Case Study

Common Ambition Bristol (CAB) is a programme initially funded by The Health Foundation, in partnership with:  

Brigstowe (lead partner): Bristol-based HIV support charity with strong track record of involving people living with HIV in design and delivery of services. 

African Voices Forum: network of community organisations from different cultures and faiths aiming to amplify voices and empower people to take part in policies and initiatives that concern them. 

Unity (NHS): Bristol’s integrated sexual health service; includes STI and HIV testing and treatment. 

University of Bristol: responsible for formative and summative evaluations plus iterative measurement and feedback to improve programme delivery. 

Bristol City Council Public Health: has city-wide sexual health commissioning and wider public health role facilitating community and institutional engagement, ensuring ‘whole systems’ approach to delivery. 

Bristol Health Partners: strategic collaboration between universities, providers, commissioners, councils and people with lived experience, which provides a mechanism for change in our health and care community. 

CAB is working in equal partnership with African and Caribbean Heritage Communities (ACHC) and sexual health professionals to co-produce new ways of increasing HIV awareness and testing and tackling HIV stigma. 

New thinking: CAB has invested in a holistic ‘co-production plus’ approach, and applied this to a challenging, highly stigmatised area of health amongst an underserved community. This approach goes beyond the core principles of co-production: putting lived experience in the driving seat and championing community involvement across the system.

Leadership: Senior leaders from partner organisations play an active role alongside community members, inputting to advisory and project meetings, providing oversight and support, enabling system change to ensure that decisions can be implemented quickly. Partners come together to provide leadership and direction. 

Outcomes & Sustainability: CAB is co-producing adoption and spread strategies to share learning across the system. CAB is working closely with commissioners to ensure that knowledge generated is included in the service specification developed for the local sexual health service recommissioning process. Partners are networking out to embed new knowledge and ways of working.

Involvement & Inclusion: CAB takes pride in embedded community involvement. Community members lead the delivery of the project: from outreach to setting up two dedicated clinics. The project co-ordinator, outreach workers and community researchers are all from ACHC. CAB is committed to empowering the community and using learning to address inequalities faced by those who use sexual health services and beyond. 

Transferability & dissemination.CAB is ensuring that learning from the programme is disseminated locally and nationally.  Team members are meeting and discussing with, and presenting and publishing to, diverse stakeholders from academia, health and care, local authorities, community groups. 

HIV inequities persist among UK African and Caribbean heritage communities (ACHC) in the UK, leading to disproportionately high rates of HIV, late diagnosis and limited access to HIV testing and pre-exposure prophylaxis (PrEP). The Common Ambition Bristol project aimed to tackle these inequities, by co-producing and co-delivering interventions with the ACHC to reduce HIV stigma and increase HIV testing and access to PrEP. The four CAB interventions involved multimedia resources; targeted health promotion; community outreach; and accessible testing.    

African and Caribbean heritage communities (ACHC) are disproportionately affected by HIV in the UK. In 2021, 37% of new HIV diagnoses among heterosexuals in the UK were from ACHC, despite ACHC making up only 4% of the population. In 2021 the proportion diagnosed late was highest among people of Black African ethnicity (55%) with negative consequences for health. The government set a goal of ending new HIV transmissions by 2030. Their 2021 HIV Action Plan emphases addressing ACHC HIV inequities and recommends i) culturally sensitive education programs, ii) reducing HIV stigma, iii) culturally sensitive community testing and iv) supporting community led initiatives. 

CAB is based on co-production. A Project Delivery Group (PDG) of community members is working with sexual health professionals to help decrease HIV stigma and increase testing. The PDG is designing and delivering interventions, including community outreach, targeted health promotion and ACHC-specific sexual health testing clinics. Community researchers are evaluating how effective these interventions are. 

The interventions are guided by research about how to change behaviour. They aim to lower HIV stigma and increase HIV testing and people using PrEP. 

