Vitality is a holistic health and wellbeing service for South West Essex, which supports individuals to improve their health by making simple lifestyle changes.
The service was developed as a result of a research exercise to understand barriers to quitting smoking. However, this research identified that residents did not want a service directed only at smoking cessation. Instead they wanted a lifestyle programme that integrated healthy eating, smoking cessation, exercise and alcohol advice.
In response to this, the Vitality brand was developed and now offers free local services including stop smoking support, weight loss groups, guided group walks and practical cooking sessions.
- Exceeded 4-week smoking quit targets by 32 per cent in 2007/08, 7.5 per cent in 2008/09 (with significantly increased target), and 12.5 per cent in 2009/10
- 412 per cent increase in call volume to smoking cessation services, from an average of 25 calls per month to an average of 132 calls within 3 months
- 6,000 telephone enquiries in 2008/09 and 9,000 in 2009/10
- 63 per cent brand awareness of Vitality among general public
NHS South West Essex is responsible for improving the health and reducing health inequalities for a population of 420,000 people across the Thurrock, Basildon, Billericay, Wickford and Brentwood areas. Its area covers a mixed urban/rural geography including the relatively affluent towns of Billericay and Brentwood and the relatively deprived towns of Basildon, Grays, Thurrock and Purfleet.
A 2008 Public Health Report highlighted that a 10-year gap in life expectancy existed between the most and least deprived areas in South West Essex. This is unsurprising given the high levels of deprivation in many wards within Basildon and Thurrock. According to the local 2006 Smokefree Basildon: Tobacco Control Strategy, Basildon had 6 wards in the top 20 per cent most deprived in England and Wales. Thurrock has a very similar demographic makeup and similar levels of deprivation to Basildon.
Behavioural risk factors, such as smoking, cause significant health inequality between people from different social classes. Not only do a higher percentage of people from a low socioeconomic status (SES) smoke, smokers who are from a low SES smoke for much longer than people in a higher SES. Helping people to quit smoking is thus a key activity in reducing health inequalities across South West Essex.
“What was a concern for the PCT (primary care trust) was that we cover a large area in which there are high levels of deprivation. We felt that not a lot of people from the deprived communities were accessing their local stop smoking service, and we were getting reports that smokers were going to hypnotherapists and acupuncturists and spending a lot of money, or purchasing NRT (nicotine replacement therapy) over the counter where again they were spending lots of money, whereas we were offering them free NRT. So we wanted to understand why it was they weren’t accessing our services and learn more about their smoking behaviour.” (Henna Ali, Health Improvement Commissioning Manager)
The overarching behavioural goal of Vitality was to increase the number of 4-week quitters in Basildon and Thurrock, and to meet the government’s required four week quit targets of 2,428 quitters during 2007-8.
Stakeholders that were identified for this project included:
- NHS Stop smoking service
- Primary Care Trust Board of Directors (responsible for commissioning services)
- PCT Provider services (responsible for delivering services)
- Local pharmacies
- Local doctors/primary care physicians
- Acute sector (local hospitals)
- Local councils
- Local schools
- Local businesses
- Local leisure providers
A steering group made up of key stakeholders from within the PCT and NHS stop smoking service was formed at the start of the project and held bi-weekly meetings. The steering group consisted of only those stakeholders who had direct involvement in the project. Other stakeholders were engaged with every month or two. As the project progressed, additional stakeholders were either identified by the steering group or were self-identified to contribute to the programmes development.
This approach worked well as the group were able to make decisions effectively without too much interference from stakeholders who did not have a direct involvement in the project at that stage. This also helped with attendance of the steering group meetings as stakeholders were motivated to attend as it was in their best interest.
It was decided that the research findings were to be disseminated to as many senior people within the PCT as possible, to obtain buy-in for implementation of recommendations. Once buy-in was secured from the board and the local stop-smoking service, research was disseminated to the regional Smokefree Alliance (an organisation based locally with representation from key stakeholders working in the field of tobacco).
