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Promoting health improvement and tackling health inequalities: Local authorities perspectives - Evaluation of a pack for trainers

Executive summary

This evaluation study hasexamined a training pack which was devised to support capacity building effortsat local authority level, in promoting and delivering the Health Improvement(HI) agenda. This work stems from thevision set out in the strategic document, 'Local Authorities as HealthImprovement Organisations', COSLA, 2002. The rationale behind this paperconcerns the need to view HI as an agenda for joint delivery through a range oforganisations and agencies, and the specific role which local authorities canundertake.

The study was commissionedthrough a joint project by COSLA and the Health Education Board for Scotland(HEBS).

The training pack - fordelivery over one day - was tested and evaluated with seven local authoritysites, through exploring trainers' and senior managers' perceptions of the packat pre- and post-training stages. Specific areas for exploration included viewson the content and layout of the training pack, as well as recommendations forimprovement. More strategic areas forexploration included how the pack could be rolled out across local settings forsustainability and whether co-training partnerships would support successfuldelivery of the pack, as well as supporting its future sustainability.

Research findings at bothpre- and post-training stages were very positive, with trainers expressing verypositive views on the utility of the pack. A range of 'operational' changes to the pack were suggested and thesewill be taken forward in the short-term, to produce a finalised pack which canthen be disseminated to all thirty two local authority settings for trainingdelivery. Additionally, a range oflonger-term and more 'strategically' oriented recommendations were provided,which might support the longer-term viability of the pack and ensure that thisparticular approach to capacity building becomes embedded in local authorityplanning structures, in line with local and national plans for both HI andCommunity Planning. It is likely thatthese 'strategic' issues will be considered at a national level.

It was found that thetraining pack has been well-received at local levels by trainers and that,whilst significant efforts were required on the part of trainers to worktogether to prepare for delivery of the pack and its materials, this wascrucially important in determining how the training was received byparticipants. The 'balance' between trainer-led and practical / group-basedactivities was found to be very good and conducive to challenging participantsand focusing their thinking on key HI 'messages'. Additionally, the range oftopics to be explored over the day was considered to offer a strong basis forunderstanding key principles and practices which underpin joint delivery of theHI agenda.

A range of very practicalsuggestions for development of the pack was provided by trainers. Theseincluded:

• Providingclearer trainer guidance throughout, in terms of learning outcomes for each ofthe sessions
• Re-organisationof the training pack to bring together all necessary support materials for eachsession (i.e. the trainer guidance, the background notes and the presentationmaterials)
• Reviseddesign and purpose of pre-course questionnaire with early return for prior consideration by the trainers
• Inclusionof 'ice-breaker' activities at the outset of the day
• Flexibilityof the presentation (overheads or powerpoint) with scope for local corporatebranding, as well as a reduction of detail on some of the transparencies
• Clearercontextual introduction to the day is required, through additionaltransparencies which detail aims and objectives and which demonstrate how theHI agenda 'fits' with both national priorities and local planninginfrastructures, relating to the JHIP and Community Planning
• Someflexibility around timings for each of the sessions to ensure that the'balance' between trainer-led and group work activities supports participantlearning
• Specificchanges to some sessions concerning clearer focus on learning outcomes, somereductions in content, stronger process support (through, e.g. the use offlipcharts and incremental summarising / updating throughout the day)
• Guidanceon pitching content and delivery to suit audience
• Retainneed to deliver training through co-training support (two trainers)

It is anticipated that these'operational' changes can be made to the training pack in a relatively shorttimescale and with the support of trainers involved in the pilot study.

Findings from the studywhich require more 'strategic' consideration are primarily concerned withensuring that the training becomes embedded within local authority planningstructures, for future sustainability. As part of wider capacity building efforts for HI, this training packshould be positioned within the local authority setting in a planned andsystematic way. This implies a nationalguidance role which will support local authorities in considering a range ofissues, such as:

