COMMUNlTY HEALTH STUDIES VOLUME X N NUMBER 2,1990

THE ROLE OF COMMUNITY EDUCATORS I N ACHIEVING AUSTRALIAN HEALTH GOALS: A PUBLIC HEALTH APPROACH TO WEIGHT CONTROL ON THE NORTH COAST, NSW

Ray James, Eric van Beurden, Cave Steiner. Colin Tyler and Karen Fardon

Heart Health Program. North Coast Health Region, 31 Uralba St., Lismore 2480.

Abstract This paper describes the recruitment, training

and supervision of Community Educators for weighttontrol programs, reports the results they have achieved to date. and offers suggestions for improving similar programs. This material is discussed in relation to suggestions about nutrition published by the Better Health Commission.

Introduction Cardiovascular diseases related to lifestyle are

responsible for a large percentage of disability and premature deaths in Australia.' There i s overwhelming evidence that smoking. elevated cholesterol levels, obesity. poor nutrition and hypertension directly contribute to the prevalence of cardiovascular disease (CVD) in Australia.'4

A report issued by The Better Health Commission (BHC) in 1986 indicated that poor nutrition and obesity play a primary role in the development of coronary heart disease and together, cost the community over 6 billion dollars a year in lost productivity and medical costs.' The BHC outlined dietary goals for Australia which include better eating habits (less sugar, salt and fat) and a reduction in the prevalence of obesity. Work by Kannel and Gordon indicates that, aside from smoking control, obesity is probably the most important risk factor for CHD because of its association with hypertension, hyperlipidemia and diabetes.' Studies by the National Heart Foundation (NHF) indicate that nearly 40 per cent of the Australian population is overweight and 7 per cent can be classified 'obese'.'

Behavioural research conducted during the last 25 years indicates that individuals can be helped to initiate weight loss although long-term maintenance is still a problem. Obese individuals are taught to monitor eating patterns, body weight and physical activity. They are also helped to develop skills in goal setting and problem

Positive results have also been found in weight-control interventions with small groups.

Solving.'

JAMES et al. 146

Research conducted by Stunkard and colleagues indicated that clients in small groups who received behavioural therapy were better able to maintain weight loss than control groups who received pharmacotherapy (fenfluramine).' Brownell's work indicates that behaviour-based weight-control groups are equally as effective for children as they are for adults.

Recently there has been a great deal of interest in work-site interventions for nutrition education and weight-control. A special issue of the Journal of Nutrition Education published in 1986 reviewed the major programs in this area and Foshee et al. have evaluated nine studies dealing specifically with worksite weight-loss pro- grams."." These programs reported absolute weight loss from 0.22 to 1.63 kg per week. One of the most interesting results was from a study by Stunkard and Brownell who reported that attrition was less in groups run by lay therapists." Peterson et al. have reported that lay volunteers trained to conduct self-help groups did as well as trained health professionals."

There is now abundant evidence that behaviour-based weight-control programs can produce significant weight loss in the majority of obese participants. Key issues for community- based nutritionists and health educators are: whether it is possible to offer weight-control programs to sufficiently large enough numbers to make a public health impact and whether this can be done in a cost-effective manner. Matarazzo has discussed many of the problems that behaviour- based programs face when attempting to change population trends and values." Programs need to be developed which: (a) produce clinically significant weight loss and maintenance. (b) can reach large numbers of people. (c) are cost- effective, and (d) can be easily duplicated in other areas. In 1985, at the International Symposium on Nutrition and Obesity, Albert Stunkard argued strongly that behavioural technology can be "easily taught and applied" and that "lay-led groups" are an important resource for the public health control of obesity."

COMMUNITY HEALTH STUDIES

The North Coast Region The North Coast Health Region covers 32.000

sq km and includes a population of 353,000 in north-eastern New South Wales. The Region has a higher than average percentage of elderly or retired persons, single parents, unemployed. disabled, pensioners and aboriginals. It also has the highest rate of population increase in NSW." Surveys conducted in 1987 and 1988 indicate that at least 45 per cent of the population has elevated blood cholesterol levels and 46 per cent of the population have a body mass index over 25. These are clear indications that public health interventions are needed to reduce obesity and elevated blood cholesterol levels and to improve the nutrition status of the population. The Community Health Education Program (CHEGS) is one approach; other strategies have been reported elsewhere.Ww

Communlty Health Education Programs (CHEGS)

The main strategy for dealing with obesity in the North Coast Health Region has been to run weight-control groups with trained Community Educators. These groups are run on a fee-for- service basis and the entire program is financially self sustaining. "community Educators" are trained lay people from the local community who are employed on a sessional basis to conduct health education programs for Area and Regional Departments of Health in NSW. Community Educators have been trained to run Stress Management Programs, Weight-Control Groups, Fitness Groups and Parent Effectiveness Training Groups.

