HEALTHY HEARTS APPROACH: IMPACT AND LESSONS LEARNED

SOCIAL PRESCRIBING AND COMMUNITY BASED INTERVENTIONS

Healthy Hearts is funded by The Public Health Agency and Belfast Local Commissioning Group (HSCB)

HEALTHY HEARTS APPROACH: IMPACT AND LESSONS LEARNEDSOCIAL PRESCRIBING AND COMMUNITY BASED INTERVENTIONS

Contents

Context Page 3

The Healthy Hearts Model Page 7

Evaluation Methodology and Approach Page 10

Healthy Hearts Interventions Page 12

The Fit Kids Survey: Highlights and Impact Page 16

The Fit Kids Programme and Fitness 8: Impact Page 19

Post-Primary Schools Programmes: Impact Page 22

Corpus Christi College: Impact Page 27

Springvale Employment and Learning: Impact Page 29

Couch to 5k and Falls Park Run: Impact Page 33

Tullymore Walking Group: Impact Page 35

Community Pharmacy Programmes: Impact Page 37

Falls Women’s Centre Healthy Hearts Programme: Impact Page 40

Cardiac Rehabilitation Programme Phase 3: Impact Page 42

Cardiac Rehabilitation Programme Phase 4: Impact Page 46

Critical Factors to the Healthy Hearts Model Page 48

Appendix: The Nine Key Messages from the Marmot Review Page 53

Jane TurnbullHealthy Hearts Evaluator / ResearcherSeptember 2015

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CONTEXT

“Reducing health inequalities is a matter of fairness and social justice”

In 2010 the Marmot Review was published following an independent review (led by Sir Michael Marmot) to propose the most effective evidence-based strategies for reducing health inequalities. Central to the content of the Review is that reducing health inequalities is “a matter of fairness and social justice”, and that health inequalities result from social inequalities. Marmot emphasized that action on health inequalities requires action across all the social determinants of health; which will only happen by empowering individuals and local communities1. Marmot suggests “tackling social inequalities in health and tackling climate change must go together” and that policy objectives need to be established and actioned in order to reduce health inequalities. Appendix One shows the nine key messages presented in the Marmot Review.

Background

The predecessor to the Healthy Hearts Chronic Disease Prevention Hub was the Healthy Hearts in the West initiative. This initiative developed a collaborative, community assets approach to addressing heart health inequalities. It ran from 2012 to 2015, and sought to work in partnership with organisations from the community, voluntary, statutory and private sectors, so that people living in disadvantaged communities across Belfast experience heart health equivalent to the best in Northern Ireland / Europe; and do not die prematurely due to cardiovascular disease and other chronic diseases. An overview of the Healthy Hearts in the West initiative is given in Appendix One.

Highlights and achievements of Healthy Hearts in the West included: Engaging over 10,000 people in programmes addressing heart health risk factors 757 people accessed vascular risk screening (167 referred to GPs due to

potentially at risk health results. Community Pharmacists report greater engagement with customers

Work place Healthy Hearts events Delivery of the Fit Kids Diet and Nutrition Programme to over 1400 Primary

School pupils Belfast Health and Social Care Trust Cardiac Rehabilitation Phase 3 delivered at

The Maureen Sheehan Centre (in the heart of West Belfast) and linking into the

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

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community Complementary Therapist, Counsellor and CR Phase 4; resulting in increased uptake of CR Phase 3 by eligible patients

Enhancing existing community based physical activity programmes and coaching through the delivery of diet and nutrition workshops

221 people in West Belfast trained in a range of heart health related programmes; programmes such as Cook It and Weight to Health continue to be delivered through community organisations

Linkages to the Falls Park Run, facilitating increased registrations ‘Highly recommended’ in the 2014 NICE Shared Learning Awards Receiving joint first place in the Belfast Healthy Cities Awards for Addressing

Health Inequality The Cardiac Rehabilitation Nurse being shortlisted under the British Heart

Foundation UK Healthcare professional Awards, within the Integrated Care category.

The Evaluator / Researcher has an invitation to speak at the 2015 NICE Conference; the topics she is presenting fall within the ‘Integrating Services: building a business case’ and ‘Investing in a healthy community’.

Context

The Healthy Hearts Chronic Disease Prevention Hub was established to build on Healthy Hearts in the West and mobilise existing resources and assets of communities in Inner East, in addition to West Belfast. The Project - funded for one year by the Public Health Agency and Belfast Local Commissioning Group - built on the experiences, lessons learnt, and the evaluation of the Healthy Hearts in the West Initiative.

The overall objectives of the Healthy Hearts Chronic Disease Prevention Hub were to: Raise awareness about the risk factors contributing to heart disease and chronic

diseases. Raise awareness about how to achieve a healthy lifestyle through local

programmes. Strengthen partnerships between community, statutory, voluntary and private

sectors to improve heart health and reduce long-term chronic disease. Identify opportunities to improve access to preventative, diagnostic, treatment

and rehabilitation services. Undertake a Belfast-wide scoping study to identify programmes, opportunities

and support in relation to physical activity, healthy diet and nutrition, stress management, and smoking cessation.

Facilitate locality planning events. Share learning and good practice models.

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The National Institute for Health and Care Excellence (NICE) Guidance on Community Engagement to improve health (PH9, 2009) emphasises how active communities can have a positive impact on health outcomes by improving services and influencing the governance of health services.

During 2014 – 2015 a series of discussions and negotiations took part between representatives from the community, voluntary, and statutory sectors, GPs and Pharmacists with the Belfast Local Commissioning Group, the Public Health Agency, and the four Belfast Integrated Care Partnerships. Currently a Belfast-wide Chronic Disease Prevention Hub model is under development.

Social Prescribing and Community Based Interventions

This Report presents a précis of follow-up evaluations undertaken to ascertain the medium-term impact of the social prescribing and community based interventions developed, facilitated, and delivered by the Healthy Hearts Initiative, in partnership with community, voluntary, statutory, and private sector organisations.

Social prescribing is about linking people up to activities in the community that they might benefit from. The aim is to connect people to non-medical sources of support. There is increasing evidence to support the use of social interventions for people experiencing a range of health problems2.

Effective social prescribing should be a clear, coherent and collaborative process in which healthcare practitioners work with patients and service users to select and make referrals to community-based services3.

The ‘People Powered Health programme (2011-2013), involved hospitals, GP practices, community organisations and patients groups across England. The aim was to tackle patients' social and physical wellbeing by referring patients directly to a social solution, in collaboration with the patient. The project focused on people with long-term illnesses, but social prescribing can also be effective as a preventative and early intervention approach.

Evaluation of the People Powered Programme found that the NHS in England could realise savings of at least £4.4bn a year if it adopted these People Powered Health innovations that involve patients, their families and communities more directly in the management of long term health conditions. These savings are based on the most

2 http://www.wellbeingenterprises.org.uk/what-we-do/our-work/social-prescribing/3 http://www.nesta.org.uk/publications/more-medicine-new-services-people-powered-health#sthash.tmhi7fbx.dpuf

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reliable evidence and represent a 7 per cent reduction in terms of reduced A&E attendance, planned and unplanned admissions, and outpatient admissions4.

4 http://www.nesta.org.uk/project/people-powered-health

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THE HEALTHY HEARTS MODEL

A Community Assets Model

One of the key messages on challenging health inequalities in the Marmot Review is that “effective local delivery requires effective participatory decision-making at local level. This can only happen by empowering individuals and local communities”. The community asset approach promotes well-being by building social capital, facilitating face-to-face community networks, encouraging civic participation and citizen power. High levels of social capital are correlated with positive health outcomes, well-being and resilience. A community asset approach values the capacity, skills, knowledge, connections and potential in a community; and relies on community knowledge and engagement. It also, as a consequence, considers a more effective use of (limited) resources.

With the focus on community Hubs, and engagement of community groups (which work with different target groups within the community), Healthy Hearts sought to build a community assets approach to addressing health inequality. This approach also necessitates working together (where all partners have an equal voice and share decision making) across the community, voluntary, statutory and private sectors.

The community asset approach does not replace investment in improving services or tackling the structural causes of health inequality. The aim is to achieve a better balance between service delivery and community building. A community asset approach seeks to make best use of the services and programmes available (across all sectors); signpost people to the range of quality provision available; and facilitate ease of access to services.

Coordination of effort at strategic and operational levels across a range of partner agencies and organisations, including linking into existing infrastructure and initiatives, resources, and engaging senior managers and people ‘on the ground’ (engagement at different levels across organisations) is necessary to achieve effective ‘buy in’ and action. Such linkages build on the community assets approach. Increased participation; and building social cohesion, mutual respect and confidence has the potential to result in sustainable change. Healthy Hearts has sought to mobilise community resources and individuals, moving towards changes in the current systems to better support heart health and reduce heart health inequality.

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Supporting Behaviour Change

Changes in cardiovascular disease (CVD) risk factors can be brought about through intervention at both an individual level in terms of behaviour change and at population level though development of appropriate policy and legislation (Prevention of cardiovascular disease at population level. Public health guidance 25. National Institute for Health and Care Excellence, 2010).

Buck and Frosini (Clustering of unhealthy behaviours over time: implications for policy and practice, The Kings Fund, 2012.) suggest that there is a need to find effective ways to help people in lower socio-economic groups to reduce the number of unhealthy behaviours, which in turn will address health inequalities. They propose that this is only likely to work through an integrated, cross-sectoral holistic approach to policy and practice.

The ethos throughout the Healthy Hearts Initiative is to break down barriers to healthy lifestyle options. This has been achieved through; Creating linkages with community organisations, including sports clubs, Sure

Start, older people’s groups, women’s groups, and youth groups; and delivering accessible, tailored heart health activities and workshops

Local provision of physical activity and healthy eating programmes Working with pupils and teachers in Primary and Post-Primary Schools Local, accessible Vascular Risk Screening delivered by ten participating

Pharmacies Cardiac Rehabilitation Phase 3 and Phase 4 available in a community setting.

Recognition of Healthy Hearts

There has been UK and Ireland wide recognition of the Healthy Hearts Initiative. This included the Initiative being ‘highly recommended’ in the 2014 NICE Shared Learning Awards; receiving joint first place in the Belfast Healthy Cities Awards for Addressing Health Inequality; and the Cardiac Rehabilitation Nurse being shortlisted under the British Heart Foundation UK Healthcare professional Awards, within the Integrated Care category. Oral presentations and posters have been delivered at the Faculty of Public Medicine Winter Scientific Conference (Dublin) and the Public Health Agency Annual Scientific Conference (Belfast) and also in the 2015 NICE Conference presentations.

