded from the mainstream “stop smoking” programmes, where it is often perceived as being too difficult to engage those facing mental distress. With no other model to follow the organisation demonstrates that by working with the client group they have met the challenge of providing a smoking cessation service specifically for those experiencing mental health issues. When Mind Aberystwyth moved to the new building in 2005 and expanded from their one day a week drop-in, it was decided that to be in line with the organisation’s ethos, the building should be smoke free. The need to offer the members and staff support for this was identified as a priority. Money from the healthy heart programme funded the recognised Maudsley hospital smoking cessation training for a member of staff, additional training specific to mental health clients and the salary cost of the member of staff to work part time as a smoking cessation counsellor within the local Mind organisation. 1. How do you feel the initiative has helped the members of the group? Mind Aberystwyth now offers people who are experiencing the effects of mental distress, including family, friends and carers, a smoking cessation service designed to meet their specific needs. Many of those accessing the service have smoked for many years, never feeling they could give up and not having anyone encouraging them to try or seek help. Some have even experienced discouragement. When giving up smoking people often feel empowered to make further positive changes to their lives as a result, a large number of people who access our service to give up smoking have accessed other parts of our service. This includes relaxation techniques to cope with stress, as well as help in the areas of socialising, exercising and healthy eating. Having a smoking cessation service gives members a prompt to start talking about smoking, which is the first step towards giving up. Members have been educated about smoking. Members talk about their smoking behaviour and how it relates to mental health. General education means that members who are giving up feel better supported by their peers and support workers because there is more understanding. All our staff are trained in ‘Brief Intervention’ and when discussing smoking with members

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they will use this to have smokers reflect on their habits and help them take the step towards considering giving up. Other professionals such as the Ceredigion Mental Health Team (CMHT) have received ‘Brief Intervention’ training which has had a beneficial effect on our members as their support helps people to consider giving up. 2. What have been the benefits to your organisation? It was a real challenge to start the smoking cessation service as nothing similar was in existence to model ourselves on and it was often perceived, even by professionals, as something difficult for people to tackle in addition to their mental health problems. With the money from the Healthy Heart programme we have been able to develop a holistic smoking cessation service for people experiencing mental distress, the first of its kind. We work on transferable coping skills such as relaxation techniques and stress management and refer clients to activities within the organisation like walking or yoga to help with exercise and stress and social activities to combat isolation. Any clients who access other parts of our service receive additional support with giving up from our core staff, who have been trained in brief intervention. It is the only smoking cessation service catering for people experiencing mental distress in Mid-Wales 3. What developments have occurred within your organisation following the project’s initial investment? We now have a widely known service working together with, the Ceredigion Mental Health Team (CMHT) the local GP surgeries, as well as other local organisations such as Ceredigion Training. 4. How many people took part? In total about 200 people; including 39 individuals who went through or are going through the stop smoking programme as well as people accessing information days in and out of house, attending staff training sessions in and out of house, receiving brief intervention and introduction sessions to the smoking cessation service. Results: Eligible for follow-up: 38, Number quit at four weeks: 16 (42%, Ceredigion All Wales Smoking Cessation Service (CAWSCS) 44%) …at three months: 12 (38%, CAWSCS 36.4%), …at twelve months: 6 (21%, Mid and West Wales All Wales Smoking Cessation Service 28%.) All numbers self-reported. 5. Do you have feedback from your members and/or staff? eg. quotations Members: ‘Giving up has totally transformed my life! I don’t cough at all anymore, I am less stressed and can think more clearly now. I couldn’t have done it without this service. I feel you understand my mental health problems and that I can talk about them, which has helped a lot.’ ‘Now I have given up with your help I am able to join your swimming group; I am not so out of breath and have more confidence I can do it.’ Staff: ‘We often have members saying they want to give up smoking. In the past we didn’t know what to do with that, now we know how to encourage them and we have somewhere to refer them to within our service for specialist help.’ 6. Were there any spin offs i.e. unintended benefits? Because of inquiries received, we have developed a training package for other organisations to set up a similar service. We have written a fact-sheet for Mind National’s website called ‘Smoking, giving up and mental health’ informing mental health staff, carers and people experiencing mental distress. We have an article in the Mind National News letter and delivered a workshop at the Mind Rural Conference. We have developed a relaxation CD with

