Richard Shircore MSc FRSPH, independent consultant in Community and Public Health, looks at the reasons why the health trainer service has an impact on public health and what we can all learn from their approach.

At a time of ever more stringent budget cuts, it is more important than ever to demonstrate the value and effectiveness of a service. We must go beyond this however, to not only look at service outputs, but also look at how a service gets there.

It is crucial to understand why services, in this case health trainers, are successful in what they do and to see what lessons need to be learnt, both for the development of health trainer services, the wider public and clinical health workforce and not least the well-being of the public.

In seeking to do this, I hope this blog will help commissioners, CCGs and others involved with health trainers to critically appreciate the findings of the recent Minded to Change report on the effectiveness of health trainers in the area of mental health and wellbeing.

Mental health – choice and personal action

The important news from this report, released in November, is that health trainer interventions can and do engage positively with people in the lowest deprivation quartiles, and engagement does lead to positive outcomes in respect to mental wellbeing.

It also aptly makes the point that mental health is all about making choices. This blindingly obvious fact is not readily accepted into some areas of public or clinical health. For many, taking care of oneself is a logical and rational process where the primary requirement for the individual is knowledge.

I started out in Health Education. Knowledge, facts and information were seen as the key to better health choices. This is correct up to a point, but only if the assumption is made that rational choices can be made. This assumption is misplaced in many populations – especially those experiencing deprivation or other stressors such as domestic violence.

For many, especially those in deprived populations or with limited resources, the logical application of health or other knowledge is a constant and enduring challenge. The emotional drives out the rational.

For them, affective (emotional) issues are physically felt as panic or fear and are all encompassing. Cognitive considerations (what’s best for me) are squeezed out by the affective (I shall fail/I am incapable, I fear, etc.) It is a mental lockdown resulting in behavioural paralysis.

Tony Coggins is spot on when he states that “The use of health trainer services...creates a feedback loop, in which the service user can bring about better mental health outcomes for themselves...”

These are critical words that need to be understood by all in public and clinical care if we are to enable more people back to better health, mental or physical.

Mental health is unlike physical health issues. Immunisation and vaccination will work even if the client is antithetical to the whole process and does not believe it will work. If you accept the inoculation, it will work. Your belief has nothing to do with it.

With mental health improvement the client needs to be actively and positively committed and involved. This can be encouraged by the right type of client engagement. In turn, this is largely dependent in the initial stages on the skill of the practitioner with which the client is working. Health trainers have an excellent track record in meeting people literally on their own turf, gaining trust and developing that all important psychological “working relationship”.

Health trainers benefit local communities in a variety of ways; the most important being that they are recruited from the locality in which they operate. Their training in turn increases the social capital of their area, which is in itself health promoting. Being from the local community may also lessen the sense of social difference, the disadvantaged client feels when engaged with a health trainer.

My research with health trainer clients has given me an insight into the health trainer-client dynamic and revealed several reasons the service is so highly valued by those who use it. In particular many cited all or some of the following:

• An end to a feeling of isolation in dealing with difficult personal health habits
• Positive about the action taken and the likelihood of success
• Mutuality of the relationship
• Empowered to make change
• Learning how to make changes in one area of life could be used in other areas
• Knowledge of health and how to stay healthy

This leads me to consider the following questions;

Is it because they are seen as unlike other health staff that they are successful? What is the “it” that makes the relationship work?  All of us in public and community health need to understand what makes the helping process work.