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Legacy and Sustainability

After three and a half years the legacy from the Healthy Hearts Initiative includes:

The Fit Kids Physical Activity and Nutrition Programme is now delivered through the Belfast City Council Active Communities Initiative adapted as the Fitness 8 Programme.

Springvale Employment and Learning Solutions have adopted a whole organisation health and wellbeing strategy, supporting the physical and emotional wellbeing of young people, adult trainees, and staff.

Over 400 people in West Belfast have been trained in a range of health related programmes; programmes such as Motivational Interviewing, Gym Instructor Level 2 (and above), Cook It and Weight to Health continue to be delivered through community organisations.

The Cardiac Rehabilitation Phase 3 will continue to be delivered in heart of the community from the Maureen Sheehan Centre.

The Cardiac Rehabilitation Phase 3 Follow-Up Patient Survey will continue to be used.

The Falls Park Run continues, with over 800 people registered Ashfield Boy’s High School and St Louise’s Comprehensive College are both

introducing School Health and Wellbeing Plans following Healthy Hearts physical activity, healthy eating and stress management interventions, and School health day events.

Community Pharmacists report greater engagement with customers The evaluation tools and processes, and the Healthy Hearts ‘model’ developed

and tested during the Initiative have been recorded and are available (on the West Belfast Partnership Board website5) for use or adaptation by other initiatives and projects seeking to address health inequalities.

5 http://www.westbelfast-partnership.com/publications/healthy-hearts-publications

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EVALUATION METHODOLOGY AND APPROACH

A robust evaluation was built into Healthy Hearts from the outset; informed through the Logic Model and the National Institute for Health and Care Excellence (NICE) Guidance on Behaviour Change (PH6, 2007), which addresses behaviour change at individual, local and community level; and Guidance on Community Engagement to Improve Health (PH9, 2009), which emphasises how active communities can have a positive impact on health outcomes by improving services and influencing the governance of health services.

The evaluation collected baseline, quantitative and qualitative data, with a focus on outcomes. Regular evaluation reports have informed the Healthy Hearts Steering Group and Operational Management Group, contributing to ongoing review and informing the development and delivery of the Initiative.

Healthy Hearts Outputs and Outcomes

The Healthy Hearts collaborative, community assets approach demonstrated that within an economic context where resources are limited, there are opportunities to make optimum use of resources through working together and using alternative approaches such that health and social care services and health promotion interventions are more accessible. Cross-sector initiatives have proven to be successful, including: The Fit Kids Programme: delivered to over 1400 Primary Schools pupils through

a partnership between Healthy Hearts, Belfast City Council Leisure Centres, BHSCT Health Improvement Team, and Extended Schools, which following negotiations with Belfast City Council and their Active Communities Initiative has been sustained by Active Community Coaches delivering the Fitness 8 Programme to Primary Schools across Belfast during 2014 and 2015, involving over 500 children to date.

Springvale Employment and Learning Solutions (a training centre located in West Belfast for young people and adults) engaged with Healthy Hearts and has organised several health days supported by Healthy Hearts. Healthy Hearts carried out focus groups and surveys collecting data on the lifestyle choices of young people; and supported the delivery of the physical activity Fit 4 Work Programme in partnership with Falls Leisure Centre. Building on this, and recognising the benefits not only for young people but also for staff (and potentially adult learners in the future), Springvale Learning developed a Whole Organisation Health and Wellbeing Strategy (supported by Healthy Hearts).

Adding nutrition workshops and sessions to physical activity programmes delivered in the community: by community groups, sporting groups, and Leisure Centres.

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Running workplace Healthy Hearts events; which have been followed up with input from the host company and other agencies – an example of Healthy Hearts being a catalyst for others.

Piloting two new programmes through ten Community Pharmacies (Vascular Risk Screening and the Weight Management Programme); which have been accessed by 757 individuals; 167 of whom were referred to their GPs due to potentially at risk health check results.

Belfast Health and Social Care Trust (BHSCT) Cardiac Rehabilitation Phase 3 linking into the Heart Healthy Living Centre Complementary Therapist, Counsellor and CR Phase 4; all delivered at The Maureen Sheehan Centre in the heart of West Belfast – and increasing the uptake of eligible patients by 11%.

Linkages with the Falls Park Run – a weekly event organised by volunteers, which has benefitted from support and input from Healthy Hearts and partner organisations, with over 800 people registered with the Falls Park Run.

Delivery of four heart health programmes, focusing on physical activity, healthy eating involving 100 students in Post Primary Schools in West and East Belfast. Two Schools have subsequently developed a Whole School Health and Wellbeing Policy, supported by Healthy Hearts.

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HEALTHY HEARTS INTERVENTIONS

The Healthy Hearts team sought to be catalysts. Much of the work aimed to demonstrate and facilitate the benefits of heart health interventions at a community level; seeking to raise awareness about heart health risk factors, and signpost individuals, groups, and companies to accessible opportunities available within their locality.

Raising awareness of risk factors to heart health was a valid starting point. Baseline data showed that many people were aware of some of the risk factors to heart health (but not all). It also demonstrated that people did not know where to start, or how to take the first step. Population-wide health promotion campaigns were not working in disadvantaged areas; which suggested that alternative approaches needed to be developed in order to raise awareness and signpost people to accessible programmes and services.

Interventions included:

Healthy Hearts in Schools The Fit Kids Survey, gaining a snapshot of children’s diet and physical activity

has been administered with over 3000 children (aged 7 to 10 years old) in 37 Primary Schools across Belfast. Each School received a report presenting data analysis; additionally Reports have been compiled for North, South, East and West Belfast; and a city-wide Report has been circulated to key stakeholders.

Development of the Fit Kids Physical Activity Programme, delivered to more than 1400 Primary School Children in West Belfast (a partnership between Healthy Hearts, Belfast City Council, and Belfast Health and Social Care Trust).

The successor to the Fit Kids programme has been Fitness 8, developed in South Belfast through Active Communities. This programme has been delivered to over 500 children in South and East Belfast; and will be delivered in North Belfast this autumn.

Support for post Fit Kids and Fitness 8 Programme Celebration Events; bringing children from different Schools together.

A range of physical activity and healthy eating programmes delivered in Primary Schools in Upper Andersonstown, supported by Integrated Services for Children and Young People.

Multi-Sports Event at Sarsfields, delivered in partnership with community, voluntary, and statutory organisations (March 2012) involved 460 pupils from five primary schools.

A Cookery Demonstration by celebrity chef, Paul Rankin and a Cookery Competition at the Christian Brothers School (involving 230 young people)

Healthy eating and stress management workshops delivered in Primary and Post-Primary Schools

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Corpus Christ College - Healthy Hearts day for School staff; and baseline lifestyle surveys with pupils in Y8 and Y9; followed by a physical activity intervention.

Ashfield Boy’s High School - Healthy Hearts day for all students and staff A baseline Survey with students in Y9 (second year) attending four Post-Primary

Schools in West and East Belfast; followed by a four-week physical activity, healthy eating, and stress management programme.

Development of a School-wide Health and Wellbeing Policy with Ashfield High School and St Louise’s Comprehensive College.

Community Activity Healthy Hearts supported community organisations to organise heart health

events; involving organisations from the community, voluntary, statutory, and private sectors promoting ways to reduce risk factors to heart health.

Tullymore Walking Group, established to provide older people a safe environment to walk regularly; with additional activities such as the Healthy Eating Class at Mourne Seafood Cookery School.

Healthy Hearts Weight Management Programme and Workshops: delivered at the Falls Women’s Centre in partnership with Boots the Chemist, BHSCT Health improvement Team, and the Ulster Chemist’s Association.

Working in partnership with the Falls Park Run; initially supporting events to promote the Park Run (increasing membership by over 300 people) and then support for the Couch to 5Km programme.

Delivering healthy eating messages and sessions at sports club training sessions (for example with GAA Clubs, football clubs, and boxing clubs)

Cook It and Weigh to Health Programmes delivered to community groups Multi-cultural dance programmes delivered to After Schools Groups (and

Schools) Zumba dance sessions in community groups Dig It, Eat It programme for parents and children The Heart Start Programme delivered to adults and young people The Falls Women’s Group Weight Management Programme Junior Olympics in Casement Park, with a parallel Health Event in

Andersonstown Leisure Centre (involving 850 people, June 2012) Linkages with Sure Start organisations

Settings Events Springvale Employment and Learning Solutions - Healthy Hearts days for staff

and young people. These events led to Springvale developing a whole organisation Health and Wellbeing Strategy, the development of which was supported by Healthy Hearts, the Public Health Agency, and Belfast Health and Social Care Trust.

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LBM – a Call Centre; Healthy Hearts day for staff Belfast Taxi Company of Interest - Healthy Hearts day for taxi drivers; follow up

activities included Healthy Hearts facilitating a Taxi Driver’s Walking Group and a Physical Activity Programme for Taxi Drivers.

Partnership events with the Falls Park Run

Community Capacity Building and EmpowermentHealthy Hearts has facilitated the delivery of a range of training programmes including: Personal Training and Fitness Instructor: Level 1 and 2 and 3 The British Heart Foundation Healthy Heart Toolkit and Chest Pain Toolkit Motivational Interview Techniques – Level 1 and 2 Stoke and Aphasia training delivered by Stroke Association Walking Leader Training Primary School Nutrition training delivered by BHSCT community dieticians Top Tips for Looking After Yourself training programme Creative Mindfulness Training for Healthy Living Centre staff Stress Management and Self Massage  Weigh to Health -delivered by BHSCT and Healthy Living Centres; programmes

then delivered in community centres and community groups by those trained as trainers

Cook It - delivered by BHSCT and Healthy Living Centres; programmes then delivered in community centres and community groups by those trained as trainers

Breast, Cervical and Bowel Screening Awareness Training delivered by the Women’s Regional Development Agency

Cardiovascular Awareness Training delivered by the Women’s Regional Development Agency

Pharmacists attended motivational Interviewing workshops and Pharmacy Continuing Professional Development modules for pharmacists and staff: Obesity – its impact and its management, Supporting change motivational interviewing and Activity and exercise.

Cardiac Rehabilitation Phase 3 Programme located in the Community Offering the Cardiac Rehabilitation Phase 3 Programme from a venue located in

the heart of the community (the Maureen Sheehan Centre) increased uptake by 11%.

Patients attending the Cardiac Rehabilitation programme were referred by the Cardiac Rehabilitation Nurses to counselling and complementary therapy sessions (as appropriate) delivered by the Heart Healthy Living Centre, located in the same building.