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Yoga i Bawb, who deliver our in-house yoga sessions, which smoking cessation clients and yoga participants receive as a self-help tool. We have improved partnership working with, the Ceredigion Mental Health Team (CMHT) the local GP surgeries, as well as other local organisations such as Ceredigion Training. 7. How was the initiative supported by a) members. b) staff?. a) Our members supported the initiative from the beginning. About half of the people experiencing mental distress who smoke have expressed an interest in giving up. All our smoking members are very happy about the service even if they don’t want to give up at present they find it helpful to discuss their smoking with a member of staff who is trained in the subject so they can explore their behaviour. We have the experience and expertise to take peoples’ mental health issues into account, which is something our smoking cessation clients rate highly; We take note of people’s medication and make sure that this is monitored during a quit attempt if necessary. We also work closely together with other support agencies where possible. It helps clients tremendously if they are supported by their CPN or Support Worker. b) All the staff have attended the training available. Everyone is enthusiastic about the initiative, even the smokers; they all can see how it complements the rest of our service which is focussed on the health and wellbeing. 8. Do you see this initiative as being sustainable? We are and have been since our start-up, a successful smoke free service with the help of the smoking cessation service. Our staff are trained in brief intervention and general awareness. We have also trained a second smoking cessation specialist to make the service more sustainable longer term. We are constantly collecting evidence for future funding which we are looking for at present. It is not a service we can charge our members for but we hope to cover some of our costs by training other organisations in the future. The information is being monitored by the local public health team and fed into the NPHS to support future programmes.

Case Study 5: Jig So Family Centre – Healthy lifestyle The following case study illustrates how an organisation, having been given the support and initial investment to introduce a health initiative, not only makes that initiative sustainable but develops its own confidence to develop other health initiatives through consultation with the users. Jig-So Children’s Centre is open four days a week to all members of families with young children. Funding from the Healthy Heart programme allowed the centre to start up a fruit tuck shop and later develop a weekly healthy lunch programme. 1.How do you feel the initiative has helped the members of the group? The initiative has enabled users to understand how easy it is to cook good healthy food. We have promoted health issues in an informal manner e.g. reducing salt and fat intake, heart problems and diabetes and we have provided access to many health and exercise organisations. Jigso has enabled free discussion between users, staff and health professionals in a non threatening environment and given opportunities for trying new food and cooking methods. We have encouraged a change in diet without being dictatorial and offered children and adults the opportunity to eat a more balanced diet by having good food available (fruit, raisins instead of sweets and crisps). It has been the development of a lifestyle and not just an initiative 2. What have been the benefits to your organisation?

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The benefits have been that by providing the funds and the expertise you have allowed us to provide a real change in the ways that people eat and exercise. You enabled us to develop the project with our users at their pace and with their input. 3. What Developments have occurred within your organisation following the project’s initial investment? Our organisation has developed many health, diet and exercise initiatives. We applied for funds to provide yoga, swimming, gym and walks and encouraged and enticed our users to participate. This has led to users requesting further exercise programmes. We recently applied for a 3 year programme to develop walks and signpost levels of difficulty and accessibility for our users. We now host a Health, Safety and Wellbeing Day every year and this year it was sponsored by Health Challenge Wales. Our users now choose to exercise without our staff organising and often meet in groups to participate outside of Jig-So. The development of the cooking programme has been requested and funds will be sought. This year, users have challenged our workers to deliver a healthy Christmas dinner - less fat, salt and grilled sausages etc. We will continue and develop all areas of health. 4.How many people took part? From the Annual Report 06-07, 138 families attended the centre. Our sessions are open to everyone who has a child. This also includes carers and childminders. We also use the initiative at our Community events such as our Community Fun Day (provision of small bowls of fruit salad as an alternative to all the other food stuffs available) and this is open to the general public. 5.Do you have feedback from your members and /or staff? “Great ideas for healthy breakfasts which we will be trying out at home” (Parent) “I use all the recipes at home, followed your advice and the kids really enjoyed it.” (Parent) “We have become more aware of cooking methods and health issues” (Staff). 6.Were there any spin offs i.e. unintended benefits? Users look forward to Mondays and help to plan the cooking sessions. In general, it has helped greatly with social integration within our organisation. 7.How was the initiative supported by a) members b) staff? Staff fully supported the initiative, undertaking training on healthy eating. They have learnt through success and mistakes on how to provide and promote useful information to our users who are regularly consulted. This is essential for success. If the staff enthusiasm and users ideas are not considered the initiative would not work. Constant changes and talks are essential to develop within the needs of our diverse culture and society. Every day there are new dietary recommendations and reports. Staff also try to provide locally available produce and investigate the availability for the users before promoting a product. 8.Do you see this initiative as being sustainable? This initiative is sustainable. We now charge 15p per fruit item (bananas sell best)and £1 per family for food on a Monday . Our users requested a Christmas lunch but as the cost would be higher they suggested £1.50 per family. Our users feel this is very cheap but that gives us leeway to change the price. We want to encourage and enable all users to eat healthy food, even if money is an issue.