• Howlocal trainers might be 'recruited' within the local authority setting and whatlearning and development support they might need - as well as how this capacitywill be developed - to deliver the training pack. Research findings suggested that a skills 'mix' would consist oftraining and facilitation experience, a clear understanding of the localauthority culture, structure and planning mechanisms and at least a basic'grounding' in health improvement principles and practice
• How local and national networks and partnerships can be established for trainers, where they can: share ideas and practice in both training delivery and wider HI and partnership working policy issues; keep up-to-date with relevant policy agendas - nationally and internationally; make effective linkages with HI practitioners both within and across the local authority setting
• how strategic and senior level staff within local authority settings can be encouraged to play a significant role in promoting the HI training at a local level
• how the training pack might be 'launched' at a local level, to engender maximum awareness, support and enthusiasm
• how quality assurance and consistency will be achieved and monitored in both the pack's content and how it is delivered
• how the training might be monitored and evaluated at local and national levels and taking account of the pack's content and sustainability (the 'outputs') and what has been achieved as a result of the training, in terms of service delivery (the 'outcomes')
• how the training strategy will link with other capacity building efforts and initiatives, in the interests of progressing the HI agenda, at local authority level

Both these 'operational' and'strategic' level recommendations offer clear direction for the future shaping,rollout and sustainability of the HI training pack. Considerable momentum has already been gathered in piloting thepack and there is clearly strong will and commitment at local levels toprogressing the HI agenda through this mechanism. It will be important to sustain this enthusiasm and to ensurethat the national and local support mechanisms are in place to deliver thecapacity building requirements for HI at the local level, and so support theachievement of both local and national plans for HI.

1. Introduction

1.1 Background to the project

Local authorities aredeveloping as Health Improvement Organisations ('Local Authorities as HealthImprovement Organisations, COSLA, 2002). The rationale for this is based on theUK Government and Scottish Executive's vision of reducing health inequalities.Both local authorities and NHS Boards have been tasked with developing theircapacity as 'public health / health improvement organisations' and to worktogether to promote better health. A rangeof initiatives has been taking place at partnership level and at local levelswithin local authorities to tackle this 'health improvement' agenda. Developing the health improvement capacityof the organisations has been integral to this, in terms of both the humanresource and training and learning perspectives. Local authorities now have new roles in place - 'Local AuthorityHealth Improvement Posts' - and the capacity building from other perspectivesis being considered.

As a partnership projectbetween COSLA, HEBS and United Kingdom Public Health Association (UKPHA)Scotland, four half-day workshops were designed and targeted at senior staffwithin the local authority setting. These workshops were designed to raise awareness of the national policyagenda as well as to prompt consideration and action at a local authoritylevel, in addressing health inequalities and promoting health improvement, andwere delivered through the following themes:

• thecontested nature of health
• inequality and health
• understanding the NHS
• howdo we know we're making a difference.

An independent evaluationstudy was commissioned to determine the overall value of these modules,resulting in the creation of a newly designed one-day training pack, createdfrom an amalgamation of the first two workshops listed above.

This new pack was piloted byseven local authority sites. Four ofthese sites have provided extensive contributions to this current evaluationstudy (Dumfries and Galloway Council, East Ayrshire Council, Highland Counciland Inverclyde Council), while the other three sites (Fife, East Renfrewshireand Perth and Kinross) provided written feedback after delivering theworkshop. Within each of the fourstudied sites, there were three trainers who were brought together to plan andprepare for co-delivery of the pack.

1.2 Aims and objectives of the research

This current evaluationproject has been commissioned to evaluate the utility and sustainability of thetraining pack which was devised to support the delivery of the new one-dayworkshop.

This pack was designed tosupport local trainers within local authorities in delivering the workshop toaudiences from different departments and disciplines within their localauthority setting. The specificobjectives attached to this evaluation study are:

• toobtain local trainers' overall assessment of the appropriateness, relevance andeffectiveness of the test pack, both before and after using it to deliverworkshops
• toobtain trainers' recommendations for improvements in the content or format ofthe pack, after using it to deliver workshops
• todetermine whether the pack as it stands could be used by local authority basedtrainers as a stand-alone resource in local authority areas, without specifictrainer-training or other support
• toexplore the perceptions of trainers and senior managers in the chosenauthorities of the sustainability of rolling out the programme, and / orelements of the training pack to relevant staff
• toexplore the capacity of trainers in the chosen authorities to form partnershipswith relevant co-trainers and to examine the nature of those partnerships.

Trainers were requested touse the training pack (including the guidance, activities and all materials) aspresented in the pack. This was toallow for more effective comparability of findings across settings. Such comparability would not be possible ifchanges were made by local trainers, depending on perceptions of localneeds. Subtle changes which were madeto the pack at a local level are reported in Section 6, below.