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Increased progression to the Cardiac Rehabilitation programme Phase 4, delivered in the Maureen Sheehan Centre by qualified individuals trained through the Heart Healthy Living Centre.

Community Pharmacy Programmes 757 people accessed the Community Pharmacy Healthy Hearts Vascular Risk

Assessments offered by ten Pharmacists in West Belfast (using the Keito Machine followed by a one-to-one consultation.

131 people were referred to their GP due to ‘high-risk’ assessment results. 253 people signposted by Pharmacists to community heart health programmes. 104 people participated in the Community Pharmacy Healthy Hearts Weight

Management Programme. 76 people completed the Programme; and the majority who completed, have lost weight.

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THE FIT KIDS SURVEY: HIGHLIGHTS AND IMPACT

Context

In Northern Ireland, over one in five children starting Primary School is overweight. The initial findings of the Health Survey Northern Ireland 2013/146 show that three-quarters of children aged two to ten years old were classed as either normal weight or underweight, while 18% were classed as overweight and 7% were classed as obese. The proportion of children classified as either overweight or obese has not changed since 2005/06.

The Fit Kids Survey

The overall aim of the Fit Kids Survey (developed by Healthy Hearts, building on the Healthy Choices Fit Kids Survey, and supported by the Public Health Agency and Queen’s University Belfast) was to gain a snapshot about the food children eat and other dietary behaviours, and the extent to which they participate in different kinds of physical activity. The Fit Kids Survey has now been administered with pupils in 37 Primary Schools across Belfast through Healthy Hearts (South Belfast carried out the Survey with P6 pupils independently). Over 3500 children have completed the Survey. Each School received a Report presenting the data findings for their School. In addition Fit Kids Survey Reports were written for each area of the city; and the most detailed Fit Kids Report presents the data analysis Belfast-wide.

The Fit Kids Survey has also been administered in with 1000 children in ten Primary Schools across the former Carrickfergus Borough Council area. This demonstrates the adaptability and opportunity to transfer the Healthy Hearts evaluation and research tools. Feedback from Carrickfergus is that the Leisure Centre Manager intends to use the data to enhance opportunities for Primary School children; and Hearty Lives Carrickfergus hope to be able to build on the data analysis in the future.

Diet and Nutrition

Highlights of the analysis of the Fit Kids Survey data in relation to diet and nutrition showed that: 5% of children say they never eat breakfast on a school day. 22% of children eat breakfast most school days 71% of the pupils said that they eat a school dinner (many would be eligible to

Free School Meals).

6 Framework for Preventing and Addressing Overweight and Obesity in Northern Ireland 2012-2022, Department of Health, Social Services, and Public Safety

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Overall almost 1 in 5 children (19.5%) had a take away the evening prior to completing the Fit Kids Survey.

Over four fifths of the children (81%) had something to eat before they went to bed.

12% of the children said that they did not eat any fruit and vegetables the previous day.

72% of children ate less than five portions of fruit and vegetables a day – this is the identical figure gathered from children across all West Belfast.

Physical Activity

Public health guidelines, endorsed by the Chief Medical Officer, suggest that all children aged between five and eighteen years old should spend an hour a day engaging in physical activity. Boreham and Riddoch7 highlight three main benefits from adequate childhood physical activity: 1. Direct improvements in childhood health status; evidence is accumulating that

more active children generally display healthier cardiovascular profiles, are leaner and develop higher peak bone masses than their less active counterparts.

2. A biological carryover effect into adulthood, whereby improved adult health status results from childhood physical activity. In particular, childhood obesity may be a precursor for a range of adverse health effects in adulthood, while higher bone masses in young people reduce the risk of osteoporosis in old age.

3. A behavioural carryover into adulthood, whereby active children are more likely to become more active (healthy) adults.

Approximately 50% of children aged 7 to 8 years old, in the UK, achieve the recommendation that they should take an hour a day of moderate to vigorous physical activity (MVPA) and fewer (43.4%) do so in Northern Ireland (NI), compared to England, Wales and Scotland8.

Highlights of the analysis of the Fit Kids Survey data in relation to physical activity showed that: 58% of the children walk to School; a slightly higher number of children (116

more, about 6%) walk home from school than walk to school. The majority of Primary Schools have a school policy that all pupils go out to play

at Break Time and Lunch Time at School 73% of the children said that they always enjoy PE lessons at school. 62% of children participate in sports clubs and teams outside of school; over one

third more than the numbers who participate in school sports clubs and teams.

7 Colin Boreham and Chris Riddoch, The physical activity, fitness and health of children, Taylor and Francis Online, 20108 Griffiths LJ, Cortina-Borja M, Sera F, et al. How active are our children? Findings from the Millennium Cohort Study. BMJ Open 2013;3:e002893.doi:10.1136/bmjopen-2013-002893

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27% of children at Primary Schools in Belfast are meeting the recommended target of 60 minutes physical activity every day.

43% of children are engaging physical activity three days a week or less. The most popular out of school activities are swimming, football or rugby,

walking, active games and riding a bike. 81% of children say that they enjoy being physically active ‘a lot’. 31% of children report watching television, or playing computer games three

hours or more every school day. 48% of children report watching television, or playing computer games three

hours or more at the weekend.

Physical Education (PE) is a compulsory part of the curriculum for all pupils at every Key Stage, from age 4 to16.  It is up to schools to determine how much time is devoted to PE in the curriculum but Departmental guidance recommends that they should provide pupils with a minimum of 2 hours curricular PE per week9. However, it became evident during the Fit Kids Survey that many Primary Schools offer only one PE lesson during the school week. Furthermore, anecdotally Schools reported that when approached by external organisations to deliver a programme of physical activity in the School (for example the GAA) that this coaching takes place during the time usually allocated to the PE lesson.

The Fit Kids Survey data show that 43% of the children are participating in physical activities and exercise three days a week or less. This suggests that for whatever reasons (and these may include for example a lack of resources, a lack of local opportunities, lack of parental time, and the effort required to encourage children to ‘go and do something active’), although 81% children say they like being physically active a lot, opportunities are not happening in practice. These data also raise the question – if there were more opportunities available in and out of school for children to participate in physical activity and exercise would they choose to or be able to be involved?

Overall Impact from the Fit Kids Survey

The impact of the Fit Kids Survey was that it provided schools and the community with baseline data about children’s physical activity and diet and nutrition habits. This has provided Healthy Hearts, schools, community groups, and statutory agencies with an evidence base from which to lobby for additional activities promoting physical activity and healthy eating to children and Families.THE FIT KIDS PHYSICAL ACTIVITY AND NUTRITION PROGRAMME AND FITNESS 8

9 www.deni.gov.uk/index/curriculum-and-learningt-new/curriculum-and-assessment-2/80-statutory-curriculum/physical-education-2.htm: accessed 22.05.15

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Context

In 2007 the National Centre for Clinical Excellence NICE concluded that there is a strong rationale for promoting physical activity among children and adolescents; specific population sub-groups in which levels of activity are low include children from lower socio-economic groups, and overweight and obese children.10 NHS UK Livewell and guidance from the Chief Medical Officeri recommends that to maintain a basic level of health, children and young people aged 5 to 18 years old need to do at least 60 minutes of physical activity every day. Fruit and vegetable consumption decreases and sugar intake increases from affluent to disadvantaged social classes.11 One strategy to prevent adult obesity is to focus attention on preventing obesity in children.12 The Director of Public Health has stated “there is a need to develop effective and sustainable ways of helping young people choose a better diet. Schools can play a crucial role in improving the health of children and are a key setting for public health interventions”.13

The Fit Kids Physical Activity and Nutrition Programme

Observations and analysis of the Fit Kids Survey data identified the need for opportunities to address physical activity and nutrition among school children. The pilot Fit Kids programme, delivered in partnership between Healthy Hearts, Belfast City Council (Falls Leisure Centre), and BHSCT Health Improvement Team, delivered two different twenty minute physical activity sessions, and a twenty-minute diet and nutrition session once a week for six weeks. The only criteria for the Schools wishing to take part was that this activity would be in addition to the School PE lesson.

Highlights from evaluation of the pilot Healthy Hearts Fit Kids Physical Activity and Nutrition Programme (informed by discussion with teachers, group discussions with pupils, pupil evaluations completed by the Coaches and Health and Lifestyle Facilitator, and discussions with those delivering the Programme) found that children: Participated in new activities Made changes to their diet Showed improved levels of physical fitness Exhibited increased levels of interest in physical activity Showed increased confidence in their ability to participate in physical activity 10 Promoting physical activity for children: Review 1 The National Centre for Clinical Excellence (NICE), 200711 www.gov.uk/government/publications/uk-physical-activity-guidelines, accessed 22.08.201312 Prescott-Clarke P, Primatesta P. Health survey for England: The health of young people ’95–97. London: Joint Surveys Unit, 199813 Gable and Lutz, Household, Parent, and Child Contributions to Childhood Obesity, 2000

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Retained the information about diet and nutrition given during the Programme (evidenced through the Nutrition Quiz on the final day of the Programme).

The Fit Kids Physical Activity Programme has been delivered to more than 1400 Primary School Children in West Belfast.

The Fitness 8 Programme

The Fitness 8 Programme, designed by Glen McCrum of Fit for Life at the Greater Village Regeneration Trust (GVRT) supported by The Belfast Health and Social Care Trust, was initially delivered in South Belfast. Fitness 8 has been delivered to 16 Primary Schools across Belfast, involving over 500 children to date. Highlights from the teachers evaluation of the Fitness 8 programme show that: Pupils are more confident about taking part in sports Pupils are spending more time doing physical activities Pupils understood the health messages given Pupils are making healthier eating choices, for example in their lunch boxes or

choosing to eat vegetables at school dinners.

Teachers said that the Programme included good links between nutrition and fitness, it accounted for all levels of ability, and that pupils both enjoyed the physical activity and gained a lot of information about healthy lifestyles.

Furthermore, teachers recognise that the Fitness 8 Programme messages link to the National Curriculum; and two-thirds report using the games and activities at School; with a greater number (75%) revisiting the health messages given during the Fitness 8 Programme in class.

The children’s evaluation of Fitness 8 (undertaken during the Celebration Events), completed by 433 pupils reported: 90% of the children enjoyed taking part in the physical activities 80% of the children feel more confident about taking part in sports now 68% of the children enjoyed hearing about how they can can be healthier 67% of the children are spending more time each week doing physical activities 58% of the children tried new fruit at home or school 53% of the children tried new vegetables at home or school

Overall Impact of the Fit Kids and Fitness 8 Programmes

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Overall, impact of the Fit Kids Physical Activity and Nutrition Programme and the Fitness 8 Programme - as evidenced by teachers, coaches, children, and observation – includes: Children are more confident taking part in physical activity Children are doing more physical activity during the week Children are eating more fruit and vegetables, and an increased variety of fruit

and vegetables Children have taken on board some basic health messages.