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Launching the Cardigan Calorie and Step Map with the help of Jigso

3.3.1 Impact on health inequalities

Impact on health inequalities • The Healthy Heart project has enabled community organisations working with

disadvantaged people to promote healthy lifestyles in an informal and practical way, providing the opportunity for members to make informed choices and begin to take responsibility for their own health.

• The project has encouraged organisations to develop their own responses to the promotion of healthy lifestyles, based on the needs and knowledge of its staff and members. This has given the group ownership of the initiative, and ensured that the programme is needs led.

• The target group, through participation in the programme, have undertaken training on healthy eating, undertaken accredited training and a small group have developed an enterprising activity to promote healthy eating.( see case study 1)

• Health initiatives, especially the provision of a healthy meal, have helped to break down barriers within the target group. It has encouraged those people who would not normally come into an organisation to attend thereby accessing other services and support provided by the organisation. The initiative has also allowed for increased engagement with the particularly hard to reach groups and identified further needs.

• Children attending projects with parents have shown how they are able to influence sometimes reluctant parents to make changes in their lifestyle.

• To engage with those who do not access community organisations, the project officers have worked with individuals directly on the social housing estates. The engagement process has shown that at times it has been necessary to address the wider determinants of health prior to addressing personal change. The response to the health agenda from this sector has been positive but requires locally based workers to provide continuous support and drive (see case study 1).

The project worked in partnership with the following organisations: Young people at risk, youth offenders, those in the care of Social Services and those in alternative education, people with mental health problems, families and individuals needing additional support, people who were unemployed, on low incomes and/or in

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poor quality housing, people with disabilities and those in poor health, women who had experienced domestic abuse and older people.

o “A major challenge to implementing this strategy is the engagement and empowerment of the people in the various communities in Ceredigion to make them fit for the crucial roles that they are envisaged as fulfilling”

o “It is necessary to address the barriers discouraging people from choosing a healthy lifestyle.”

o “The need to invest more in preventing disease…” Ceredigion Health, Social Care and Well-being Strategy”

Spinbikes – Aberystwyth Day Centre

3.3.2 Service change and provision

• The use of community organisations as an existing structure has proved to be an efficient and effective platform from which to promote health and well-being and brought about positive change in policy, practice and provision within the participating organisations.

• These community organisations have increased the capacity within their communities for the target group to experience and participate in healthy lifestyle changes.

• Community organisations which have worked with the project have made their initiative sustainable and will therefore continue to provide their healthy lifestyle initiatives after the end of the programme.

• The project has shown that a modest investment to set up health initiatives has encouraged organisations to develop further initiatives.

• Working with a local arts and culture organisation has shown how the arts is a valuable “point of entry” for those hard to reach individuals who are not members

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of community organisations. This technique has been valuable in breaking down barriers between estates.

• The project has delivered a health agenda outside the primary health care service. The project leaves behind a variety of resources: • The provision of equipment and the facilitation of “healthy eating” training,

developed by the Ceredigion Public Health Team Food Advisors, for community organisations’ staff and members, has given them the knowledge and confidence needed to promote health lifestyles.

• The project has funded the training and employment of a smoking cessation counsellor, specifically trained to work with mental health problems. This initiative has also developed a training pack for other mental health workers and a relaxation CD to support smoking cessation clients (see case study 4).

• The “Healthy Communities Toolkit” has provided a resource to support other community organisations in the promotion of healthy lifestyles.

• Health Visitors have received training based on the toolkit to enable them to deliver healthy lifestyle initiatives within their local community organisations. They now have Performance Review targets relating to work of this nature.

• Two of the organisations working with the project are to become Open College Network (OCN) accredited training centres on healthy eating.

• A fully accessible kitchen has been part funded by the project. This will be a community resource aimed at the target group to help them learn about food, including how to prepare and introduce healthier food options for the family.

3.3.3 Implementation of NSF The Healthy Heart project forms part of the Ceredigion implementation plan which responds to Standard 1 of the CHD National Service Framework. Most of the work in Ceredigion which responds to Standard 1 has been short-term, project funded and will end around the same time as this programme.

3.3.4 Partnership and joint working Primary care involvement • The design and implementation of the work has involved the Local Authority, the Health Alliance, Health Visitors, Primary Care, the Local Health Board and all members of Ceredigion Health Promotion Team. Other stakeholder involvement • The project is led by the NPHS and Ymlaen Ceredigion (a not for profit organisation concerned to promote sustainable community development).