1.3 Content of workshop and the trainer's pack

The workshop comprised of arange of activities including information giving / presenter-led sessions,group discussions and debate and the undertaking of specific tasks. The workshop was broken down into seven keyareas. These are as follows:

1. themeaning of health - raising awareness of the different understandings thatexist about what constitutes 'health' and its determinants

2. influencinghealth - considering the relevance of different approaches to health to thework of local authorities

3. therole of a local authority - the role of local authorities in the design anddelivery of initiatives that impact on health

4. socio-economicstatus of health - examining the factors that lead to health inequalities

5. tacklinginequalities - exploring the role of local authorities in addressinginequalities in health

6. creatingthe conditions for health - an overview of the partnerships which can deliverimproved health

7. therole of a local authority - identification of challenges and opportunities

The trainers' pack wasdevised to provide direction, background information and general support indelivering the one-day workshop. The pack contained:

• aims and learning points
• programme with attached timings for each activity
• facilitatorguidance - advising on the expected experience of trainers, the target groupfor the workshop, organising and preparing for the event and recruiting thegroup, methods of working and the necessary materials
• asession leader's guide, explaining how the trainers should work through thesession, with direction on the order of activities and what materials arerequired at each stage
• thetransparencies to be used
• facilitators'background notes, providing further detail and information about healthimprovement - history, policy issues and detailed information regardingassociated health models
• backgroundreading for facilitators - in addition to the notes above, additional readingreferences were provided
• backgroundreading for participants
• pre-programmehandout for completion by participants
• handoutsfor participants during programme

1.4 Research methodology

The study was undertaken byapplying the following approach:

• afocus group session undertaken at pre-training stage, with each of the fourareas, with the three trainers present at each session (see Appendix 1)
• analysisof all trainers' written feedback (across the seven sites), following thedelivery of the workshops, through a questionnaire (see Appendix 2)
• one-to-one,in-depth meetings, at post-training stage, with each trainer from the foursites and an additional one-to-one meeting with a senior manager from each ofthe four sites, whose remit is connected to the health improvement agenda (seeAppendix 1)
• collationof responses at 'pre' and 'post' training stages, to identify key themes forthe future delivery of the pack and training
• apresentation of key findings to all individuals closely involved in theevaluation project, with an opportunity for further discussions
• allfindings analysed and presented in a report

In order to conduct thefocus group sessions and the one-to-one interviews, a topic guide was devisedto explore a wide range of areas, relating to the evaluation study. This topic guide is attached at Appendix 2. Thesame topic guide was used at both pre and post training stages of the researchproject, in order that views could be compared. Indeed, it was anticipated that trainers' pre training viewsregarding delivery of the workshop might prove not to be founded at posttraining stage. By using the same topicguide, this could be identified more easily.

1.5 Research limitations

This project was conductedusing qualitative research techniques. As such, it is subject to the usual limitations of such anapproach. These include an inability toquantify exactly the findings (since similar themes might be discussed butstrength of opinion might differ); a need to generalise findings which mightonly have been expressed in one area but which might have wider resonanceacross other areas not involved in the research; an appreciation that thesubjective nature of qualitative research can produce findings which are notentirely accurate - this can be consciously or unconsciously driven byinterviewee responses.

It should also be noted thatthis evaluation project focused only on the views of trainers and does notinclude the views of participants. Whilst some participant views might be factored into trainers' posttraining interview responses, this was not an objective of this study. Where senior managers - who were interviewedat post training stage - had attended a training session, they might also havefactored this into their one-to-one interview but this was not part of theoverall project. As such, it cannot beassumed that the findings of this report would reflect fully the views ofworkshop participants.

Additionally, several otherwider influences exist which might impact upon the views and opinions oftrainers. These include the nature ofthe internal operating culture within the local authority setting, theprogression of and support for the health improvement agenda within eachsetting and the nature of strategic, internal support for both the trainingworkshop and the wider health improvement agenda. These issues could potentially influence both how participantsrespond to the workshops and how, in turn, trainers perceive the overall valueand effectiveness of the workshops or specific elements. It is unlikely that any two audiencesettings will be the same - even within the one local authority setting - andit is likely that trainers' views regarding the training pack are influenced byaudience perceptions, based on the specific audiences who took part in thispilot project. The researchers haveattempted to minimise the influence of such potential distortions to theoverall findings by asking trainers about the cultural and policy contexts oftheir local settings, and by relating these findings to overall post trainingfindings.