The health education programs that Community Educators conduct are developed jointly by the educators and the professional staff of the New South Wales Department of Health. The North Coast Health Region sponsors and supports the CHEGS programs:

to increase community participation in health enhancing initiatives; to increase participation amongst particular target groups by including members of that group as educators; to further develop the skills of members of the community through "on-the-job-training"; to provide paid employment to members of the

to increase the effectiveness of health education programs by providing familiar 'models' in the community; to create a group of 'key informants' who can keep the health promotion planners aware of unmet health needs and interests and'

community;

JAMES et al. 147

to provide a cost-effective service that is not available within the normal resources of the Region.

Community Educators are most often recruited from participants in existing programs; occasionally they are health workers who are not currently employed. All potential Community Educators on the North Coast are interviewed by the project officer for CHEGS. and. if selected they are invited to attend a 5 day training workshop that covers group skills and specific content area. The workshop costs candidates $50. If they are then amedited by the training officer they are eligible to commence duty for which they are paid $40.00 per 2 hour session or $400.00 per 9 week group (including preparation time).

The North Coast CHEGS program has run one weight-control Leader Training Course every year since 1979 and 2 courses were run in 1988. During this time 135 Community Educators have been trained to conduct weight-control groups. The one male amongst these did not run a group. The Region has subsidised the program by paying parts of the salaries of a project officer and a half-time nutrition consultant. In 1982 a recipe book was compiled by the group leaders and a nutrition consultant. The income from the groups and from the sale of this book has financially supported the organisation.

When running groups, Community Educators follow a structured program that is contained in a manual which i s written for each separate content area. The North Coast CHEGS program has implemented weight-control, parenting skills, and fitness groups in the past but the Region is currently concentrating on weight- control groups.

Training for Weight-Control Leaders The training course provides information on

nutrition. behaviour modification techniques. food requirements for special populations, safe exercise guidelines and relaxation exercises. Those participants who successfully complete this training program are appointed as 'Community Educators' and encouraged to start weight-control groups in their own towns.

During their first year these leaders are required to attend either a Communication Skills Workshop (3 days) or a Group Leaders' Skills Course (5 days) which are provided by CHEGS. There is a formal agreement that leaders will renew their skills by attending a training program at least every two years. and many group leaders attend at least one of these each year.

COMMUNITY HEALTH STUDIES

Special 'Leader Training Days' are held during the course of each year for active Community Educators. These days provide time to discuss any difficulties leaders might be having, updates on diet and nutrition information, formative feedback on the groups and a special 'educational segment' on a relevant topic. The co-ordinator of the CHEGS program and the consultant nutritionist plan and conduct these training days. There are usually 7 of these days offered each year and leaders are required to attend the majority of these. This agreement has always proved beneficial for both the co-ordinators and the group leaders. Certificates are presented to group leaders when they complete their basic training. Some leaders have now completed over 100 hours of training in connection with CHEGS.

CHEGS Weight-Control Groups CHEGS Weight-Control Groups are designed

to provide appropriate information and social support for members of the community who are interested in weight reduction. Leaders are trained to assist participants to set realistic weight goals, eat a balanced diet, maintain an exercise program, and utilize behavioural modification techniques in order to maintain a 'desirable weight'. An important aspect of the CHEGS program is the flexible food plan which recommends an intake of a specific number of units from each of the five food groups but allows individual decisions about the combinations. The main emphasis in the nine 2-hour sessions is to provide participants with practical skills to maintain their weight after the completion of the course.

There have been 18.510 participants in the weight-control groups in 11 years; approximately 1.682 per year. Few men have joined the groups (2%) although those who do come seem to do very well; 53 per cent of the participants are between the ages of 31-49; 78 per cent are married and 22 per cent have an income average below $10,000 per year.