• Ceredigion Association of Voluntary Organisations, Communities First, 30 local community organisations

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3.3.5 Sustainability • By setting up health initiatives within established organisations, the healthy heart

programme addressed the issue of sustainability from the outset. • The use of a community development, ’bottom up’ methodology which has allowed

the organisation to design and implement their own responses to promote healthy lifestyles and given members ownership of the programme, has been key in achieving sustainability of the programmes within the organisations.

• The support for health initiatives has frequently resulted in members agreeing to take over the funding of the project to ensure its continuation.

“Staff are now trained and as the initiative is so successful, parents will continue to pay for the fruit and juice options.” Family Centre, Penparcau, Aberystwyth • Community organisations have been positive in their response to promoting healthy

lifestyles. Health initiatives, especially those related to food, have encouraged participation and have benefited the organisation through increased attendance, greater social engagement with the target group and the support of members to develop further initiatives. These benefits have on occasion inspired organisations to seek alternative funding in order to sustain a health initiative.

• As stated in the previous section, the project leaves behind a variety of resources. • The project officers have taken the messages generated by this work to decision

makers and funders within Local Authorities and the NHS via presentations to the Local Health Board Executive, Health Alliance, Community Strategy, Communities First and the Chief Medical Officer. However, funding to develop or “roll out” the programme has not been identified.

“The projects that were started as part of the Healthy Heart initiative have become part of the curriculum and programmes of study have been written to gain qualifications as part of the ASDAN award. The Basic Skills Enrichment programme has included Environmental Studies based on the garden project.”

Ceredigion Pupil Referral Unit The following “sustainability matrixes” show what happened to each project and whether and how sustainability was achieved. “Mainstreamed /Completed” (MS/COMP) means that the work was continued after the initial investment and became part of the organisation’s regular programme or that the initiative achieved a finite aim, e.g. the creation of a resource, the purchase of equipment, the training of staff etc. “Alternative funding” (AF) means that the initiative was continued with funding identified from a source other than this project. “Requires strategic funding” (SF). This means that whilst the initiative was evaluated as worthwhile, to sustain the work in the long term would require regular core funding from outside this project. Examples of this were residentials

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with young people at risk, employment of staff to support healthy lifestyles, and subsidies for healthier options (e.g. Café Finch’s “Healthier breakfasts” project.) “Discontinued” (DIS) means that the work stopped. This could be due to loss of interest by participants, external factors beyond the control of the project or because following evaluation, the PO’s considered it did not represent sufficient value for money.

HL = healthy lifestyle, HE = Healthy Eating PA = Physical Activity Sustainability Matrix HOST ORG. PROJECT OUTCOME Camau Bach PA play equipment MS/COMP: Equipment purchased Plascrug Milk Bar MS/COMP: Facility created Ceredigion Care Soc. Food prep. training MS/COMP: Staff trained

Equipment food storage

MS/COMP: Equipment provided

Age Concern Also: Women’s Aid

Training to support clients with HE options

MS/COMP: Staff Trained

Crymych Leis. Centre

Training re CHD response

MS/COMP: Staff trained

Ysgol Feithrin Penparc

Exercise video

MS/COMP: Resource produced for MYM

Ceredigion Training Stepping Stones (playgroup), Cardi Cardiacs, Careers Wales and Surestart

HL advice sessions

MS/COMP: organisations integrate practice into main programmes

Plascrug Leisure Centre

PA taster sessions with HE options

MS/COMP: HE to be combined with PA programmes in future

Cardigan After Schls Club

Instructor for PA Healthy snacks

MS/COMP.Staff trained to deliver PA MS/COMP:Parents to fund initiative

Ceredigion WI HL Open Day AF: Obtained for further HL initiatives Plascrug Leisure Centre

Safe cycling course

AF: County Council continues

Walking the Way 2 Health

Contribution to prog.

AF: Programme continues in new form

Ceredigion PRU Also: Social Services / Youth Offending Team

Camping and other HL themed residentials

SF: Needs alternative funding

Finch Square Café

Subsidised healthy Menu options

SF: Subsidy led to increased take up but needs strategic funding


Subsidised access

SF: Funding needed to extend subsidised access to those experiencing inequality

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CYP Partnership and Coleg Ceredigion and SS/ Youth Justice

Camping and other HL themed residentials

SF: Funding required to extend these opportunities.