This evaluation study isalso limited to gauging trainers' reactions to training delivery, following oneor two workshops. As such, this studydepends on assessing trainers' immediate perceptions and does not track theextent to which overall, longer-term workshop objectives have beenachieved. These longer-term objectivesrelating to capacity building, applying approaches to joined-up working andmore effective service delivery cannot be ascertained at this stage. However, they are crucial to determining theoverall viability of this training workshop, in relation to advancing the wholehealth improvement agenda. This issomething which should perhaps be considered for the future, in order that thebaseline information generated from this study can be used to track future progressand achievements in these areas.

Thequalitative research approach applied to this project required the researchersto undertake in-depth investigations and so produce highly analyticalresults. Given that the project wasprimarily concerned with garnering the views of a range of individuals, thisapproach was found to be extremely effective.

1.6 The context of each of the four local authority environments

As detailed earlier, of theseven sites who contributed to this pilot exercise, four sites participated inextensive consultation, regarding trainers' views at pre and post-trainingstages. Before exploring any of the research findings, it is important that aclear picture is conveyed of the four sites taking part in this study. This is detailed in the table below whichidentifies the health improvement context within each local setting, thetraining experience 'mix' within each area, how the programme was delivered, towhom and where any changes were made to the training pack.

Table 1.1 The training context of each of the four local authoritysettings

Local Authority
Dumfries and Galloway	the 'Safe and Healthy Communities' plan, emanating from the Community Plan is almost completed and is expected to become the Joint Health Improvement Plan (JHIP). A local authority action plan is currently being considered, which will come from this due to a current restructuring programme, senior members of staff could not be targeted for this workshop. However, a newly formed group of Health Improvement officers from services across the authority attended it was expected that between 17 and 20 participants would attend. In practice, 10-11 attended the workshop was delivered over one day no changes were made to any materials the 3 trainers comprised of the health improvement (HI) co-ordinator, a policy officer and a corporate services trainer
East Ayrshire	the JHIP has been devised and is awaiting approval. An action plan for the authority has yet to be agreed the Corporate Health Issues Group, who have been meeting for some time, formed the target audience for strategic group delivery. This group is comprised mainly of principal officers, whose roles span strategic and operational settings. A second, more operationally-oriented group also attended a separate workshop 6 participants from the senior grouping attended, from the anticipated 12; 10 participants from the operational grouping attended, from the anticipated 11 the workshop was delivered over one day, for each of the two groupings transparencies were converted into a powerpoint presentation and delegate packs were produced according to the guidance in the trainer pack, but within an East Ayrshire corporate framework the 3 trainers comprised of a HI officer (with some training experience), a social services training officer and a corporate services training officer.
Highland	the JHIP was approved in December 2002 and the local authority health improvement plan (HIP) is now being worked on a Health Improvement Group from each service area across the authority has been meeting for a few months This group comprises a range of strategic roles and those which span strategic and operational roles 12 individual were targeted and 2 could not attend, leaving an attendance of 10 participants the workshop was delivered over one day transparencies were used as requested in the pack and an extra overhead was included to complement the Whitehead / Dahlgren model of determinants of health. This additional model was the Evans and Stoddart model the 3 trainers comprised of a HI officer, and 2 training officers
Inverclyde	the JHIP is in draft format and a local authority plan is being considered the Public Health Group has been meeting for a few months and was targeted for this training. They comprise Heads of Service the workshop was delivered over 2 half days of the 14 delegates targeted (including 2 Councillors), 12 attended, with a further 3 not attending the second session a powerpoint presentation replaced the transparencies, with no changes to content but some presentational changes and the inclusion of corporate branding. A delegate pack was produced with corporate branding the 3 trainers comprised of a HI officer, an NHS health promotion officer (with a background in training) and a corporate services training officer (with a background in Scottish Health at Work or SHAW).

The above table demonstratesthat progression and planning of the health improvement agenda, together withan integrated vision for health improvement, exists at different stages and isbeing pursued in different ways across these four local authoritysettings. As noted earlier, thesedifferences could potentially impact upon perceptions of the overalleffectiveness of the workshop, since 'readiness' and 'susceptibility' to thecore themes and messages from the workshop might be related to prior knowledgeand contextualising, as well as the extent of perceived internal drive andsupport for the HI agenda.

Additionally, these foursettings had a 'ready-made' grouping at whom the workshop was targeted. This might not be the case in all localauthority settings, making it difficult to predict how easy or difficult the'recruiting' stage of the workshop might be. However, in two of the local authorities, the pack was also delivered tomore operationally-based employees, who had no or very little prior exposure tothe health improvement agenda. This is important to note as further roll-out ofthe programme across local authority settings will involve targeting staff whohave had no or very little prior exposure to health improvement 'messages'. Itis also quite difficult to predict how those who have less current 'proximity'to the HI agenda might react to being targeted for attendance. From the pilot sites who delivered to moreoperational groupings, it appears that targeting efforts will probably need tobe increased in order to attract such delegates to the programme.