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POST-PRIMARY SCHOOLS PROGRAMMES: IMPACT

Context

Recent research in Ireland has reported that children as young as ten years old show evidence of Cardiovascular Disease risk factors14. In 2013 researchers from across the island have said that public policies aimed at helping people to manage their obesity should place more focus on promoting physical activity alongside a healthier diet, and emphasise the positive benefits of a more active life and healthier diet15. In 2007 the National Centre for Health and Care Excellence (NICE) concluded that there is a strong rationale for promoting physical activity among children and adolescents; specific population sub-groups in which levels of activity are low include children from lower socio-economic groups, and overweight and obese children16.

Research and previous baseline data collected through Healthy Hearts has shown that there is an increasing tendency for young people to decrease the amount of time they spend engaging in physical activity once they enter early teenage years. Reasons given for this decline are: Dislike of communal school changing rooms Issues around make-up and hair after engaging in sport (especially for girls) A fear that if they do sport they will get muscle-y bodies Not enough time No one to go with A lack of female sports role models (for girls)

In addition to reducing premature death and the incidence of disease, participating in physical activity also has benefits for mental health, quality of life and wellbeing and maintaining independent living in older age. It can also play a key role in reducing health and social inequalities17. As a result of this wide-reaching impact, physical activity has been described as the ‘best buy in public health’.18 Beginning at a young age, physical activity is an essential component for energy balance and weight control19.

From 2005/06 to 2011/12 the percentage of children in Year 8 who are overweight or obese has increased from 27% to 31%. Research demonstrates that children who are obese or overweight are more at risk of being obese as adults and of developing

14 Irish Medical Journal, January 201315 Institute of Public Health website16 Promoting physical activity for children: Review 1 The National Centre for Clinical Excellence (NICE), 200717 Marmont M. Social determinants of health inequalities. The Lancet. 2005;365(9464):1099-1104. 18 Morris JN. Exercise in the prevention of coronary heart disease: Today’s best buy in public health. Med Sci Sports Exerc. 1994;26(7):807-14. 19 Chaput J, Klingenberg L, Rosenkilde M, Gilbert J, Tremblay A, Sjodin A. Physical activity plays an important role in body weight regulation. J Obes. 2011;2011(360257)

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a range of related health problems. It is increasingly important, therefore, action is taken to seek to improve the health and well-being of children and young people.20

The World Health Organisation believes that we live in an obesogenic environment in which a range of factors in our physical, socio-economic and cultural environment act to promote calorie intake and discourage physical activity21. Factors such as the advertising and promotion of an unbalanced diet, the availability of high calorie, energy dense, convenience foods, the relative cost of healthy food options and inadequate cooking skills were identified as contributing to a less than perfect diet by the Health Select Committee22. The greater use of cars, parental reluctance to let children play outdoors due to concerns about traffic and stranger danger and the popularity of access to television and computers and other sedentary pastimes were identified by the Chief Medical Officer for England as threats to children’s overall activity level23.

The Fit Futures steering group, based on the discussions at an intersectoral stakeholder event, established a vision of a Fit Future. “In the Fit Future, children and young people, of all ages and from all sections of our society, will be motivated and supported to access a range of readily available, quality, enjoyable opportunities to be active and eat healthily.” Creating healthy schools is one of the six priorities identified by the Fit Futures Taskforce.

The Post Primary School Healthy Hearts Lifestyle Survey

373 young people in Year 9 (aged twelve and thirteen) completed the Lifestyle Survey; 283 girls from St Rose’s Dominican College, St Louise’s Comprehensive College, and St. Dominic’s High School; and 89 Year from Ashfield Boy’s High School.

Highlights from the Lifestyle Survey showed that: 8% of students are meeting the recommended target in relation to physical

activity. 48% of the students are engaging physical activity three days a week or less 50% enjoy being physically active ‘a lot’ More students are members of sports

clubs and teams out of School than in School Barriers to being physically active include lack of time, fitness levels, the weather,

distractions, laziness and homework

20 Food in Schools Policy; Department of Education NI and Department for Health, Social Services, and Public Safety, September 201321Obesity: Preventing and managing the global epidemic. Report on a WHO Consultation. Technical report series, no. 894. WHO, 200122 Obesity. Third report of Session 2003-04. House of Commons Health Committee. HMSO, 200423 At least five a week. Evidence on physical activity and its relationship to health. A report from the Chief Medical Officer. Department of Health, April 2004

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23% of students have screen-time levels of over 3 hours a day 87.5% of girls said it is important to eat breakfast, but only 41.67% eat breakfast

everyday 90% of the boys said it is important to eat breakfast, but only 45.68% eat

breakfast everyday 10% of boys and 17% of girls are eating ‘five a day’, although 83% and 86%

(respectively) were aware that they should eat five portions of fruit and vegetables a day

28% of students say they have a healthy diet 78% of students feel anxious about things Two thirds of students said that when they feel stressed it affects their

schoolwork.

The Post Primary School Healthy Hearts Programme

The Post-Primary School Programme was developed and delivered in partnership between Healthy Hearts, Top of the Rock Healthy Living Centre, and the Post-Primary Schools. Each partner organisation took on specific roles, including the delivery of the physical activity sessions (Peripheral Heart Action, Insanity, and Boxercise), diet and nutrition sessions, and stress management.

Healthy Hearts coordinated the Programme; and also administered the Lifestyle Surveys and post-Programme evaluation questionnaires; data collation and analysis of the surveys and questionnaires; and delivery of the School Reports following the four-week Programme.

80 students from Post Primary Schools participated in the programmes – which were delivered to class sizes of twenty students at each school.

Girls Programme: 60 participants Week 1: Physical Activity Introduction Weeks 2 and 3: Physical Activity and Nutrition Week 4: Stress Management

Boys Programme: 20 participants Week 1: Physical Activity Introduction to Insanity Fitness Week 2: Insanity Fitness and Nutrition Weeks 3 and 4: Boxercise and Nutrition.

The post-Programme evaluation showed a high level of enjoyment of all sessions. Learning for the students included:

How to be more relaxed The need to be physically active

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Personal stress management To eat more healthily (information about sugars, fats, portion sizes, and

‘energy’ and fizzy drinks) Information about nutrition How to give massages

The Post-Primary School Programme Impact

Students reported the following benefits after the Healthy Hearts Programme: 64% of students are doing more physical exercise than before 56% of students have made changes to their diet 72% of students feel better able to cope with stress

The initial four week intervention led to two of the participating Post primary Schools, Ashfield Boy’s High School and St Louise’s High School to organise health and wellbeing days in the School, in partnership with Healthy Hearts. Both Schools have now developed Health Action Plans. One of these is outlined below.

Ashfield Boy’s High School Health and Wellbeing Plan

Ashfield Boy’s High School sought to organise a whole school health and well being event for staff and students, based on the impact of the relatively short Healthy Hearts Programme intervention. One member of staff took on the role as the health and wellbeing champion prior to this event; and with Healthy Hearts and East Belfast Community Development Agency,27 different stands and activities were available to staff and students throughout the day. Staff and students signposted to GPs and specialist services; and 23 registered for the Park Run.

Taking on board lessons learned during the development and delivery of Healthy Hearts, all attending organisations asked about follow up opportunities with the School. This provided Healthy Hearts and Ashfield Boy’s School with a number of practical opportunities to follow up when developing the Ashfield Boy’s High School Health and Wellbeing Plan.

The School have identified health champions from staff and students, and established the Health Action Group. Healthy Hearts, supported by the School, drafted the Health and Wellbeing Plan. This includes: Walk Leader training Events planned for each month, linking in with ‘national weeks’:

o National Eye Health Week: eye testso Mental Health Awareness Week: Top Tips Training

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o Sexual Health Week: HYPE Clinic and Workshop Plans built in based on the support offered by organisations after the health

event, including:o British Heart Foundation: All staff and students to be trained on

lifesaving CPR o East Belfast Counselling: Clinic o Belfast Health and Social Care Trust: Eating Disorder Workshop,

Sugar Charts, and Healthy Eating Campaigno Cancer Focus: three Smoking Cessation Clinics p.a.o FASA and ASCERT to deliver programmeso NI Fire and Rescue Service one day programmeo Stroke Association: Health checks for all staff.

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CORPUS CHRISTI COLLEGE: IMPACT

Context

Four in every five pupils attending Corpus Christi College live in the top 10% of the most socially deprived areas in Northern Ireland according to Multiple Deprivation Measures collated in 2010. According to National standardised tests for Year 8 pupils (age 11), the normal distribution of achievement would place 23% of pupils below the average category. In 2011 78% of Y8 pupils began their education at Corpus Christi below the average category in English. In 2011, 3 in every 5 pupils availed of free school meals. 91% of pupils from Corpus Christi live in the top 10% of the most health deprived areas of Northern Ireland.

A staff survey, carried out by the School, recorded high levels of stress across the staff; and concerns about health and wellbeing. The College was aware that Healthy Hearts were delivering a number of programmes in the Primary Education sector and he felt that there was an opportunity to develop some of these programmes with Post Primary Schools.

Corpus Christi College Staff Health Event

In February 2013 Healthy Hearts delivered the Health Event for staff at Corpus Christi College. The Event was organised in partnership with the Top of the Rock Healthy Living Centre and the Belfast City Council Widening Participation Officer.

Opportunities for 40 members of staff included health checks, complementary therapies, nutrition advice, and physical activity taster sessions. Data received from the stand holders showed: 12 members of staff fell within the BMI target weight, 7 had a BMI of over 30 (ie

classified as obese) 6 members of staff were signposted to the Healthy Hearts Community Pharmacy

Vascular Risk Screening Programme 7 members of staff were signposted to their GP, due to ‘high-risk’ health check

results.

Corpus Christi Health Event: Impact

The Principal agreed that there were benefits in asking staff to complete a follow-up questionnaire three months after the Health Event. The aim was to ascertain the short to medium term impact of the Health Event; and to see whether the positive comments and intentions stated by staff about making lifestyle changes (armed with

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new information and health check results gathered during the Health Event) would be put into practice in any tangible way.

At the end of May 2013, staff at Corpus Christi were invited to complete a short follow-up questionnaire; asking about any lifestyle changes or follow-up actions they have made following the Corpus Christi Staff Health Event. 38 questionnaires were completed and returned.