Over the years, NHS South West Essex has used several media campaigns to promote the local stop smoking service. However, despite these efforts the number of people accessing the service had remained roughly constant.
In an attempt to explain this, NHS South West Essex carried put research to understand why more smokers were not attracted to the cessation service, and whether this was due to the nature of the advertising campaigns or to the actual services being offered.
The objectives of this research were to:
- Understand the barriers that local residents from deprived communities face in quitting cigarettes (particularly people of a low SES, living in Basildon and Thurrock)
- Explore how the barriers to stopping smoking might be overcome through improved service delivery
- Develop individual level and population level public health campaigns to increase the number of people quitting cigarettes
- Evaluate the effectiveness of public health campaigns and develop better communication with the target population
A literature review was conducted by the programme lead at NHS South West Essex from July 2007 50 January 2008 to identify what the barriers to quitting smoking were and to identify effective methods used to overcome these barriers. However, what the literature review found was that that although there was a significant amount of insight about what the barriers were, there was not a lot of literature on how you may overcome them.
As a result, a qualitative study with potential service users was commissioned to identify methods to overcome these barriers. The study included the use of semi-structured focus groups with open ended questions. The reason for selecting this model was that this type of research is inductive, generates hypotheses and has a focus on how and why things happen, rather than that they happen.
The research aims of the qualitative study were to:
- Understand the barriers that local residents from deprived communities face in quitting cigarettes
- Explore how these barriers to quitting cigarettes might be overcome
A marketing company was commissioned to recruit participants from lower socioeconomic communities for six focus groups, with the following characteristics:
- Males over 30
- Males under 29
- Females over 30
- Females under 29
- Pregnant women (two focus groups)
All focus group sessions were voice-recorded and transcribed, before being analysed using abbreviated Grounded Theory, which enables researchers to analyse individual and interpersonal processes and look at how they are developed, maintained or transformed.
The focus groups revealed some of the barriers that were inhibiting successful quit attempts, ways in which the target population felt these barriers might be overcome, and their reactions to different marketing approaches.
Research findings were disseminated to senior staff within the PCT to obtain buy-in to implement the recommendations. Once buy-in was received from the board and the local stop smoking service, research was shared with the regional Smokefree Alliance.
“I needed lots of stakeholder support. So from October until December time I started presenting to board level, SMTs and other partners. The key was to disseminate the findings to as many people as possible, so they were aware of: a) what the research was about; b) what we found; and c) what we should do about it.” (Henna Ali, Health Improvement Commissioning Manager)
The most fundamental insight identified in the focus groups was that people did not want the stop smoking service on offer, but instead wanted a more holistic approach to health:
“Having listened to potential clients’ views we realised that the way our services were currently running was in direct contrast to how our target group would like them. They wanted to access an integrated service, a service which could look at their health in a holistic manner. Our biggest stumbling block was working in silos. As individual teams we were running a great deal of services, but if we could come together and integrate these services we could become much more effective.” (Henna Ali, Health Improvement Commissioning Manager)
Focus group participants associated their smoking behaviour with a number of factors, including weight gain, stress management and alcohol. They held a common view that by quitting cigarettes, they would gain weight, become more stressed and enjoy drinking alcohol less:
“I’d rather smoke than be fat”.
Because of these interrelated factors, focus group participants wanted a support service that was similarly cross-cutting.
This insight informed the decision to develop a new service that was dedicated to overall health and wellbeing, rather than just smoking, and that offered attendees individualised care and support.