Indoor Skateboard facility

DIS: Unable to find appropriate staffing

Cardi Cardiacs

Subsidised swimming

DIS: Did not achieve aim of increased family membership

Canolfan Padarn

Spinbikes sessions

DIS: Initial positive response, but participation subsequently declined

Penparcau Youth Club

HE options / equipment DIS: Club currently closed

Aqua Serena Leisure Club

Membership

DIS: Access and slow payment problem, subsequently interest declined

Wallich Clifford HE options DIS: centre temporarily closed ??? End of Phase One (2002 -2005)

• Following the 2005 evaluation, in line with the principle of Action Research, it was decided that the second phase would not establish new initiatives but rather build on success, strengthen certain initiatives and concentrate on issues of sustainability. This also followed WAG guidelines which in general advised against starting new initiatives.

Projects taken forward following the end of phase one evaluation:

Host Organisation Project Outcome Developments Ceredigion PRU

Veg and fruit garden

MS/COMP: 2 gardens created

Integrated into school programme

Ceredigion PRU

Parents/Pupils Open Day PA taster sessions

MS/COMP: To be repeated MS/COMP:PA integrated into school curriculum

Issues within school caused some delay. PA integrated into school curriculum.

Social Services, Youth Offending Team

Provision of healthy options at activity sessions

MS/COMP: Adopted as good practice for future

Staff trained on healthy eating/budgeting (via Food Prog.)

Women's Aid Aberystwyth

Training to support clients with HE options

MS/COMP: Staff trained

Staff trained on healthy eating(via Food Prog.)

Women's Aid Aberystwyth

Smoking counselling

MS/COMP: Designated areas for smoking agreed

Linked with Mind counsellor for support

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Family Centre Penparcau

Cooking training

MS/COMP: Staff and members trained.

Weekly healthy meals

Family Centre Penparcau

Fruit snacks

MS/COMP: Parental support/self funding

Fruit snacks provided daily. Staff trained on healthy eating/budgeting (via Food Programme)

Ridgeway residents

Environment clean up

MS/COMP: Estate cleared of rubbish. Positive response from residents.

Instigated engagement process for other initiatives with Small World Theatre

Golwg residents

Fruit and veg. co-op

DIS: Insufficient impact - participants moved to new joint initiative with Ridgeway

Residents working with Small World Theatre on healthy eating project – see case study 1

Ridgeway residents

Calorie/Step Map

Produced and distributed

Health Alliance paid for more copies. Distributed to all Cardigan households. Also available via Age Concern, Cardigan.

Small World Theatre ( SWT)

HE with residents from Golwg / Ridgeway estates

MS/COMP: Produced art work based on healthy eating. Presented at local festivals. Organised healthy eating events on estate. See Case Study 1.

Increased knowledge and confidence re. healthy eating. Staff and residents attended training on healthy eating /budgeting (food prog.)

Small World Theatre

Smoothie Maker Bicycle

MS/COMP: Residents involved with promoting smoothies at local events

On-going enterprise in area

Small World Theatre

Community kitchen in new premises

MS/COMP: Kitchen created as training

OCN training offered to target group and

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facility

community organisation staff

Homestart

Fridge for storage of fruit

MS/COMP: Equipment provided.

Fruit snacks provided at sessions

Homestart

Provide cookery books for loan scheme.

MS/COMP: Equipment provided.

Identified need for cooking skills. Practical demonstrations started during local sessions Staff trained on healthy eating/budgeting

Aberystwyth Mind

HE breakfasts drop in

MS/COMP: Café facility developed - healthy menu

Dev. further HL initiatives: group swimming, yoga and walks. Training: Staff trained on healthy eating/budgeting.( food prog.) Staff trained as walk leaders. Drop in café open

Aberystwyth Mind

Smoking Counsellor

MS/COMP: Providing one to one support for mental health clients within the community.

Produced Smoking cessation leaflet for MIND Cymru. Produced training pack for smoking cessation in mental health (See Case study)

Area 43

Employ staff member to promote HE and HL

MS/COMP: Some work carried on with other trained staff. Practice enhanced

Staff trained on healthy eating/ budgeting (Food prog.)Provide healthy option meals daily

Family Centre JigSo

Provision of fruit snacks

MS/COMP. Parental support. Self funding.

Dev other HL initiatives see case study.

Family Centre JigSo

Provision of new cooker and funding for healthy lunches

MS/COMP. Parental Support .self funding

Staff Trained on healthy eating and budgeting (food prog.)Healthy lunches provided

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once a week. Family Centre Jig So and Cardigan Youth Centre

Cooking classes

MS/COMP: See Case Study 4 - policy and practice enhanced

Awaiting funding to enlarge kitchen area

Healthy Heart Project Healthy Communities Toolkit

Toolkit developed to support community orgs promote HL

MS/COMP: Toolkit Produced. Training programme developed to promote HL in Ceredigion

Available from CAVO, NPHS,Ymlaen Ceredigion at end of programme.