Highlights from the data analysis showed: 95% of staff made more health lifestyle changes than they had anticipated The 7 staff referred to the GP, all went 27 staff report eating more healthily 24 staff take more care of their health 22 staff take more exercise 22 staff drink more water 14 staff have started walking regularly

Progression

Building on the success of the Health Event, and the impact for staff following a half day intervention the College has progressed with a number of health and wellbeing strategies: A new College Fitness Suite for staff and local residents; supported by funding

from Active Communities Belfast Lifestyle Survey completed by pupils in Year 8 and Year 9 (aged 11–13 years) Pilot Heart Health Programme for Year 8 and Year 9 pupils Whole College health approach.

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SPRINGVALE EMPLOYMENT AND LEARNING SOLUTIONS: IMPACT

Context

Springvale Employment and Learning Solutions is a community based centre providing new skills, qualifications and job opportunities for young people (aged over 16) and adults in a range of vocational training areas; including plumbing, electronics, hospitality, digital media, and electronic engineering. In late February 2012 Springvale Employment and Learning Solutions approached Healthy Hearts to ascertain whether it would be possible to work in partnership to deliver a smoking cessation event, which would be the first time such an activity had taken place at Springvale Employment and Learning Solutions. Recognising the opportunity to work with a group of disadvantaged, ‘hard to reach’ young people the first Springvale Employment and Learning Solutions / Healthy Hearts health event was organised on in March 2012.

Following the success of this event, further discussions between Springvale Employment and Learning Solutions and Healthy Hearts identified a series of events with young people participating in focus groups, lifestyle choices surveys, and a physical fitness programme (in partnership with Falls Leisure Centre). All activity to date has been subject to evaluation by the Healthy Hearts Evaluator / Researcher, who also facilitated the Focus Groups and administered the Lifestyle Surveys.

During 2012 to 2015 more than 270 young people and 100 staff at Springvale Employment and Learning Solutions have engaged in heart health initiatives.

Lifestyle Survey Highlights

The Healthy Hearts Evaluator / Researcher facilitated eight Focus Groups with 75 young people talking about their lifestyle choices in June 2012. In September the same year the Evaluator / Researcher facilitated the administration of the Lifestyle Survey, which was completed by 120 young people (the new intake).

Analysis of the lifestyle data from the focus groups and survey data (involving 195 young people in total) highlighted: A lack of physical exercise Unhealthy diets High levels of smoking and alcohol consumption Unhealthy / abnormal sleep patterns High levels of stress and anxiety An interest in knowing about healthy lifestyle options and choices.

In addition, staff completed the internal ‘Work Well’ questionnaire.

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Springvale Employment and Learning Solutions and Healthy Hearts Events and Programmes

During the past three and a half years Springvale Employment and Learning Solutions, supported by Healthy Hearts, has organised and delivered a range of health and wellbeing interventions for staff and young people. These include: A range of themed health days including:

o Smoking cessation event o Movember - promoting awareness of men’s health issueso Sexual Healtho Stress Management

Fit 4 Work Programme – 90 young people started; 70 completed Health and wellbeing assessments and diagnostics Smoking cessation initiatives Sexual health initiatives Counselling sessions on-site A Breakfast Club The Springvale Walking Group The Springvale Pedometer Challenge Complementary Therapy sessions on-site The Bike Club

Impact for Staff and Young People at Springvale Employment and Learning Solutions

General impact from the health and wellbeing events and activity included behavioural changes and reduced engagement in risk factors that contribute towards heart disease and other chronic diseases. Programmes and activities have contributed towards disease prevention and primary prevention; through staff and young people gaining information and engagement in activities to combat risk factors. There has been an increased take up and interest in physical activity and a significantly greater awareness of risk factors to heart health and other chronic diseases.

Quantifiable examples of impact include: 90 staff and learners have taken part in walking groups and the Springvale

walking challenge.  40 plus young people have been referred to physical activity programmes

through the GP Referral Scheme 10 staff and learners have permanently stopped smoking following the Pharmacy

Smoking Cessation Programme

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7 Catering students and 6 Media students wrote a Cook Book of recipes using mince 

20+ young people sought advice from the Community Pharmacist 2 young people referred to the GP and have been diagnosed with diabetes

following the Blood Sugar test at a Springvale Health Event 50+ young people benefited from Counselling 6 members of staff were referred to their GP following blood pressure check; all

are now on medication.

Sustainability and Developments

The events and programmes delivered and the positive impact led to Springvale Employment and Learning Solutions developing a Whole Organisation Health and Wellbeing Strategy. The initial development stage was supported by the PHA, BHSCT, and Healthy Hearts.

Springvale Employment and Learning Solutions staff have given presentations and shared the learning – for example at the PHA Annual Scientific Conference in August 2014, in partnership with the Healthy Hearts Evaluator / Researcher; and at the Healthy Hearts Shared Learning Event in August 2015, which was hosted by Springvale Employment and Learning Solutions.

Springvale Employment and Learning Solutions has successfully applied for funding to develop and deliver new health and wellbeing programmes.

The organisation has made changes to the curricula offered to young people based on the review and learning of the health and wellbeing interventions. This includes a Personal Development module for all learners, and the new Transitions programme, for those with learning difficulties and other disabilities.

Springvale Employment and Learning Solutions Staff – Progression and Opportunities

20 staff completed a short survey in August and September 2015 about progression and opportunities as a result of the partnership between Springvale Employment and Learning Solutions and Healthy Hearts. 17 of them had engaged in at least one Springvale Employment and Learning Solutions / Healthy Hearts health events or programmes.

12 people had a health check at one of the health events, and 6 (50%) were referred to their GP following the health check results. All report that they saw their GP; 2 were prescribed medication by their Doctor, and 3 received health advice from the GP.

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Staff reported seeking health advice at the Springvale Employment and Learning Solutions Health Events about diet and healthy eating, physical activity, smoking cessation, alcohol consumption, stress management, and complementary therapies.

Half the respondents said that they have made lifestyle changes, which they have sustained. These include (in order of frequency mentioned): Changed to a healthier diet Doing more physical activity Better stress management Stopped smoking Reduced alcohol consumption

4 of the Survey respondents also participated in the Springvale Employment and Learning Solutions Walking Group and Pedometer Challenge, and said that they felt they gained health benefits from this activity.

Over half the survey respondents said that they are aware of the Springvale Employment and Learning Solutions Whole Organisation Health and Wellbeing Plan, and that they think this is a positive way forward for Springvale Employment and Learning Solutions.

As a result of participating in Springvale Employment and Learning Solutions / Healthy Hearts health and wellbeing activity, respondents said that they now: Talk to family and friends about healthy lifestyles (11 / 16) Manage their own health more effectively (10 / 16) Have a healthier lifestyle (7 / 16) Feel healthier than before (6 / 16) Ask their Pharmacist for advice about health issues (4 / 16).

The majority of respondents would recommend this community approach to improving individual and organisation-wide health and wellbeing.

Critic factors contributing to the success of the Healthy Hearts and Springvale Employment and Learning Solutions Partnership

There are four core factors that impacted on the Healthy Hearts and Springvale Employment and Learning Solutions Partnership: Commitment from staff and senior management The value of learner assessments, including lifestyle choices The benefit of programme evaluation to support future intervention Analysis of exemplars of good practice with this target group

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COUCH TO 5K AND FALLS PARK RUN: IMPACT

Context

Healthy Hearts in with the Falls Park run; which is part of the international Parkrun initiative; where every Saturday morning (starting at 9.30 am) people run, jog or walk five kilometres. The Falls Park Run was launched at the end of May 2012, and now has over 1300 registered runners. The average number of runners each week is 55; with greater numbers attending special events. Runners register online for this activity, which is free of charge.

The Falls Park Run is organised by volunteers from the Beechmount Harriers Club. The Falls Park Run Coordinator has explained the concept: “The Falls Park Run is a run and not a race; it encourages people of all levels of fitness and all backgrounds to go along and enjoy a 5 kilometre jog, walk or run. People are encouraged to take it at their own pace. If they can’t complete 5 kilometres, they are encouraged to start at 1 kilometre and build up their distance over time”.

Falls Park Run Anniversary and Couch to 5K Programme

Healthy Hearts supported the Falls Park Run first anniversary in 2013; promoting the Park Run for the four weeks prior to the event through a billboard, ‘Bus Side Liner’ on local buses and handing out flyers at Shopping Centres; encouraging new runners to register. During the anniversary event Healthy Hearts organised the following additional activities: The Healthy Hearts Taxi was on the route for advertising Health Checks were offered by the Heart and Top of the Rock Healthy Living

Centres Sure Start provided a crèche facility at the Bowling Pavilion Live music was played at the marquee and at the foyer of the pavilion Sports massages were given in the marquee One of the Healthy Hearts Hub Coordinators was stationed at t be at the outdoor

gym equipment in the Park to show people how to use it.

The Couch to 5K Programme has been designed to get people “from the couch to running 5 kilometers or 30 minutes in just 9 weeks”.24 The approach is to start with a gentle introduction to getting the body moving, starting off alternating between walking and running small distances, and slowly building up until after 8 weeks, people are ready to run five kilometers or 30 minutes non stop. The Programme has been offered in conjunction with the Falls Park Run, supported by Healthy Hearts; the Programme was delivered in Autumn 2013.

24 http://www.c25k.com

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Couch to 5K Programme: Impact

In September 2015 (two years after the Couch to 5K Programme was delivered) fifteen people who had participated in the Couch to 5K programme completed a short survey, asking about progression and impact of the Programme. Highlights from the survey data showed: Everyone felt physically healthier since they took part in the C25K programme 93% said they feel a lot healthier in terms of emotional wellbeing (7% said they

felt ‘a bit more healthy’ in relation to emotional wellbeing)’ since they took part in the C25K programme

Everyone has continued to take part in the Falls Park Run after the Couch to 5K Programme finished. 40% attend the Falls Park Run every Saturday; whilst 40% said they take part in the Falls Park Run at least three Saturdays a month.

Everyone who took part in the C25K Programme said that they have made lifestyle changes as a result, and have maintained a healthier lifestyle:

o 100% are doing more physical activityo 80% have changed to a healthier dieto 73% have reduced their alcohol consumptiono 73% report that they manage their stress levels more effectivelyo 2 people have stopped smoking

Almost everyone has found out more information about diet and healthy eating and physical activity during or after the C25K Programme. The majority have also found out more about managing stress; and some have looked into smoking cessation programmes, reducing their alcohol intake, and complementary therapies.