•  – Multimedia resources – CAB film, printed materials, radio adverts, and website that includes information on sexual health, HIV, HIV myth busting and testing options 
•  – Targeted health promotion – CAB community-based events, combining education and a social space where HIV was openly discussed. 
•  – Community outreach – CAB outreach team weekly sessions attending more than 30 ACH business, providing testing social role models, distributing instant HIV self-tests, CAB condoms and promoting the CAB website and clinic. 
•  – Community accessible testing – dedicated CAB drop-in ACH community sexual health clinic, and changes to existing NHS sexual health services. 

The EIDO leaflet is used by trusts throughout the UK, thus sharing learning outside of the organisation. There have been no further local complaints received relating to this issue since interventions have been implemented. Additionally the most recent patient survey (2017) indicated that 100% of patients were either completely satisfied or satisfied to some extent with the consent process for this procedure. The team have also introduced ongoing monitoring of patient awareness of how to withdraw consent through annual patient survey.

Patient Satisfaction Survey Results

On average around 100 patients are surveyed per year, about their experiences at the endoscopy unit. Patient comments:
“The leaflet explained the procedure in a manner which was easy to understand” – Annual Survey 2017.

“I found I understood all of the information given out. Very satisfied with everything given”
Annual Survey 2017.

“Full information provided by Consultant and information leaflet about the procedure” Annual Survey 2017.

“It wasn’t explained to me, but the leaflet said you could put you hand up to stop the procedure”
Annual Survey 2017

“Withdrawal of consent was discussed prior to procedure in the treatment centre – private room”
Annual Survey 2016

“The information was in the leaflet, I cannot remember being told verbally, but I’m not quite sure”
Annual Survey 2016

HIV and sexual health are still taboo subjects in many marginalised communities, not only ACHC. These communities are not homogenous but have varied intersectionalities. Each area of the community CAB works with has its own needs and challenges, but all deserve equity, and good service provision.  

CAB is powered by the community, with the elevation of the community at its heart. As the programme has progressed, it has impacted on many lives. CAB has improved knowledge, increased wellbeing, improved health, empowered communities and impacted inequalities.   

These impacts normalise this way of working in future. The programme tackled life-changing areas, both within a specialised and heavily stigmatised medical field, and navigating the complexities and intersectionalities of race, discrimination, inequalities, inequities and social deprivation. The work is nuanced, creative, essential, and important. 

CAB is keen to recognise the input of community members, who are using their connections, knowledge and time to ensure that the work resonates with and is accessible throughout the community. 

The programme team is committed to continuing dissemination of this learning by developing a robust adoption and spread strategy: taking every opportunity to share learning, transferable across health condition areas, and to different geographic areas working with ACHC. 

CAB’s community members are not just members of their respective communities, but a valued and indispensable part of CAB. Their involvement has been vital to the success of CAB, enabling a sustainable, authentic and valued programme of work that resonates with the community.  

Community member involvement has proved a valuable two-way learning process. Being part of the programme is enhancing their skill set, knowledge, and ability to influence. In turn, researchers and health professionals have been exposed to, and embraced working in different and culturally sensitive ways. 

One of the reasons for the project was the lower rates of HIV testing amongst ACHC.  Through ideas from our paid Community Members, we have increased attendance at our drop-in testing clinics which are now regularly full, with extra people being given a postal testing kit.  This huge success has been achieved through the dedication and commitment of all the partner organisations and individuals involved in CAB.   

Representation matters: Representation, in every sense, is crucial in any programme that works with marginalised communities. It has an impact on partner organisations, which must consider their level of representation internally and externally if they are to become part of the solution not the problem. 

Co-production must be meaningful: CAB is based on genuine co-production, which involves active participation of individuals and communities in designing, developing, and implementing interventions, services, or initiatives through equal and reciprocal relationships. 

The team has conducted interviews and observations and has learning to share based on over 4 years of meaningful co-production. This includes issues around shared decision-making, power-sharing, roles, responsibilities, communication and capacity-building.  Community members must be paid to facilitate and value their involvement.  

Trust and relationships take time to build: Time is required to build trust and relationships, particularly when working with groups experiencing systemic discrimination. 

Leaders must buy-in to change: Senior leadership involvement is crucial to enable system change and resource allocation and respond to the voices of those involved.