Health Visitors

"Healthy Communities" Toolkit Training provided

MS/COMP: Health Visitors to support local orgs to promote HL as part of their public health role.

Public health role identified on HV performance reviews

Youth Service

“Healthy Communities Toolkit” training

MS/COMP: Youth leaders to set up HL initiatives. Staff attended training on healthy eating and budgeting via Food Programme)

Youth Service to develop staff training into an OCN course in healthy eating based on food programme training

Summary: The overall outcome of the 55 projects can therefore be illustrated as follows:

05

10152025303540

Mainstreamed orcompleted (38)Rec'd alternativefunding (3)Need strategicfunding (7)Discontinued (7)

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4. CONCLUSIONS AND RECOMMENDATIONS

4.1 Discussion and Interpretation of Outcomes Evaluation showed that:

Many community organisations not previously engaged in the health agenda have now taken policy and practice on board. Organisations are generally receptive to the health agenda and make effective partners to achieve the programme’s aims. Many went on to develop further initiatives of value. The programme has provided an opportunity to pursue the health agenda outside the Primary Care sector.

Community Organisations needed:Information, guidance and support Resources Training Finance

Community organisations are an effective platform from which to deliver the

health message to the target client group. Their use: Avoids the need to create new structures (so is an efficient use of time) Provides a platform for delivering the health agenda in an environment

in which the target group feel safe and are properly consulted with and involved.

Furthermore: Group leaders have already developed good working relationships based on mutual respect with the target group.

Community organisations offer the opportunity to bring about change, not

simply by telling and informing but by allowing the client group to experience change, through seeing, doing, or tasting something new.

The provision of healthier food benefited both clients and the organisation by

allowing greater engagement which has led to increased identification of their clients’ health needs and the range of services available to them.

The project demonstrated how to go about the important and necessary

process of direct engagement with that section of the target group who do not access community organisations.

Reflective practice (Action Research) has allowed for a flexible response to the

needs of the target group.

A good level of sustainability was achieved because the requirement for sustainability was considered from the outset.

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Where training and support are put in place (e.g. for health visitors, youth workers and other community leaders) good practice can be disseminated.

Low cost, simple interventions which open the door to the health agenda and

options for experiencing change amongst the client group represent excellent value for money.

4.2 Summary • The community development approach and working in partnership with community

organisations have proved an efficient and effective in engaging with and involving the target group and thus addressing inequalities.

• Community organisations and their staff offer a safe, positive, flexible

environment in which to promote and implement the healthy lifestyle message in a holistic way. This should be of particular interest to those concerned with addressing the primary prevention agenda which features so strongly in key policy documents relating to health service practice for the future.

• Many of the initiatives have affected both policy and practice within these key

organisations and a number of the initiatives have been sustained. • The programme can be seen to be responding to the national policies outlined in

“Designed for Life”. • The difficulty of ensuring recognition for the positive contribution community

development and engagement can make to the health agenda has been recognised in other countries in the UK as posed by this Sheffield conference question in January 2008, following research in England by Wakefield PCT and Bradford University.

“Despite initiatives such as ‘Tackling Health Inequalities’ and ‘Choosing Health’, community development and participation methods have not been taken up to any great extent within public health strategies. How can community development and community engagement take a more prominent role in health care delivery at a time when there is a robust defence of all things medical, and whilst community based interventions are being cut or shut down as resources are moved to fund deficits and shortfalls in other NHS areas?” • Whilst many individual projects have achieved a level of sustainability, the Project

Officers have been unable to identify funding to roll out the programme to other areas in Ceredigion or Wales. Funding for the promotion of healthy lifestyles / health and well-being belongs as a priority on the agendas of the HSCWB partnerships and the NPHS. However, funding is needed to increase their capacity to deliver operationally.

• A bid was made via Ymlaen Ceredigion to the Health Challenge Wales Voluntary

Sector Grant Scheme 2008. The bid would have “rolled out” the programme and training to the community sector throughout rural Wales, but was not successful,

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principally because it was seen by the assessment panel as relying too heavily on existing Ceredigion based, rather than national contacts and networks.

4.3 Core Elements of Project The essential elements of the Healthy Heart project in Ceredigion which have contributed to its success are:

• The use of community organisations who without exception responded positively to the health agenda,

• The use of community organisations to access and prioritise the target group, • The use of community organisation to address “the wider determinants of

health” in a holistic way which went beyond health service and illness boundaries,

• The engagement with “hard-to-reach” members of this target group, • The opportunity to bring about change, not simply by telling and informing but

by allowing the client group to experience change, through seeing, doing, or tasting something new.