Some people have taken part in other community heart health opportunities including joining an exercise class, having a health check, healthy cooking programmes, and attending health days.

100% report managing their own health more effectively. 100% said that they would recommend this community based approach as a way

to improve their physical and emotional wellbeing.

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TULLYMORE WALKING GROUP: IMPACT

Context

Healthy Hearts adopted a collaborative, community assets approach to addressing heart health inequalities. This included carrying out a scoping study to identity programmes, interventions, and support services delivered across communities that contributed to addressing risk factors to heart health. In particular this focused on physical activity, diet and nutrition, stress management, and smoking cessation programmes.

Healthy Hearts provided support and capacity building where gaps in provision were identified. One such example was the Tullymore Walking Group. In addition to meeting need, Healthy Hearts also provided additional input to enhance existing programmes, for example – delivering healthy eating messages and sessions at sports club training sessions (for example with GAA Clubs, football clubs, and boxing clubs).

Tullymore Walking Group: Impact

The Tullymore Walking Group was established to give people the opportunity to engage in physical activity within a safe environment, with the added benefit of promoting social inclusion across the community. The participants were mainly over fifty. The Walking Group intervention contributed towards two of the original Healthy Hearts objectives: to raise awareness about the risk factors contributing to heart disease and to raise awareness about how to achieve a healthy lifestyle through local programmes. In addition to the weekly walk; additional opportunities were promoted to those engaged, including a half day workshop at the Mourne Seafood Restaurant, delivered by Belfast Cookery School.

Those involved in the Walking Group said that: They enjoyed being out and about with other people They feel they have made changes to their lifestyles and are healthier as a result They have learnt more about key health messages They feel the benefits of walking They have got involved with other activities in the community that benefit their

health.

The Healthy Hearts Hub Coordinator who supported the development of the Walking Group noted that the most frequently mentioned short term outcomes to which this programme has contributed are ‘improved lifestyles’ and ‘reducing behaviours that can increase the risk of heart related disease’.

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It is noted that the Tullymore Walking Group started in 2012, and that the Group continue to meet weekly. This is in spite of the fact that there has not been a Healthy Hearts Hub Coordinator in Upper Falls for over eighteen months. This demonstrates an additional impact – that of self-resilience.

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COMMUNITY PHARMACY PROGRAMMES: IMPACT

Context

Reducing CVD in areas of deprivation presents significant challenges; but there are effective interventions, which, in addition to medical interventions, can reduce risk, prevalence and deaths from CVD. These include promoting and recommending healthier choices, such as eating healthier foods, using alcohol sensibly, undertaking regular physical activity, stopping smoking, and accessing services appropriately.25

In 2003 the Department of Health highlighted that pharmacists are the biggest untapped resource for health improvement.26 Pharmacies are located in the ‘heart of communities’, and are well placed to make an important contribution to improving public health and the wider promotion of health.

The Community Pharmacy Programmes

Two Community Pharmacy Programmes, aiming to reduce risk factors to heart health, were piloted in West Belfast, linking into the Healthy Hearts in the West Initiative (2012 – 2014). The Vascular Risk Screening and the Weight Management Programme were promoted and delivered by ten Pharmacies in West Belfast. The Healthy Hearts Community Pharmacy Programmes pilot were coordinated by the Ulster Chemist’s Association (UCA), building on similar programmes that had been previously delivered by TA Maguire Pharmacy.

The majority of the funding - awarded by the Belfast LCG and PHA - was used to pay 50% of the cost of ten Keito machines, purchased by the participating pharmacists. The Keito machines measure height, weight, BMI, and blood pressure; and can be accessed by individuals, after instruction, without the Pharmacist present. Whilst the Keito machines may be operated by individuals the intervention is based on the support from the Pharmacist.

The Pharmacists who delivered the Vascular Risk Screening and Weight Management Programme sought to engage with individuals to raise awareness about the risk factors to heart health; to discuss how clients can realistically change their lifestyles; to provide advice on diet, physical exercise, alcohol, and smoking; and to provide an accessible service to promoting and supporting lifestyle change.

25 Closing the gap. Tackling cardiovascular disease and health inequalities by prescribing statins and stop smoking services. Belfast: Care Quality Commission, 2009.26 A Vision for Pharmacy, Department of Health, 2003.

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This approach links to research undertaken by The National Heart Forum; which believes that the lifetime risk of CVD is strongly influenced by obesity and physical inactivity levels (Landon and Graff27). The risk amongst adults is determined by a variety of ‘upstream factors’ (such as food production and availability, access to a safe environment that encourages physical activity and access to education). It is also influenced by ‘downstream’ behavioural issues (such as diet and smoking).

The Vascular Risk Screening and Weight Management Programme seek to deliver behaviour change interventions. Michie28 cites three necessary conditions for behaviour change to be successful: capability, opportunity and motivation. Using this framework, pharmacies are well placed to provide the ‘opportunity’ including accessibility, location in the heart of the communities, and that the programmes are offered at no cost. Pharmacists offer the knowledge and skills required to make the changes, ie ‘capability’. The third necessary condition, ‘motivation’ is down to the individual. The two Programmes were subject to robust evaluation.

The highest numbers of referrals made by Pharmacists to the GP following the Vascular Risk Screening were due to high cholesterol results; this was followed by blood pressure and BMI readings. 15 clients had two potentially high-risk health check results and 1 had three high-risk health factors.

Community Pharmacy Programmes: Impact

Of the 757 people who accessed the Community Pharmacy Healthy Hearts Vascular Risk Assessments, 131 people were referred to their GP due to ‘high-risk’ assessment results. This suggests that these individuals were ‘ticking time bombs’; who had not sought a check up or sought advice from their GP. Follow up with some people referred to their GP showed that two thirds were given prescribed medication and / or health advice. A minority were referred to specialist services.

253 people signposted by Pharmacists to community heart health programmes. Those referred to community heart health programmes across West Belfast reported seeking advice from a Healthy Hearts Hub Coordinator, joining a Healthy Hearts walking club, starting physical exercise programmes, taking part in a healthy eating programme, sessions with a community based counsellor, and attending group classes at the Leisure Centre.

27 J Landon and H Graff, What is the role of health-related food duties? National Heart Forum, 2012.28 The behaviour change wheel: A new method for characterising and designing behaviour change interventions, Michie et al. Implementation Science 2011, 6:42http://www.implementationscience.com/content/pdf/1748-5908-6-42.pdf

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104 people participated in the Community Pharmacy Healthy Hearts Weight Management Programme. 76 people completed the Programme; and the majority who completed, lost weight. In addition to regularly weighing themselves (using the Keito machine) and meeting with the Pharmacist to review their personal action plan and goals; people also linked into community support, including healthy eating programmes and physical activity programmes. The majority of the 76 people who completed the Community Pharmacy Weight Management Programme lost weight.

People also reported changing their lifestyles following the Community Pharmacy interventions. This included eating more healthily, taking more exercise, and cutting down or stopping smoking (Pharmacists also advised clients to join their Stop Smoking Programme, offered by Pharmacies and funded by the Public Health Agency).

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FALLS WOMEN’S CENTRE HEALTHY HEARTS PROGRAMME: IMPACT

Context

The Falls Women’s Centre is a community development organisation established in 1982 in West Belfast by local women. The Centre works to improve the quality of life for women and their families living in areas of extreme deprivation and most affected by the conflict; providing advice and advocacy, education and training, childcare, and a range of projects.

The Falls Women’s Centre contacted Healthy Hearts in the West to look at the possibility of delivering a Weight Management Programme based at the Centre. Following discussions, the twelve week Community Pharmacy Programme at The Falls Women's Centre started in January 2013. It was the first Healthy Hearts Community Pharmacy Weight Management Programme to be delivered in a community setting.

The Programme

The Falls Women’s Centre Weight Management Programme piloted the delivery of a series of heart health presentations over the twelve weeks. Following the introduction session, the topics covered during the Programme included Diet and Nutrition (six weeks), Smoking Cessation, the Colour Breathing, a Beauty Day (at Boots the Chemist), and stress management.

Each woman had a one to one consultation with a Pharmacist (either the Pharmacist based at Boots or the Support Pharmacist). This followed the same process as the Healthy Hearts Community Pharmacy Weight Management Programme; comprising a series of health checks, including height, weight and waist measurements; blood pressure, glucose, and cholesterol. The women were asked about their dietary habits, and goals were identified in terms of weight loss and other lifestyle changes.

Some of the women on the Weight Management Programme also attended physical exercise programmes, including Yoga, Armchair Aerobics and Aerobics, delivered by the Active Communities Coaches.

The Falls Women’s Centre Weight Management Programme: Impact

Eight of the ten women lost weight. The eight women who lost weight, lost a total of 54.9 pounds (almost four stone) over the twelve week Programme. Two of the women lost over 5% of their body weight.

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All women reported (in the evaluation questionnaire and evaluation focus group) that they had made lifestyle changes. In addition to losing weight, this included: stopping smoking, doing more exercise, reducing salt in food, swimming, and eating more healthy meals.

The women said that they planned to continue their lifestyle changes once the programme finished. They talked about intending to maintain the weight loss, through exercise and continuing to eat well. They enrolled on the follow-on Cook-It Programme; which built on the diet and nutrition workshops.

The group approach to weight management: impact

During the end of Programme Focus Group the women were asked whether they felt there were benefits trying to lose weight as part of a group. The participants were unanimous in saying that they thought losing weight as part of a group had made the Weight Management Programme more enjoyable, and their personal goals more achievable. They said this was due to: Support from other members of the group All working towards a common aim A feeling that 'you didn't want to let the others down' Sharing ideas about physical exercise and healthy eating Motivating each other Attending regularly An element of competition.

The Pharmacist also felt that the engagement of the Group was very positive. Taking into account her experience in delivering the Healthy Hearts Community Pharmacy Programme, she thought the Falls Women's Centre group worked very effectively for those involved. She said that in many ways this was a preferable approach to delivering the Weigh Management Programme.