- Smoking was viewed as a reward
- Blame minimisation – Some smokers did not take responsibility for their smoking
- Some smokers labelled themselves as a ‘social smoker’ and thus did not view their smoking as a problem
- Healthcare professionals were found to be judgmental, sometimes patronising, and dictatorial in their attitude to stopping smoking, which discouraged people from accessing services
- Smokers felt they could not speak to their GP regarding smoking, due to the
- professional’s negative body language and feeling rushed during health appointments
- Many smokers had low self-esteem and lacked confidence in their own ability to quit smoking, claiming they did not have the willpower needed to quit smoking and feared failure
- Female research participants said they would be influenced by materials that were graphical, gruesome, factual, made reference to ageing and focused on children
- Male research participants said they would be influenced by materials that were more subtle and made reference to men’s issues, such as impotence
Research identified why people continue to smoke and why they are reluctant to make quit attempts. This understanding allowed the development of a responsive service that addresses some of the barriers to quitting and offers an alternative set of incentives.
“Cigarettes are a reward”
Individuals from low socioeconomic backgrounds can have a restricted range of opportunities available to ‘reward’ themselves. Smoking is seen as a reliable reward, especially amongst women:
“Once the kids have gone to bed, lighting up a cigarette, in peace, is ‘me-time’.”
“Giving up smoking feels like parting from a friend.”
In addition, individuals can lack confidence in their ability to give up smoking and to replace it with an alternative rewarding activity.
In response, Vitality emphasises the rewards and benefits of not smoking (including reduced stress, higher energy levels, generally feeling better, and improved skin, hair and nail condition) by shifting the focus to overall health and wellbeing.
The Vitality team also highlight the financial benefits of quitting smoking, undercutting the excuse that ‘it costs more to quit than to smoke’ by reminding smokers that a pack-a-day smoker will spend £162 a month on cigarettes (£1,913 a year) whilst the Vitality services and NRT scheme are absolutely free.
“Healthcare professionals are off-putting”
Research participants claimed that one of the key barriers to quitting is the lack of empathy from healthcare professionals.
“I don’t want go to my GP about giving up cigarettes. They are just patronising and give me a lecture.”
Some women also reported that whilst they were pregnant, midwives told them not to quit as the stress could harm the unborn child.
In response, Vitality offers training to GPs and midwives to improve their body language and approachability. The smoking cessation service also avoids holding sessions in clinical settings and medicalising the issue, instead offering more one-to-one opportunities and sessions for couples who want to give up together.
In all its work, Vitality offers the end reward of a happier, healthier lifestyle – not just of a non-smoking lifestyle:
“Just about everyone we know, including us at Vitality, want to be healthier and happier. Whether you just want to tackle one particular problem or take a whole look at the way you live, we can help you stop the rot and start working towards a better life.” (Henna Ali, Health Improvement Commissioning Manager)
There are many sources of competition for any stop smoking service, including:
- Smoking is an addiction
- Enjoyment of cigarettes
- Low threat perception
- People’s willingness to pay for alternative therapies, such as hypnosis and acupuncture
- Other concurrent stop smoking promotions
However, research from focus groups identified that the most significant source of competition for the programme was the issue of brand recognition. People were confusing the original stop smoking service promotions with other smoking cessation promotions running at the same time (such as Tesco’s and Boots’ promotions on NRT products). They were also failing to connect all of the different advertisements that the PCT had run to promote its services, as there was no unifying brand. Instead, each stop smoking team was referring to itself by location (such as Thurrock Stop Smoking Service or South Essex Stop Smoking Service).
Research participants identified that they did not have confidence in their own ability to quit smoking. The participants claimed to lack ‘willpower’ in order to quit smoking and feared failure. The majority of the research population were from lower socio-economic groups and it was found that these participants had a very restricted range of opportunities available for reward. As smoking is seen as a reliable source of reward, they did not have confidence in their ability to quit smoking and replace it with another rewarding activity. The programme team would thus need to build a strong exchange element into the marketing mix, in order to offer an appealing and achievable alternative to smoking.
"I’ve tried before and can’t give up"
Low self-esteem and self-belief were identified as common barriers to quitting, especially if a previous failed attempt had been made.
In response to the belief that ‘if you've failed to quit before, you'll never stop’, Vitality emphasises that it usually takes people at least two tries before quitting for good, and that by using the help of the Vitality stop smoking service individuals are four times more likely to succeed.