Evidence of Program Success In order to gauge the effectiveness of the

CHEGS Weight-Control Program we analysed all the available data from one term: February to April 1989. While similar data is routinely collected during the weight-control program it is no t usually possible to do such a detailed analysis. The Project Officer usually calculates the average weight loss per group, conducts two quality control audits per group leader, collects process feedback from the participants and conducts an evaluation session with the group leaders.

Research Design Participants for CHEGS Weight-Control

Groups were recruited via articles and advertisements in local papers, notices in community health centres and hospitals, and public service announcements. Cost for the weight-control program was $40.00 for 9 two hour sessions. Concessions were available for anyone on a pension or unable to pay the full fee. Participants were considered to have completed the program if they attended 7 or more sessions.

In order to estimate possible external influences on participants, a comparison group was also measured for weight loss. This group consisted of community members who had signed up for CHEGS Weight-Control Groups but who completed less than 4 of the sessions. These 'non- completed had all expressed an initial interest in weight control and had a similar socio-economic background to those who completed the Weight- Control Program.

Weights of all participants were taken at the initial meeting, at all sessions, and at the completion of the program with spring scales. (Seca 7-60) Subjects removed all excess clothing, shoes and personal objects from pants. Heights were measured at the initial session using a tape measure set on a wall poster. All measurements were taken by the group leader according to the protocol taught in the training sessions. BMI was calculated during evaluation.

Results A total of 707 North Coast residents

participated in the CHEGS Weight-Control Program during first term 1989 (February to April); 85 per cent of these had a BMI over 25. The majority of these were women (98%). their average age was 44 and 58 per cent completed the program. Sixteen males initially joined the program (2%) and 56 per cent of these completed the program.

The 41 1 participants who completed the weight-control program lost an average of 4.7 kgs during the course, or 0.52kg per week. This represented 6.1 per cent of their commencement weight. Just over half of the completers (53%) were able to achieve their goal weight.

A total of 108 participants who entered the weight-control program but did not complete at least 4 sessions were eligible for the comparison group. From this 108. 48 were not able to be contacted after 3 phone calls leaving a total of 60 for the study. Of these 60, 12 declined to participate and 23 did not arrive for a weigh-in at the appointed time. This left a comparison group of 26. This group is well matched with the

JAMES et al. 148 COMMUNITY HEALTH STUDIES

TABLE 1

Comprboa of CHECS partklpantr who compkted program altb thosc who attended 4 or lcfs d o a s

Compkters Noa-Complcters n = 411 a = %

Mean Age (sd) Female Mean Weight (sd) Man BMI (sd) % who lost weight Man loss (sd) % .arining desirable weight % attnbhg 53% goal weight

sd = standrrd deviation

44 98%

76.4 kg 29.4 97%

4.7 kg 37% 53%

experimental group and initially expressed a desire to lore weight. (see Table 1.)

Ninety seven per cent of the 'completers' reduced their weight and 37 per cent were able to reduce to a desirable level (c25 BMI). Among the non-completers 65 per cent reduced their weight but none of these were able to reduce below 25 BMI.

When weight loss for the experimental p u p is corrected by the loss achieved by the non- completers. the adjusted estimate is 3.6 kg. Because all of the comparison group attended at l w t the initial session. when weight-loss goals were act, this figure may be a conservative estimate of the weight reduction that can be directly attributed to the CHEGS Weight-Control

DLsca~rion These results compare fsvourably with other

behaviour-based weight-control groups reported in the literature. Foreyt e t al. reported that completus in a program run by dietitians lost 0.53 kg per week (women).- Stunkard e t al. have shown that participants in a behaviourd therapy group reduced by 0.45 kg per wed? and Peterson et al. reported a reduction of 0.39 kg per week in groups run by lay volunteers and a reduction of 0.36 kg per week in groups run by trained profersionals.14 A review of these and other studiu is shown in Table 2.

While our results may be biascd by the number of drop-outs (42%). other studies that we have reviewed indicate that attrition ram of 40 per cent to 80 per cent are normal for weight-control

Program.