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CARDIAC REHABILITATION PROGRAMME PHASE 3: IMPACT

Context

Cardiovascular disease (CVD) is a major cause of death and disability in Northern Ireland. In 2012 more than one in four deaths (27%, 4,001 deaths) in Northern Ireland were due to diseases of the circulatory system.29 West Belfast is the most deprived geographical area in Northern Ireland. Approximately three quarters (76%, 71,709 people) of the West Belfast (AA2008) population live in one of the 20% most deprived Super Output Areas in Northern Ireland.30

People living in deprived areas are at higher risk from cardiovascular disease than those living in more affluent areas. Those living in West Belfast have the lowest life expectancy in Northern Ireland (average life expectancy for males 72.5 years v Northern Ireland average 77.1 years; for females 78.4 years v Northern Ireland average 81.5 years)31 CVD is a major contributor to the gap in life expectancy.32 Between 1997-2001 and 2006-2010 CVD mortality decreased across the geographical area of the Belfast Health and Social Care Trust (BHSCT). However, the decline in mortality in the most deprived areas stopped in 2003-2007 and as a result the inequality gap within BHSCT increased from 57% to 67%.33

There is robust evidence that comprehensive Cardiac Rehabilitation is associated with a reduction in both cardiac and total mortality. Effective Cardiac Rehabilitation results in improved outcomes for patients with heart disease and reduces unplanned readmissions. Cardiac Rehabilitation improves patients’ functional capacity and their perceived quality of life, whilst also supporting early return to work and development of self-management skills.

The Cardiac Rehabilitation Phase 3 Programme is currently delivered from four centres in Belfast (ie within the Belfast Health and Social Care (BHSCT) area). The rationale for lobbying for the delivery of the Cardiac Rehabilitation Phase 3 Programme from the Maureen Sheehan Centre (located in the centre of the Greater Falls, West Belfast) was due to concerns that patients living in West Belfast were not taking up the opportunity to attend Phase 3 Programmes due to the distance they had to travel, and that the Programme was not delivered in their own community.

29 Northern Ireland Statistics and Research Agency. Deaths in Northern Ireland 2012. Belfast: NISRA, 2013.30 Based on Census 2011 Usual Resident Population data SOA and MDM 201031 Life Expectancy (administrative geographies) (AA),2008-2010. Neighbourhood Statistics for Northern Ireland (NINIS).32 NI Health & Social Care Inequalities Monitoring System. Life Expectancy Decomposition An overview of changes in Northern Ireland life expectancy 2001-03 to 2008-10. Belfast: DHSSPS, 201333 Northern Ireland Health and Social Care Inequalities Monitoring System Sub-regional Inequalities – HSC Trusts 2012. Belfast: Department of Health, Social Services and Public Safety, 2012.

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The Community Based Cardiac Rehabilitation Phase 3 Programme

Delivery of the Cardiac Rehabilitation service at the Maureen Sheehan Healthy Living Centre started on the 15th January 2012. The Maureen Sheehan Centre is located in the heart of the Greater Falls (Albert Street); included in the Centre is the Heart Healthy Living Centre, a Pharmacy, Clan Mór Sure Start, and a GP surgery. The Cardiac Rehabilitation Phase 3 Programme is delivered by a team of three specialist nurses and one dedicated physiotherapist from Belfast Health and Social Care Trust.

As well as attending the CR Phase 3 Programme; the Cardiac Rehabilitation Nurses were able to refer patients to the Counsellor and Complementary Therapist, working for the Heart Healthy Living Centre in the same building. During the first fifteen months of delivery of the CR Phase 3 Programme from the Maureen Sheehan Centre 30 patients on 3 Programme were referred to the Counsellor and 53 patients referred to the Complementary Therapist to access additional support. Feedback from the patients and the CR Nurses report that these interventions were beneficial to the patients.

Patient numbers and clinical and quality of life impact

Delivery of the Cardiac Rehabilitation Phase 3 Programme started at the Maureen Sheehan centre in January 2012. From 15th January 2012 to 31st March 2013, 278 patients were eligible to participate in the Programme. Of these 137 enrolled on the Cardiac Rehabilitation Phase 3 Programme, ie an uptake of 49.3% (data collected by The National Audit of Cardiac Rehabilitation (NACR, funded by the British Heart Foundation). This represents an 11% increased take up of the opportunity to engage with the Cardiac Rehabilitation Phase 3 Programme by eligible patients.

At the individual Pre- and Post-Assessment of patients undertaken by the Cardiac Rehabilitation Nurses (approximately 12 weeks between the pre-assessment and the post-assessment) a number of clinical checks are taken, and measurements are recorded for each patient. Following participation in the Cardiac Rehabilitation Phase 3 Programme: 26 patients increased their level of exercise to within the government

recommended guidelines 5 patients’ total cholesterol level reduced 3 patients stopped smoking (it is noted that new guidelines for pre- and post-

assessment now capture data about when patients stopped smoking – ie before or after the event)

3 patients waist measurements reduced to falling within the recommended range The BMI of 1 patient fell below the BMI obese range

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The waist circumference of 3 patients increased – whilst data is not available to explain this increase the CR Nurses suggest this might include patients who have stopped smoking and put on weight.

Two standardised questionnaires are used within the National Service Framework: Hospital Anxiety and Depression Scale (HADS) and Dartmouth COOP - Quality of Life. Pre- and Post- Assessments (ie before and after participation in the Cardiac Rehabilitation Phase 3 Programme) showed: An increase of 9 patients falling within the ‘normal’ anxiety level A reduction of 3 patients assessed as ‘clinically anxious’ An increase of 8 patients with a ‘normal’ depression rating A decrease of 8 people assessed as ‘clinically depressed’. Increases in quality of life assessments (in order of greatest impact) for physical

fitness, daily activities, social activities, pain management, overall health, feelings, and quality of life.

Comparative data with Cardiac Rehabilitation Centres across Northern Ireland, England, and Wales (collected and analysed by NACR) showed that patients who attended the Cardiac Rehabilitation Phase 3 Programme at the Maureen Sheehan Centre had: Above average outcomes in relation to reduced BMI, increased exercise, reduced

number of smokers and reduced blood pressure (within the guidelines for people following hospital admission due to a heart related event).

Above average outcomes in relation to anxiety and depression. Above average outcomes in relation to reduced pain, increased daily and social

activities, and positive feelings.

Feedback from Patients: Impact

Following discussions with the Cardiac Rehabilitation (CR) Nurses it was agreed that it would be beneficial to carry out a formal follow-up with patients once they have completed (or left) the Cardiac Rehabilitation Phase 3 Programme delivered at the Maureen Sheehan Centre. The aim was to gather feedback about the provision of the Programme within the community setting. The Follow-Up Patient Questionnaire was drafted by Healthy Hearts (based on other Cardiac Rehabilitation questionnaires used in the UK and pilot telephone interviews). In addition to the Follow Up Patient Questionnaires, Healthy Hearts also carried out case studies with six people who completed the Cardiac Rehabilitation Phase 3 Programme.

67 Follow Up Patient Satisfaction Questionnaires were completed and returned for the period January 2012 to March 2013, representing a 52.8% return. Highlights from the data analysis show:

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62 of the 67 respondents said that the Maureen Sheehan Centre was their first choice of venue for the Programme, predominantly because it was local and easy to get to

75% of the patients found almost all the elements of the Programme ‘very useful’; including exercise sessions, information on heart disease, information about their medication, advice about diet, advice about alcohol, access to the fitness suite, and help to cope with anxiety.

All 17 patients who received additional support (from the Counsellor or Complementary Therapist) said that this was useful

86% of the patients who completed the Questionnaire felt ‘much better’ or ‘better’ in terms of energy levels, general health, and overall quality of life on completion of the Cardiac Rehabilitation Phase 3 Programme

73% felt their level of independence, self-confidence and ability to manage stress is ‘much better’ or ‘better’.

88% of respondents have improved their diet and eating habits 75% of respondents exercise more regularly 70% of those who smoked before admission to hospital (16 people) quit smoking

Further Impact Regionally

The Follow-Up Patient Satisfaction Questionnaire developed through Healthy Hearts has been taken up by Cardiac Rehabilitation Centres at regional level in NI.

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CARDIAC REHABILITATION PROGRAMME PHASE 4: IMPACT

Context

Phase 4 is the ‘long term maintenance phase’ following discharge from Hospital. The aim is that the Cardiac Rehabilitation Phase 4 Programme is the element of recovery that people feel they can maintain for the rest of their life, helping re-habilitate patients who have suffered with a heart attack or had a heart operation or who have suffered or are suffering with any type of heart disease. The Programme is only available to people who have completed the Phase 3 Cardiac Rehabilitation Programme.

On completion of the Cardiac Rehabilitation Phase 3 Programme at the Maureen Sheehan Centre (see above section), patients may be referred by the CR Nurses to the Cardiac Rehabilitation Phase 4 Programme. The Heart Healthy Living Centre employs two people who have qualified in the delivery of the Cardiac Rehabilitation Phase 4 Programme. This is delivered in the small gym located within the Maureen Sheehan Centre.

An advantage of this is that patients can meet the Cardiac Rehabilitation Phase 4 Programme coaches whilst attending the Phase 3 Programme; and for those referred on to Phase 4 the transition is seamless; and the programme is delivered within an environment that people are familiar with.

Cardiac Rehabilitation Phase 4 Programme: Impact

In September eight people, who had all completed the Cardiac Rehabilitation Phase 3 Programme at the Maureen Sheehan Centre, completed a short survey about progression and opportunities in relation to the Cardiac Rehabilitation Programme Phase 4. Highlights from the Survey data show: All people had requested that the Maureen Sheehan centre was their first choice

for the CR Phase 3 Programme, because the location was convenient to get to Everyone found all elements of the CR Phase 3 Programme relevant to them

(with one exception, as this person felt that stress management was not relevant to them)

2 people were referred to the Heart Healthy Living Centre counsellor by the CR Nurse whilst on the CR Phase 3 Programme; both said this was useful additional support

2 people were referred to the Heart Healthy Living Centre complementary therapist by the CR Nurse whilst on the CR Phase 3 Programme; both said this was useful additional support

The reasons people attended the CR Phase 4 Programme were because:

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o To help the self-management of their own healtho The CR Nurse said it would be usefulo To maintain being physically activeo To build on the CR Phase 3 Programmeo Convenient location, in which people feel comfortable as CR Phase 4

is in the same place where they attended CR Phase 3 During CR Phase 4, as well as the physical activities, everyone said they

received information about diet and healthy eating. 7 out of the 8 respondents said they received additional information about

counselling and complementary therapy. All survey respondents have made lifestyle changes, these include:

o Doing more physical activity (8/8)o Better management of stress (8/8)o Changed to a healthier diet (6/8)o 2 people have reduced their alcohol consumptiono 1 person has stopped smoking

When comparing their physical and emotional wellbeing after they left hospital (before participating in the CR Programmes) and now everyone reported: Having a healthier lifestyle Managing their own health more effectively Feeling healthier than before.

Everyone who responded to the Survey said that they would recommend the community approach.