Revised aims and objectives
Research was initially conducted to identify barriers to quitting smoking. However, what this research indicated was that residents did not want a service directed only at smoking cessation. Instead they wanted a lifestyle programme which integrated healthy eating, smoking cessation, exercise, stress management and alcohol advice.
Although the overarching goal of Vitality was to meet the Government’s required 4- week quit targets of 2,428 quitters during 2007/08.
As a result of the findings from the scoping study, the programme now aimed for the selected target audience to:
- Give up smoking
- Adopt a healthier diet
- Introduce exercise into their lives
To measure these outcomes, Vitality aimed to prompt individuals to:
- Call the freephone number to seek further information and make an appointment (with an aim of achieving 100 calls or more per month)
- Access the www.lovevitality.org website
- Refer themselves online
Service specification for the programme in 2010 included:
- 50 per cent 4-week success rate
- 30 per cent success rate at 54 weeks (for those who quit at 4 weeks)
- 45 per cent quit rate for pregnant smokers
- Alcohol: 1,000 screens
- Cardiovascular disease (CVD): 80 per cent completion rate for preventative rehabilitation programme
- Cooking skills programme: 60 per cent retention rate on course, and for 45 per cent (of starting participants) to have sustained lifestyle changes at 3-month follow-up
NHS South West Essex understood that the ‘one size fits all mantra’ simply does not work when it comes to health promotion. Based on the research, they hypothesised that in order for the service to be successful, they would need to evolve the services it was offering to the public, and evolve the way in which it marketed these services. Working in silo’s was not delivering the results they had wanted, and user research had demonstrated that the health improvement team needed to adopt more integrated working practices and service delivery.
Based on the insight generated from the focus groups, the changes made to service provision were divided into two categories;
- Service reconfiguration
It was agreed that, instead of a traditional stop-smoking service, a lifestyle programme which integrated factors such as healthy eating, smoking cessation, exercise, stress management and alcohol advice would be developed. If people were reporting that they would ‘rather be a smoker than be fat’, then the PCT needed to provide them with help and advice on healthy eating and exercise, alongside smoking cessation advice.
Based on feedback, it was concluded that this integrated programme would work best if it was tailored to individuals’ needs. It was also important to increase self-control and self-efficacy within the population. It was proposed that this could be done by providing them with a lifestyle programme which would make them feel healthy and emphasise all round well-being.
The health improvement team recognised that the treatment pathway would need to be reconfigured in order to support these changes and proposed a new customer pathway into and through the new service (illustrated in graph below).
The new service pathway is outlined in the following steps:
- Referral and health needs assessment - having been referred into the service by a frontline health professional, individuals complete a ‘Health Needs Assessment Questionnaire’ (HNQ). The HNQ is conducted by a ‘Vitality’ staff member with all patients who have been referred into stop-smoking services (and now other services too, such as the obesity service). It was also intended that this questionnaire would be made available online when the fully integrated service is launched, allowing individuals to self-refer to services. A pilot of this online assessment programme is currently under development.
- Service Selection - Based on the results of their HNQ, individuals are able to access a complementary suite of ‘Vitality’ services, including smoking cessation; nutrition; exercise; alcohol; stress; and cardiovascular disease management.
- Lifestyle Modification - All ‘Vitality’ services encourage and empower clients to use the ‘Lifestyle Goal Setting Tool’, which helps the individual to plan and implement long-term lifestyle modifications, so that any changes they make whilst engaged with services can become part of a longer-term solution.
Although the initial plan was to develop a new smoking cessation services, it was conceded that ‘Vitality’ should also provide;
- 8 walking programmes running per week
- 12 weight management programmes running per week
- 8 cooking skills programmes running per week
- Two week waiting list for in house weight management
- 16 stop-smoking drop-in sessions running per week
Programme planners were also aware that there needed to be an increase in service choice, via options such as one-to-one sessions, couple only sessions (as people wanted to quit with their partner and not in groups), trail sessions (to allow people to make up their minds and boost their confidence in available services), and telephone support. Services were then developed in response to these insights, and telephone and internet support services were also made available.