51 (12) (12)

(5.0) 29.5 (5.0)

100% (13.4) 77.0 kg (13.9)

65%

1% 0

(2.3 1.1kg (1.8)

groups.'4 Schachter and Peterson et d. emphasize that behaviour change is a "complex ongoing process, and p g r u n r should not be evaluated in isolation as if the individual's present effort was 8 one-shot d ~ a l . ' ~ J ~ It may be that a person needs to enter programs like this a few times before they are ready to make the necessary changes. Low- cost weight-control programs consistently delivered in a person's local area make this possible.

It rppurs from our ruearch that the CHEGS weightcontrol program is achieving its two most important goals: (1) that of assisting North Coast residents to lose weight and; (2) of successfully training Community Educators to assist in large scale public health programs. Our impact evaluation indicates that participants are losing weight (at least 3.6 kg over 9 weeks) and our

Educuors m pleased with heir role md would, in fact like to be trained to run other, similar. groups for the community. One of the key remarks in evaluation feedback is that the leaders have gained status in the community from being 'certified' weight-control l e d a s .

The success of the CHEGS Weight-Conk01 Program can be linked to an understanding of the behaviour-change process and the important role of modelling which is provided by the Community Educators.

Changing health behaviours is a difficult activity. especially since participants have different psychological orientations, motivations and aspirations. While the concepts of health behaviour change are complex and sometimes

process evaluation indicates that the community

JAMES et al. 149 COMMUNrrY HEALTH STUDIES

TABLE 2

Cornpadson of present study With results of similar weight loss programs

Study Run by Duration n Completed Mean Weight Loss weeks (Kilograms per week)

Foreyt, et al.= PRO 8 6481817 (79%) .53 Stunkard et al? PRO 24 m 2 .45 Brownell, et a l . 'O PRO 16 38/42 (90%) .52 Peterson, et al.I4 PRO 16 18/30 (60%) .36

LAY 16 26/33 (79%) .39 Sumner, et alP PRO 8 771120 (64%) .34 This Study LAY 9 411/707 (58%) .52

pro =professional (dietitian, psychologist, etc.) lay = lay leader

contradictory21 we believe that to initiate and sustain a change in health behaviours an educational program must increase the participant's skills in goal setting, decision making and behavioural techniques in addition to improving specific skills in fitness, nutrition, smoking cessation. or stress management.= In addition, the program must also increase the participants' self esteem and confidence in their ability to make the necessary changes."

Self-esteem and confidence increase the will to make health-enhancing changes; goal setting and decision making skills provide a direct focus, while specific skills provide the proper tools. Community Educators play a major role in this process by presenting themselves as role models for their peers in the community."." Their involvement and success indicate to the community (in a strong verbal and non-verbal way) that people can make important changes in their lives. The presence of the Community Educator empowers the participant in a way that no other educational message can; truly, the medium is the message."

Conclusions The success of our Community Educators in

running health education groups indicates an important direction for public health efforts in the next decade. In order to reach a significant number of people we need more helping hands. By training lay people to deliver public health messages we not only reach more people in a

cost-effective manner but the very act of training and promoting these lay people empowers them in a way that increases the health of the whole community. One of the key problems for community development is to provide participants with meaningful and sustainable roles in worthwhile activities; training lay people, as Community Educators, to facilitate public health programs can provide one very important way to do this.

Our experience with the CHEGS Weight- Control Program indicates that the key points in running effective health education programs with Community Educators involves the following:

1. Community Educators need to be carefully selected, trained and supervised. Super- visors for Community Educators need to establish clear criteria for selection of Community Educators; they need to develop training programs and they need to provide supervision and feedback.

2. It i s l ikely that the staff selected to supervise the Community Educators need to receive in-service training in group process skills and supervision of volunteers.

3. Support from the loca l Department of Health is necessary to establish the 'credibility' of the program with the community.

4. Co-operation with local health staff helps ensure stability and continuity for the Community Educator's programs.

JAMES et al. 150 COMMUNITY HEALTH STUDIES

5 . Community Educators need to work from structured programs (and manuals) to give them clear guidelines.

6. Community Educators need to have ongoing support and supervision. preferably with at least one consistent person.

7. Community Educators need to have recurrent training to upgrade their skills, keep them motivated and to let them know that they are important. Our research indicates that health education

groups, run with Community Educators who are

adequately trained and supervised, can help participants make significant changes in their health behaviours. These programs can reach large numbers of people, are cost-effective. and can be easily duplicated in areas throughout the country. Perhaps more important than the clinical results for the participants, however, is the satisfaction that the leaders gain from helping members of their community lead healthier lives and from the knowing that all individuals can play an important role in the delivery of health care.