• The use of simple, low cost interventions with effective outcomes, • The use of a community development approach to ensure sustainability, • The provision of support and advice, monitoring, resources and training, • The production of a toolkit and the training of health visitors and youth workers

to disseminate healthy lifestyle information and practice across the county. • The use of Service Level Agreements, flexible enough to allow for individual

objectives negotiated locally and with the support and participation of potential beneficiaries in choosing appropriate and viable interventions,

• A good level of sustainability was achieved because the requirement for sustainability was considered from the outset.

• Reflective practice (Action Research) allowed for a flexible response to the needs of the target group.

4.4. Key Recommendations C. Recommendations and best practice

(i) Best practice examples: • Many community organisations not previously engaged in the health agenda

have now taken policy and practice on board. • Organisations have responded positively to the health agenda and make

effective partners to achieve the programme’s aims. Many went on to develop further initiatives of value.

• Community Organisations are an effective platform from which to deliver healthy lifestyle activities to “hard-to reach” target groups.

• Community arts as a “point of entry” to engage those especially hard-to-reach clients experiencing inequalities in health was especially effective, and there were notable “spin-offs” in relation to self-confidence, the braking down of barriers between estates and access to accredited learning opportunities.

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• The provision of a smoking cessation counsellor specifically for those experiencing mental health problems has shown that those especially vulnerable people have the potential and the right if supported appropriately to take positive action to improve their health (see Case Study 4).

• Partnership working with the voluntary sector and others has been crucial to achieve progress in addressing the wider determinants of health and thus in implementing the promotion of health and well-being in the community amongst the target group.

(ii) Recommendations: 1. The methodology of the project which ensures engagement and therefore

responses which are needs-led and sustainable, should be seen as having crucial relevance for meeting the aims and objectives of Health Challenge Wales, Designed for Life, the Wanless Report, Ceredigion Health, Social Care and Well-being Strategy, Better Health Better Wales and Standard 1 of the National Service Framework implementation plan for Ceredigion.

2. This methodology also complements the health and wellbeing objectives enshrined in: Making the Connections, The Rural Development Plan, the Community Strategy, Wales: A Better Country and the Wales Spatial Plan.

3. The report’s findings should therefore be of interest to NHS Trusts, LHB’s, GP’s, Health Alliances, County Councils, Communities First, community organisations and the voluntary sector in general.

4. The voluntary sector and community based organisations should be seen as a means of delivering the health and well-being agenda and a structure should be put in place to provide the support, training and resources necessary to implement such a programme. A “Healthy Communities Scheme” could complement the “Healthy Schools Scheme” with existing organisations such as the NPHS, Communities First, Local Authorities, the HSCWB partnership, CAVO, as the possible host organisation/s.

5. There is also a need to identify funding to employ community based workers to increase capacity for community engagement with the health and well-being agenda to reach and support the target group. This is particularly important in the light of the challenges posed by obesity and the current cost incurred by the provision of medication.

6. Consideration should be given to funding low cost, simple interventions in the community sector.

7. Health Visitors can be supported adopt the methodology and practice as part of their public health role.

8. Recognition needs to be given to qualitative data and to the fact that evaluation relating to promoting healthy lifestyles in the community belongs in a community development, rather than a clinical/ medical culture. At present, there is a lack of qualitative research in this field. Funders and practitioners of this “community development” approach need to agree acceptable evaluation methodology based on qualitative assessment.

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Cost of Cardio Vascular System medication in Ceredigion

Diuretics, beta-adrenoceptor blocking drugs, antihypertensive therapy, nitrate and calcium channel blockers, potassium activators, antiplatelet drugs, lipid regulating drugs & others. Figures provided by Ceredigion LHB, December 2007.

£5,179,207* per annum

* Figure for 2006/07; does not include cost of diagnosis, monitoring, side effects, admin. etc. This drugs cost is recognised as “unsustainable”.

Cost of “Healthy Heart” programme By using the methodology of this project and taking on board the learning from the experience of this work, the project officers estimate that a programme of this nature could be run throughout Ceredigion on a budget of ….

£50,000* per annum

*Includes staff and all operational costs.

“There should be a strategic adjustment of services to focus on prevention and early intervention.”

Derek Wanless, Review of Health and Social Care in Wales, June 2003.

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APPENDICES (1,2,3,available from the contact addresses, see inside cover) 1. Healthy Communities A bilingual Toolkit to help community organisations and groups in Ceredigion promote healthier lifestyles. 2. Cardigan Calorie and Step Map A map showing calories burned when walking around Cardigan town. 3. Poster Publicity poster for the Ceredigion Healthy Heart programme. 4. Service Level Agreement A sample SLA. 5. Evaluation interview A sample interview from 2005. 6.Case Study Pro Forma.