To respond to issues around interaction with health professionals, ‘Vitality’ also provided training for GPs and midwives, to raise their own self-awareness about their body language and the tone in which they offer information. Both GPs and Midwives are important influencers for ‘Vitality’, and the training draws heavily on undertaking role play, as evidence suggests that this is an effective training approach.
Research revealed the need for a strong, unified brand for the new holistic lifestyle service. Therefore, in addition to these substantial service modifications, a strong promotional element would have to be included for the service to be successful.
In response to this, it was agreed that one easily identifiable and well-recognised brand should be developed to promote the newly integrated services. A local advertising agency was commissioned to design several brand options that were pretested with members of the community using a feedback questionnaire. The brand that was chosen was - ‘Vitality: Your local health and well-being service’.
To ensure that the new brand was widely recognised and understood, it was decided that a wide mix of promotional activity should commence in March 2008 and continue throughout the year. These activities included elements of; media relations, outdoor advertising, print advertising, telemarketing and a ‘Vitality’ website.
Since being initially launched in March 2008, the number of programmes under the vitality brand has significantly increased; reflecting the extent to which the programme has snowballed beyond its original scope, to redesign the stop smoking service. As the programme continues to gain reputation, additional new services will be further integrated, so that clients can access an increasingly wide selection of support under a single umbrella brand.
Vitality is now a one-stop-shop for health and wellbeing, providing users with help and advice on healthy eating, exercise and alcohol, alongside smoking cessation advice. It is an integrated programme that can be tailored to all individuals according to their needs. Individuals can access a complimentary suite of Vitality services, including smoking cessation, nutrition, exercise, alcohol and CVD management.
The Vitality stop smoking services provide free support and advice including:
- Free access to local stop smoking groups
- Free stop smoking help kits, including NRT patches, gum and other stop smoking prescription medicines
- Couple-only sessions
- One-to-one support
- Drop-in sessions
The service has been modified to better meet user needs, including extended evening and weekend sessions, as well as telephone support if required.
Weight management courses were offered, as well as free courses for learning healthy cooking skills and improving eating habits. These include:
- A structured weight management programme that includes practical demonstrations, games and tips about healthy foods (such as label reading and portion sizes), as well as weekly physical activity taster sessions
- A free ‘Bite Size Cooking Course’, teaching cooking basics and easy recipes
These programmes aim to provide long-term solutions, rather than quick-fix diets.
- Walk This Way – Free guided group walks in and around the Thurrock and Basildon area, encouraging people of all ages to get more active and build new friendships
- Free three-months gym membership
- Women's physical activity programme – A 10-week programme especially designed for women, to help them identify and achieve their health goals
- Access to MEND – Aimed at helping young people and their families get fit and stay that way (weekly games, activities and swimming for children)
- Screening to identify at-risk or harmful drinkers and allow them to take management of their risk level
- Intervention and brief advice, tying into the Department of Health’s (DH’s) national alcohol strategy and using motivational interviewing techniques
An integrated service for individuals scoring high on a CVD risk assessment. Those eligible can access a free 12-week Healthy Heart course that includes exercise, relaxation and information talks, all designed to help people reduce risks like high blood pressure and cholesterol and thus reduce their risk of CVD.
In addition to these substantial service modifications, a strong promotional element underpins Vitality to ensure that the new brand is widely recognised and understood. The marketing activities started in March 2008 and messages and imagery were adapted throughout 2008/09 to reach different groups.
