Visram Phd.Pdf

Northumbria Research Link Citation: Visram, Shelina (2012) A Qualitative Exploration of User Engagement and Health-Related Behaviour Change in the NHS Health Trainers Initiative. Post-Doctoral thesis, Northumbria University. This version was downloaded from Northumbria Research Link: http://nrl.northumbria.ac.uk/id/eprint/7261/ Northumbria University has developed Northumbria Research Link (NRL) to enable users to access the University’s research output. Copyright © and moral rights for items on NRL are retained by the individual author(s) and/or other copyright owners. Single copies of full items can be reproduced, displayed or performed, and given to third parties in any format or medium for personal research or study, educational, or not-for-profit purposes without prior permission or charge, provided the authors, title and full bibliographic details are given, as well as a hyperlink and/or URL to the original metadata page. The content must not be changed in any way. Full items must not be sold commercially in any format or medium without formal permission of the copyright holder. The full policy is available online: http://nrl.northumbria.ac.uk/policies.html A QUALITATIVE EXPLORATION OF USER ENGAGEMENT AND HEALTH-RELATED BEHAVIOUR CHANGE IN THE NHS HEALTH TRAINERS INITIATIVE SHELINA VISRAM A thesis submitted in partial fulfilment of the requirements of Northumbria University for the degree of Doctor of Philosophy Research undertaken in the School of Health, Community and Education Studies October 2011 dog 1 Abstract Lay health workers have been widely used to deliver health improvement activities in developed and developing countries. Although there is some data to support their efficacy, reviews of the research literature have consistently found insufficient evidence to assess which intervention strategies are likely to be most effective. Furthermore, there is a dearth of research exploring service user views and experiences. This study contributes to evidence and theory in relation to lay-led models of promoting lifestyle change. By adopting a grounded theory methodology underpinned by a subtle realist perspective, the study aimed to understand better the experiences of users and the mechanisms underlying intervention outcomes. The focus for this research was the NHS Health Trainers Initiative, which is part of an attempt to shift the emphasis in UK public health from ‘advice on h igh to support from n ext door’. Participants were sampled from three heterogeneous health trainer services in northern England. Semi-structured interviews with service users (n=26) were conducted at 0, 3, 6 and 12 months, and with health trainers (n=13) and their managers (n=5) at 0 and 12 months. A longitudinal approach was chosen to allow for a more in-depth exploration of the processes involved in attempting to make and maintain health-related behaviour changes. Informal observations of selected health trainer activities were also undertaken in order to generate additional data for triangulation. All data were analysed using the constant comparative method. Health trainers were found to employ a tailored, holistic approach that takes into account the context of a person’s li fe and their access to resources for health. This builds upon the salutogenic theory of health, and is in direct contrast to the paternalistic, deficit model traditionally found in public health. It also draws on theories of ‘person -in-situation ’ more commonly found in the social work literature, which present an alternative to the emphasis on person-centredness and psychological aspects of behaviour change. An integrated model is developed – called the theory of lay-led behaviour change in context – and contrasted with the logic models typically used to conceptualise similar interventions. This research is one of few qualitative studies to investigate the role of lay health workers in the UK. Furthermore, the use of a longitudinal approach to explore behaviour change has produced results that are likely to have high policy relevance. The research represents an important application of a user-focused perspective affording new insights, which may also be applied to other complex interventions. 