Marion Hancock, (2003) in Health Development Today Apr/May.
Neighbourly advice pays dividends
TRAINED LAY WORKERS CAN OFTEN BE MORE EFFECTIVE THAN PROFESSIONALS AT HELPING PEOPLE CHANGE TO A HEALTHIER DIET PARTICULARYLY THOSE IN HARD TO REACH GROUPS. THATS WHY BOLTONS FOOD AND HEALTH ADVISERS OPTED TO INTRODUCE COMMUNITY NUTRITION ASSISTANS.
Bolton was one of the first places in England to get ordinary people involved in community health and nutrition work. Its community nutrition assistant (CNA) scheme achieved NHS Beacon status for health improvement in 2000: in Beacon terms it touches upon health inequalities, children and young peoples health, development, health promotion, challenging professional boundaries, and the prevention of coronary heart disease (CHD) and stroke. Boltons dietitians initially won funding for the scheme from the North West Regional Health Authority in 1995. It is based on an approach used in North America since 1968 by the Expanded Food and Nutrition Education Program. This involves matching paraprofessionals with their target audience according to ethnicity, background, income and education. The aim was to tackle Boltons premature mortality rates for heart disease and stroke and major problems with obesity and diabetes. The work is practical and hands-on. For example, community nutrition assistants help people to set up food co-ops, organise shopping outings to show them how to get the best value from a limited budget, run cook and taste sessions, organise activities with children in schools and playgrounds, and provide a forum for swapping ideas on how to cope with faddy eaters. When we started we would usually work with individuals, but now there is a lot of group work, explains Kelly Stott, a member of the remaining team of four CNAs (12 were originally recruited). We have our regular groups. For instance, a young mums group at a hostel for homeless girls, (another at) a hostel for homeless women with children. We might do activities like Ready Steady Cook, where you take in a variety of foods and cook them in a short time. Its not about standing up in front of a group and talking at people, stresses fellow CNA Georgia Cameron. We just take along leaflets, tasters and chat about cooking. Each week is different. Some weeks well have a lot of meetings, with beacon days and the like, where people can come and see what were doing, adds Stott. But some work is still with individuals Im thinking of one person we worked with who was very overweight and also on a low budget. She learnt how to manage the budget very well and also lost weight.
In a typical year, the team of four work with around 2,000 clients, mainly those on a low income and people that Boltons dietitians find hard to reach (for example, hostel residents, visitors to mental health drop-ins and older people in sheltered housing). Contacts are made via a range of organisations from local community centres to schools although sometimes health visitors refer people. In addition, a community development worker has now been appointed and is a good source of contacts, according to Cameron. Comments from people who have had dealings with the CNAs are typically positive. I can cook a lot more things than I could before, like lasagne and spaghetti bolognese, says one hostel resident. Another observes how useful it is having someone available with advice. Julie Holt, one of the food and health advisers at Bolton responsible for developing the scheme, describes it as really promising and enjoyable. They (the CNAs) are often from the same communities as the people they work with. They may live in the same area, go to the same shops, have children the same age. They are practical and communicate at the right level. They are friendly and approachable and are good at involving people. Some community members who were managing on low incomes, so in difficult circumstances, felt some professionals did not really appreciate the implications of their circumstances, she explains. They felt the CNAs not only understood and empathised but had maybe been in similar circumstances themselves and realised the barriers that have to be faced daily in trying to provide affordable, healthy meals that the family will eat. As one person said, Most people will tell you what to eat the CNAs will show you what to do and what goes with what. Since the use of these peer workers frees up trained dietitians to focus on more specialist areas - and on policy, it seems to be a win-win proposition. Indeed, initial qualms about the scheme proved unfounded, says Holt. We havent had any concerns about fanatical beliefs or obscure food habits, she explains. Any scepticism among the profession was shortlived, agrees Lynne Kennedy, lecturer in public health at Liverpool University and co-author of an evaluation of the scheme. Her evaluation found that the community nutrition assistants were locally identified trailblazers as and are highly regarded by the NHS. They were seen as potentially more skilful than professionals, in reaching groups of individuals in the community with the greatest needs. In addition, over half of a sample of people who had contact with the CNAs reported better shopping and eating habits, according to the report. (Kennedy, L. and Ubido, J. (1998). Evaluation of the Community Nutrition Assistant Food and Health Training Project, Bolton) Alison Ward, who chairs a special interest group on community nutrition at the British Dietetic Association (BDA), believes there are two reasons why CNAs are a good thing. One is that there is a massive recruitment shortage of dietitians and so, to be honest,
we dont have a choice. The other is that trained dietitians might not be the best people to do this kind of work. Community nutrition assistants are people working in their own neighbourhoodS and they can empathise with the lives and social problems they find. That cant be overlooked. (CNAs can become honorary members of the BDA.) In 2001, Holt and her colleagues secured Sure Start monies to work with families with pre-school children and last year acquired health action zone (HAZ) funds for work with minority ethnic groups. These two sources will keep the scheme afloat for a further five to seven years which is a great relief for Holt, who points out: Our regional and local health authority were supportive from the beginning, but it was short term. One to two year funding Its quite demoralising to have to reapply. You think, if its so good why can it not be made mainstream? The Bolton team now hopes to recruit more CNAs particularly men and representatives from young, older and minority ethnic groups. It also aims to increase the salary of CNAs and establish a career structure for them. A central base is being planned that could include a drop-in and cooking facilities. (To date, all practical work has been carried out wherever facilities can be found. For example, in schools, community centres and peoples homes.) At the same time, the CNa training course is being revised to make it less intensive and more practical and to include project ideas and activities from around the country. We decided to work in partnership with the local college to deliver the new training, to make it available to more people than would have been possible if we just trained those we could employ, explains Holt. The course will run as a weekly, two hour session over two terms, linked with other training and support that the college offers students. Meanwhile, similar peer support schemes are getting underway up and down the country there were 48 at the last count. Most cite Bolton as an influence, but they are all approaching training and funding in their own way. Theres a need for more straightforward funding opportunities and for generic training, says Kennedy. We need national recognition that these schemes are ...