Promotional activities have included:
- Media relations – Press releases, coverage in local newspaper, online news website coverage
- Advertising – On buses, bus shelters, billboards in central locations and half billboards in supermarkets
- Direct mail – Targeting all households, businesses with more than 20 employees and all schools within the area. Schools were targeted because female focus group participants said they read all the materials their children bring back from school with them. In total, businesses and schools have so far requested 40,000 Vitality booklets
- Newspapers – Advertising across all local newspapers, and an advertorial in the women’s section of the highest circulation local newspaper every month (as women said they always read this section of the newspaper)
- Vitality website – Providing information about all current services and allowing people to refer themselves online
Training for health professionals
Vitality provided training for GPs and midwives, emphasising their body language, the tone in which they offer information, and the content of this information.
The success of Vitality was evaluated using a range of outcome measures, including:
- Number of calls to the freephone number, allowing evaluation of the impact of marketing work
- Awareness questionnaires to ascertain brand recognition
- Number of people joining the service, completing programmes and successfully quitting smoking
This data was compared to benchmark data collected prior to the launch of the new service.
Results to date
Prior to the service redesign, the stop smoking service was hitting the 4-week quit target but often by only a small margin. Since the launch of Vitality, the service has exceeded its 4-week quit targets:
- 2007/08: Exceeded the 4-week quit target by 32 per cent
- 2008/09: Exceeded the 4-week quit target by 7.5 per cent (despite significantly increasing the set target by 774 quits)
- 2009/10: Exceeded the 4-week quit target by 12.5 per cent
Calls and website hits
- 412 per cent increase in call volume to the smoking cessation service, from an average of 25 calls per month to an average of 132 calls within 3 months
- 6,000 telephone enquiries in 2008/09, and 9,000 in 2009/10
- 7,303 hits to the website between March 2008 and March 2009
Overall 63 per cent brand awareness of Vitality among general public.
Following the development and evaluation of the project, every six months commissioners and providers organise and attend a half day event to discuss and address potential issues with the service.
The project team have disseminated and presented the project and findings at many conferences, such as; the UK Public Health Conference, East of England Strategic Health Authority conference, International Psychology conference and the UK National Smoking Cessation conference. As a result, other PCTs have contacted and met up with the team to share detailed learning’s from the project.
The project team are now working with community pharmacists to further integrate services in front line services.
The ‘Vitality’ branding was deemed a great success for both uniting the branding of local stop smoking services in the area and for the recognition it received from the general public.
The emphasis on holistic wellbeing has been highly beneficial as people live busy lives and having a one-stop-shop is very appealing.
Building a shared vision of the ‘Vitality’ programme amongst the different teams (smoking, alcohol and obesity) has been key for developing a strong programme:
“You need to have a shared vision. You need to set the vision from the very start and make sure that everybody shares that.” (Henna Ali, Health Improvement Commissioning Manager)
By bringing these separate services together under one brand, not only did ‘Vitality’ offer an improved customer experience, it also improved the effectiveness and efficiency of public health delivery and commissioning.
This is evident from the impact on the 4-week quit rates in South West Essex that demonstrates the programme’s success.
Getting all stakeholders on board can be problematic and time consuming, but is vital:
“They need to get senior management support, because if you don’t have that there’s no way you can get this kind of work through, especially when you’re changing the way you commission services or you’re changing structures of departments.” (Henna Ali, Health Improvement Commissioning Manager)
People are often used to working in silos, whereby people from different teams (e.g. smoking, weight management, alcohol support, stress management, etc) worked as completely separate entities, without much coordination and often with significant cross over and duplication. It is difficult to start them thinking about working in a more holistic manner and hence training staff is crucial when integrating services.
Staff were trained in health areas where they lacked confidence, or had no previous training, to ensure that they were comfortable discussing and delivering a wide range of services to their clients (e.g. obesity, stress management and nutrition, rather than just smoking cessation).
Without this investment in developing the skills sets of frontline staff, the ‘Vitality’ service could not have grown beyond its original scope as a simple smoking cessation service.
This project was very ambitious and it took considerable time to get systems in place and fully functioning:
“It takes a long time. If you think it’s a quick thing – it’s not. Be realistic with timelines and don’t think you can do this overnight.” (Henna Ali, Health Improvement Commissioning Manager)