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CRITICAL FACTORS TO THE HEALTHY HEARTS MODEL

Foundations and Preparation

Healthy Hearts in the West became funded and operational in January 2012. However; the development of the approach began over a year beforehand; the pilot on which the Initiative built (Healthy Choices in Lenadoon) began before this. A small cross-sectoral working group started to meet in 2010, in response to the widening health inequality gap (between those living in affluent areas and those living in deprived areas). Heart disease was highlighted as one of the causes of premature death and health inequality in West Belfast; and the working group sought to ascertain whether there was an interest across all sectors (community, voluntary, statutory and private) to address this at community level.

A seminar focusing on heart health, in March 2011, organised by the West Belfast Partnership Community Planning Health Development Worker and the working group, attracted interest from all sectors. This provided a foundation from which potential partnerships were explored; consideration was given to the resources and expertise different agencies and organisations could bring to a collaborative, community assets model to address heart health inequalities.

This preparation period laid the foundations for the Healthy Hearts proposal, including a community wide strategic vision. The first year in which Healthy Hearts became operational continued to see the building of the foundations, including: Healthy Hearts Planning Days (with 70 people attending one or more of the

Planning Days). Baseline surveys with children (the Fit Kids Survey), young people (Lifestyle

Surveys and focus groups), and adults (risk factors and assessing interest in heart health programmes).

A mapping exercise of heart health programmes across West Belfast was also initiated in 2012.

To support the development of the new Chronic Disease Prevention Hub, the Scoping Exercise was extended to cover all Belfast in 2015; with a focus on physical activity, diet and nutrition, stress management, and smoking cessation. A Directory was also delivered in 2015.

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Community Development Approach

Communities develop themselves – but intervention, such as Healthy Hearts in the West, helps to: Accelerate development addressing an identified need, in this case health

inequality Set communities on a fruitful path Link community infrastructure to local and regional policies and initiatives; win:win

outcomes Build partnerships with statutory and private sector organisations, such that they

are receptive to engaging with community organisations on an equal footing.

Community development principles have driven the Healthy Hearts Initiative, supporting individuals and groups. These include: Collective action and focus through bringing the community together: this was

achieved through local Hub Planning Days, Hub Steering Groups, and a range of Healthy Hearts and community based heart health programmes and activities.

Involving and enabling people to make better choices for themselves: delivered through the Healthy Hearts Initiative through:

o Information on diet and nutrition, physical exercise, alcohol and smoking cessation

o The local Pharmacy Vascular Risk Screening and Weight Management Programmes, accessible to people living in West Belfast

o Healthy Hearts events promoting opportunities for health checkso Engaged community groups being in a position to reaffirm and promote

similar heart health messages. Social justice: seeking to redress inequalities the Healthy Hearts Initiative has

raised awareness about heart health at a community level (for example publicity at the Falls Park Run, the Healthy Hearts Taxi, and through the Pharmacies); and made heart health programmes and services more accessible (for example Cardiac Rehabilitation Phase 3 delivered from the Maureen Sheehan Centre, and community based programmes supporting heart health).

Promoting equality between the community and statutory sectors: Healthy Hearts partners have worked together to influence, change and exert control over the social and political issues that affect people’s lives.

Seeking alternative ways of working (dynamic, creative and innovative): data show that the health inequality gap is widening between affluent and disadvantaged areas. This in turn suggests (and is supported by Healthy Hearts Baseline Surveys) that existing health and social care infrastructure and public health messages are not effectively reaching (or not being accessed by or taken on board by) those living in areas of high-level deprivation. Healthy Hearts has engaged with organisations from all sectors to consider new ways of making heart health accessible to people living in West Belfast (including raising

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awareness of risk factors, prevention, and rehabilitation for those who have experienced heart disease).

Community assets model

One of the key messages on challenging health inequalities in the Marmot Review is that effective local delivery requires effective participatory decision-making at local level. This can only happen by empowering individuals and local communities”. The asset approach promotes well-being by building social capital, facilitating face-to-face community networks, encouraging civic participation and citizen power. High levels of social capital are correlated with positive health outcomes, well-being and resilience. A community asset approach values the capacity, skills, knowledge, connections and potential in a community; and relies on community knowledge and engagement. It also, as a consequence, considers a more effective use of (limited) resources.

With the focus on community Hubs, and engagement of community groups (which work with different target groups within the community), Healthy Hearts sought to build a community assets approach to addressing health inequality. This approach also necessitates working together (where all partners have an equal voice and share decision making) across the community, voluntary, statutory and private sectors.

The community asset approach does not replace investment in improving services or tackling the structural causes of health inequality. The aim is to achieve a better balance between service delivery and community building. A community asset approach seeks to make best use of the services and programmes available (across all sectors); signpost people to the range of quality provision available; and facilitate ease of access to services.

Linking into existing infrastructure – Social Capital

The National Institute for Health and Care Excellence (NICE) Guidance on Community Engagement to improve health (PH9, 2009) emphasises how active communities can have a positive impact on health outcomes by improving services and influencing the governance of health services.

Social capital is concerned with the value of social networks, bonding similar people and bridging between diverse people, with norms of reciprocity. Fundamentally social capital is about how people interact with each other. There is now a range of evidence that communities with a good 'stock' of such social capital are more likely to benefit from better health, higher educational achievement, lower crime figures, and better economic growth (Halpern D. The Hidden Wealth of Nations 2009).

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Coordination of effort at strategic and operational levels across a range of partner agencies and organisations, including linking into existing infrastructure and initiatives, resources, and engaging senior managers and people ‘on the ground’ (engagement at different levels across organisations) is necessary to achieve effective ‘buy in’ and action. Such linkages build on the community assets approach. Increased participation; and building social cohesion, mutual respect and confidence has the potential to result in sustainable change. Healthy Hearts has sought to mobilise community resources and individuals, moving towards changes in the current systems to better support heart health and reduce heart health inequality.

Drivers, champions, and committed individuals

Identifying drivers, champions, and committed individuals to develop and deliver heart health interventions is key to any Initiative. This includes members of the Healthy Hearts team, who believed in the vision and saw the opportunity to test out a new approach to addressing inequality.

At times individuals engaged because the Healthy Hearts vision linked in well with new developments (for example the new Widening Participation role at Belfast City Council); or with existing targets (for example the Extended Schools initiative). Without the support of key people it is unlikely that delivery of the Fit Kids Physical Activity Programme would have been taken on by Belfast City Council Active Communities. However, the opportunity to meet targets through sustaining a Programme that gained positive feedback (from teachers, pupils and coaches) during the evaluation process was identified as a mutually beneficial way forward.

Other people became committed because they could see the benefits for their target group. In the case of Springvale Employment and Learning Solutions, the partnership with Healthy Hearts (delivery of several health events, lifestyle surveys with young people, and the Fit 4 Work Programme) has led to the training organisation developing a whole organisation health and wellbeing strategy.

The cross-sectoral partnership has been effective to some degree, with positive and sustainable outcomes developing as a result. There is the potential to build further on cross-sectoral partnerships; for example rather than waiting for partners to be pro-active, instead approach partners with an evidence-based need, which they have the resources to do something about. Ideally this will tie-in with the organisation’s own targets and vision – thus a win:win for Healthy Hearts and the partner organisation.

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Supporting Behaviour Change

Changes in cardiovascular disease (CVD) risk factors can be brought about through intervention at both an individual level in terms of behaviour change and at population level though development of appropriate policy and legislation (Prevention of cardiovascular disease at population level. Public Health Guidance 25. National Institute for Health and Care Excellence, 2010).

Buck and Frosini (Clustering of unhealthy behaviours over time: implications for policy and practice, The Kings Fund, 2012.) suggest that there is a need to find effective ways to help people in lower socio-economic groups to reduce the number of unhealthy behaviours, which in turn will address health inequalities. They propose that this is only likely to work through an integrated, cross-sectoral holistic approach to policy and practice.

The ethos throughout the Healthy Hearts Initiative is to break down barriers to healthy lifestyle options. This has been achieved through; Creating linkages with community organisations, including sports clubs, Sure

Starts, older people’s groups, women’s groups, and youth groups; and delivering accessible, tailored heart health activities and workshops

Local provision of physical activity and healthy eating programmes Working with pupils and teachers in Primary and Post-Primary Schools Local, accessible Vascular Risk Screening delivered by ten participating

Pharmacies Cardiac Rehabilitation Phase 3 and Phase 4 available in a community setting.

Recognition by the National Institute for Health and Care Excellence

In 2014 the Healthy Hearts Evaluator submitted a paper to the NICE Shared learning Awards. This was ‘highly recommended’ and a Healthy Hearts Poster was included (with 20 others) at the NICE Annual Conference in Birmingham in May 2014.

The Healthy Hearts Evaluator / Researcher has been invited to give two presentations at the NICE Annual Conference in October 2015. The presentation topics are: ‘Integrating services: building a business case: making the most of existing resources’ and ‘Investing in a healthy community: Using NICE’s ROI tools’.

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APPENDIX ONETHE NINE KEY MESSAGES FROM THE MARMOT REVIEW

In February 2010 the report "Fair Society, Healthy Lives: A Strategic Review of Health Inequalities in England Post-2010" was published.

The report included 9 key messages:1. Reducing health inequalities is a matter of fairness and social justice. In

England, the many people who are currently dying prematurely each year as a result of health inequalities would otherwise have enjoyed, in total, between 1.3 and 2.5 million extra years of life.

2. There is a social gradient in health – the lower a person’s social position, the worse his or her health. Action should focus on reducing the gradient in health.

3. Health inequalities result from social inequalities. Action on health inequalities requires action across all the social determinants of health.

4. Focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. We call this proportionate universalism.

5. Action taken to reduce health inequalities will benefit society in many ways. It will have economic benefits in reducing losses from illness associated with health inequalities. These currently account for productivity losses, reduced tax revenue, higher welfare payments and increased treatment costs.

6. Economic growth is not the most important measure of our country’s success. The fair distribution of health, well-being and sustainability are important social goals. Tackling social inequalities in health and tackling climate change must go together.

7. Reducing health inequalities will require action on six policy objectives: Give every child the best start in life Enable all children, young people and adults to maximise their

capabilities and have control over their lives Create fair employment and good work for all Ensure healthy standard of living for all Create and develop healthy and sustainable places and communities Strengthen the role and impact of ill-health prevention.

8. Delivering these policy objectives will require action by central and local government, the NHS, the third and private sectors and community groups. National policies will not work without effective local delivery systems focused on health equity in all policies.

9. Effective local delivery requires effective participatory decision-making at local level. This can only happen by empowering individuals and local communities.

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