(Blank)

Bicycle powered smoothie maker, Small World Theatre

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APPENDIX 4: Service level agreement

SERVICE LEVEL AGREEMENT INEQUALITIES IN HEALTH CHD PROGRAMME – CEREDIGION

1. Memorandum of Agreement: This agreement is made between: Ceredigion Public Health Team (NPHS) and Aberystwyth Mind. 2. Conditions of Agreement: The purpose of the Inequalities in Health programme is to work with the people of Aberystwyth and Cardigan to reduce their risk of developing Coronary Heart Disease by promoting healthier lifestyles. To this end your Organisation will: • Deploy your senior core worker for two days a week for 17 months on smoking cessation. Following training, s/he will support MIND clients and those experiencing inequalities in health from other parts of the community in Aberystwyth, to give up smoking. This work may be carried out one-to-one and /or in groups. • Evaluate (see 3 – below) the service through client feedback and by co-operating with any other evaluation or monitoring process operated on behalf of the IIH Programme. 3. Evaluation: Evaluation is an important part of the Healthy Heart programme. The programme officers will ask you to tell them: • What happened and what changed as a result of this project? • Was it worth the money and the effort? • If you did it again, what would you do differently? • Were there any “spin offs” – i.e. unintended benefits? • So the sort of information you may need to record is: • How many people took part? • Do you have feedback from them? For example from one or more of the following: questionnaires, individual or group discussion, a detailed account of one or two experiences (case study), quotations etc. 4. Length of Agreement: The funding is expected to cover the period from XXX to XXX and is subject to satisfactory ongoing evaluation. The total funding from the Healthy Heart programme is a maximum of £XXX payable by invoice made out to: Ceredigion Local Health Board 6. Variation of Agreement: Any variation of this Agreement must be agreed in writing by both parties. 7. Organisational Responsibilities: Your Organisation must at all times follow all legal requirements and accepted good practice within your field of work, for example with regard to Health and Safety, protection of children and vulnerable adults, insurance, financial matters, equality of opportunity, confidentiality. 8. Signatures:

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Appendix 5: Evaluation interview Project Title: Open Day. Partnership Organisation/s: Ceredigion Pupil Referral Unit (PRU). Project Description: Organse an open day for pupils and their families. Promote healthier lifestyles, show work being undertaken. Project cost: £500 (spent £689, additional cost found by organisation). Aim of project / Expected Outcomes: To encourage whole family approach to healthier living. Target Group: Children and young people attending PRU. Actual outcomes: Well attended Open Day. During subsequent home visits, parents commented on the event and said they found it useful. Nature of any evidence (e.g. quotes, photos, facts etc.) “Parents who rarely venture out attended the Open Day. Some were in significant need of advice and support. They did seek advice and did listen.” Head of PRU. “Parents need educating to make an appropriate response to the health needs of their children. “It was great, worth every penny, we’d really like to do it again.” Head of PRU. Photos and quotes to follow. Numbers involved: 30. Spin-offs and miscellaneous: One parent is now happy for their son to take part in sport when this had not previously been the case.” Head of PRU. Conclusion/s of evaluation: • worth the effort 5 • effective 4 • good value for money 4 • managed and supported efficiently and effectively 4 How might it be / have been improved? n/a Future action / Sustainability: Will do again. However, without support funding, we would delay it. Has the project had any long-term effect on the Organisation or its members? Working towards integration of healthy lifestyle message throughout agenda. Note for programme officers: Does this project need / warrant any further investment or support in 2005 – 07? Agreed that £500 of the underspend from the first residential could go to second Open Day initiative.

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Appendix 6: Case Study pro forma.

November 2007

Pro Forma These questions are intended to help, but please feel free to say what you wish.

1. How do you feel the initiative has helped the members of the group? What difference has it made? 2. What have been the benefits to your organisation? 3. What developments have occurred within your organisation following the projects initial investment? 4. How many people took part? 5. Do you have feedback from your members and/or staff? eg. quotations 6. Were there any ‘spin offs’ i.e. unintended benefits? 7. How was the initiative supported by a) members b) staff? 8. How do you see the sustainability of this initiative? eg. Are staff now trained, are you collecting evidence for future funding, are members to pay for the initiative in future…etc.

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Documents

Prosiect Calon Iach / Healthy Heart Project Ceredigion ... · makers and funders within Local Authorities and the NHS via presentations to the Local Health Board Executive, Health