2 Contents Page No. Acknowledgements 9 Declaration 10 Chapter 1: Introduction 11 Background to the NHS Health Trainers Initiative 11 Rationale for the study 14 Research aims 16 Structure of the thesis 17 Section A: Background and literature review 19 Chapter 2: Historical and theoretical context 20 Public health in the UK 20 Global and national policy developments 22 Core elements of the health trainer role 24 Targeting hard-to-reach groups 25 Facilitating health behaviour change 27 Community engagement and capacity building 32 Lay-led health interventions 34 The lay resource in health care 35 Lay health worker models 37 Reducing health inequalities 40 Chapter summary 43 Chapter 3: Review of the research literature 44 Review methods 44 Evidence of intervention effects 47 Health promotion actions 49 Health promotion outcomes 51 Intermediate health outcomes 52 Health and social outcomes 55 Summary of the quantitative evidence 57 3 Table of contents Qualitative research findings 58 Key stakeholder views 58 Feedback from lay health workers 59 Experiences of intervention recipients 62 Summary of the qualitative evidence 64 Evaluations of local health trainer programmes 65 Recruitment and training issues 65 Service delivery 67 Outcomes and impact 69 Cost-effectiveness 70 Chapter summary 70 Section B: Research design 72 Chapter 4: Philosophical and methodological approaches 73 Aims and objectives 73 Philosophical approach 74 Subtle realism 75 Interpretivism 76 Research methodologies 78 Grounded theory 80 Longitudinal qualitative research 82 An argument for pluralism 83 Chapter summary 84 Chapter 5: Data construction 85 Stage one: preparing to enter the field 85 Ethical considerations 85 Approaching research sites 87 Sampling strategy 88 Stage two: conducting fieldwork 91 Sample recruitment 91 Data collection 95 4 Table of contents Research settings 101 The research relationship 102 Stage three: working with the data 105 Data analysis 105 Enhancing rigour 109 Maintaining reflexivity 111 Chapter summary 112 Section C: Study findings and implications 113 Summary of analyses 113 Chapter 6: Contextualising behaviour and behaviour change 118 Personal characteristics 118 Age 119 Occupation 120 Disability 122 Ethnicity and religion 123 Attitudes towards health 124 Significant events 126 Social environments 127 Childhood 127 Family 129 Informal support networks 131 Formal support systems 132 The wider context 134 Economic and political factors 134 Public health campaigns and media 135 Geographical context 136 Changing times 137 Chapter summary 139 Chapter 7: Personalised intervention models 140 Time for change 140 5 Table of contents Previous lifestyle change attempts 140 Motivating factors 142 Accessing sources of support 146 Local health trainer models 146 Primary modes of user engagement 149 Access barriers 155 Intervention components 158 Individual behaviour change strategies 159 Group support and social interaction 168 Intervention settings 172 The health trainer role 175 Chapter summary 179 Chapter 8: Outcomes and impact 181 Defining and measuring impact 181 Personal outcomes 184 Knowledge gains 184 Behaviour change 185 Health improvement 190 Psychosocial outcomes 193 Organisational outcomes 197 Chapter summary 200 Chapter 9: Discussion 202 Summary and interpretation of key findings 203 Service user engagement and motivation 203 Sustained behaviour change 208 Local health trainer models 212 Appraisal of the research design and methods 215 Strengths and limitations of the study 216 Reflections on the process 219 Theoretical implications 224 6 Table of contents Comparison with behaviour change theory 224 Lay health worker theory 228 Integrated theory of lay-led behaviour change in context 230 Implications for policy and practice 233 Areas for further research 235 Concluding remarks 237 Appendices 238 References 262 List of Boxes Box 1: Key features of the health trainer role 13 Box 2: Alternative terms for non-professional workers 38 Box 3: Search terms 46 Box 4: Example of a memo 108 Box 5: Terry’s story 129 Box 6: Gail’s story 133 Box 7: Pam’s story 167 Box 8: Pauline’s story 169 Box 9: Gina’s story 192 Box 10: Maxine’s story 197 List of Figures Figure 1: Choosing Health priority areas for action 12 Figure 2: PICO framework of concepts underpinning the study 19 Figure 3: Aims of the health trainer role 20 Figure 4: Three domains of public health practice 21 Figure 5: Theoretical domains for evidence-based practice in behaviour change 31 Figure 6: Pathways from community participation to health Improvement 33 Figure 7: Three sectors of the medical system 36 7 Table of contents Figure 8: A summary outcome model for health promotion 48 Figure 9: Stages of a research strategy 72 Figure 10: Overview of the study design 79 Figure 11: Study flowchart 95 Figure 12: Anticipated and actual interview topics 99 Figure 13: Stages of the analytical process 106 Figure 14: Developing a grounded theory 109 Figure 15: Diagram showing the antecedents, processes and consequences of health trainer-led interventions 115 Figure 16: Integrative diagram showing context and complexity in the behaviour change process 116 Figure 17: Diagram showing the theory of lay-led behaviour change in context 117 Figure 18: Components of health trainer-led interventions 158 Figure 19: Applying Kleinman’s framework to

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