References

1.

2.

3.

4.

5.

6.

7.

8.

9.

Hetzel B, McMichael T. The L.S. Factor: Lifestyle and Health. Ringwood, Victoria: Penguin Books, 1987. Report of the Better Health Commission Vol 1: Looking forward to Better Health. Canberra: Australian Government Publishing Service, 1986. White CC. Tolsma DD, Haynes SG. McGee D. Cardiovascular disease. In: R. Wamler and B. Dill eds. Closing the Gap: the Burden of Unnecessary Illness. New York. Oxford: Oxford University Press, 1987. Heart Facts Report. Canberra: National Heart Foundation, 1986. English R. comp. Towards better nutrition for Australians. Report of the Nutrition Task Force of the Better Health Commission. Canberra: Australian Government Printing Service, 1987. Kannel WB. Gordon T. eds. Physiological and Medical Concomitants of Obesity. US. Department of Health, Education and Welfare: The Framingham Study, 1979; 140. National Heart Foundation, Risk Prevalence Study N0.2, 1983. Canberra: National Heart Foundation. 1985. Wing RR. Jeffery RW. Outpatient treatment of obesity: a comparison of methodology and clinical results. Int J Obesity 1979;

Stunkard AJ, Craighead LW. OBrien R. The treatment of obesity: a controlled ma1 of behaviour modification, pharma- cotherapy and their combination. Lancet

3:261-279.

1980; 1:1045-1047.

JAMES et al.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

151

Brownell KD, Kelman JH, Stunkard AJ. Treatment of obese children with and without their mothers: changes in weight and blood pressure. Pediatrics 1983;

Johnson DW, Johnson RT. The process of nutrition education: a model for effectiveness. J Nutr Ed 1985; 17 (supplement):5 1-57. Foshee V, McLeroy KR. Sumner SK, Bibeau DL. Evaluation of worksite weight loss programs: a review of data and issues. J Nutr Ed 1986; 1853943. Stunkard AJ, Brownell KD. Worksite treatment for obesity. A J Psychiatry.

Peterson G. Abrams DB. Elder JP, Beaudin P. Professional versus self-help weight loss at the worksite: the challenge of making a public health impact. Behaviour Therapy

Matarazzo J. Behavioral health’s challenge to academic, scientific and professional psychology. Am Psycho1 1982; 37:l-14. Stunkard AJ. Behavioural management of obesity. Med J Aust 1985; 142513321. Australian Bureau of Statistics Australia 1986. Canberra: A.B.S., 1986. James R. Tyler C. Van Beurden E et al. Implementing a public cholesterol screening campaign: The North Coast Experience. Community Health Stud 1989;

James R, Tyler C. Hendrikson D. Can public health work with GPs?: the North Coast Experience. New Doctor 1989;

71~515-523.

1980; 137~252-253.

1985; 16:213-222.

13(2): 130- 139.

50:15-19.

COMMUNITY HEALTH STUDIES

20. Foreyt JP. Mitchell RE, Gardner DT. Behavioural Treatment of Obesity: Results and Limitations. Behaviour Therapy 1982; 13:153-161. Schachter S. Recidivism and self-cure in smoking and obesity. Am Psycho1 1982;

Best JA, Cameron R. Grant M. Health Behaviour and Health Promotion. Am J Health Promotion 1986;1(2):48-57. James R. A theoretical model for the delivery of health education. In: Sheppard JL. Advances in Behavioural Medicine, vol 3. Sydney: Cumberland College of Health Sciences, 1986.

21.

37~436-444. 22.

23.

JAMES et al.

24. James R. Hightech - high touch: the self- care group and the healing process. Health Promotion 1988;3(3):269-275.

25. Bandura A. Social Foundations of Thought and Action: a Social Cognitive Theory. Englewood Cliffs, NJ.: Prentice- Hall. 1986. McLuhan M. Fiore Q. The Medium is the Message. Harmondsworth: Penguin, 1967.

27. Sumner SK, Schiller EC. Marr ER. Thompson DI. A weight control and nutrition education program for insurance company employees. J Nutr Ed 1986;

26.

18(1):60-62.

152 COMMUNITY H U T H STUDIES