It should also be noted thatthese 'ready-made' groups, who have already been exposed to a range of HImessages, are likely not to be a typical grouping, and are already quiteaccepting of many of the HI messages. As such, it will be difficult toascertain whether trainers perceptions at post training stage are based ongeneral views or are influenced - at least some extent - by the context of thedelivered workshop setting, with a-typical participants.

There was also a relatively strong 'mix' within each settingof trainers who have experienced training and / or HI backgrounds. As is later demonstrated, this combinationappears to be very important.

2. Pre-training findings

This chapter provides abreakdown of the key findings which were generated from the four focus groupdiscussions which took place at each local authority setting, prior to trainingdelivery. The purpose of engaging withtrainers at this stage was to ascertain the extent to which the pack supportedthem in preparing for the workshop sessions. This is important as a confidence-building and context-setting tool forfuture trainers and it was therefore important to determine whether the pack -in its current format - can offer the reassurance and clarity required atpre-training stage, in order that trainers can adopt a confident and conciseapproach to training preparation.

When the researchers metwith the trainers, they were at various states of preparation across the foursettings. Some had met on several occasionsto discuss and prepare the workshops while others still had more work todo. As such, findings were quitegeneralised with a fair degree of uncertainty. What was clear across each setting was that all trainers felt that asignificant degree of preparation was required in preparing for delivery - thiswas regardless of experience or background. This was felt to be partially due to the amount of information withinthe pack which was required to be imparted to participants, and also due to thewide range of activities to be covered in the workshop, each requiringdifferent approaches to planning and preparation.

The following tableindicates the key areas which were discussed during the focus group sessions,and allows for easy comparison across the four settings. The use of symbols in the table areabbreviations for the following:

+ positive comment

- negative comment

~ neither positive nor negative comment

In the interests ofconfidentiality, specific research findings within the four local authoritieshave been grouped as Local Authority A, B, C and D.

2.1 Pre-training findings, broken down by local authority area

Area of Discussion	Local Authority A	Local Authority B	Local Authority C	Local Authority D
Trainers (skills required and self-ratings are based on a scale of 1-5, where 1 is least positive and 5 is most positive)	Skills Required: skills of presenting to senior audiences 4-5 pitching delivery to different participants 4-5 dealing with difficult issues 4-5 effective presenting 4-5 facilitating group work 4-5 Self Ratings: understanding the holistic nature of health improvement 3-5 skills and specialities which contribute to HI 3-5 understanding HI agenda in own area 3-5 understanding own culture 3-5 training / facilitation experience 3-5 working with co-trainers 3-5 working with varied audiences 3-5	Skills Required: skills of presenting to senior audiences 4-5 pitching delivery to different participants 4-5 dealing with difficult issues 4-5 effective presenting 4-5 facilitating group work 4-5 Self Ratings: understanding the holistic nature of health improvement 1-5 skills and specialities which contribute to HI 1-5 understanding HI agenda in own area 1-5 understanding own culture 1-5 training / facilitation experience 1-5 working with co-trainers 1-5 working with varied audiences 1-5	Skills Required: skills of presenting to senior audiences 4-5 pitching delivery to different participants 4-5 dealing with difficult issues 4-5 effective presenting 4-5 facilitating group work 4-5 Self Ratings: understanding the holistic nature of health improvement 4-5 skills and specialities which contribute to HI 4-5 understanding HI agenda in own area 4-5 understanding own culture 4-5 training / facilitation experience 4-5 working with co-trainers 4-5 working with varied audiences 4-5	Skills Required: skills of presenting to senior audiences 4-5 pitching delivery to different participants 4-5 dealing with difficult issues 4-5 effective presenting 4-5 facilitating group work 4-5 Self Ratings: understanding the holistic nature of health improvement 3-5 skills and specialities which contribute to HI 3-5 understanding HI agenda in own area 3-5 understanding own culture 3-5 training / facilitation experience 3-5 working with co-trainers 3-5 working with varied audiences 3-5
	Comments: sustaining the training is the key issue future'training for trainers' will be required, due to specialist nature of HI agenda essential to have training updates through national and local inputs perhaps consider how NHS can contribute to future delivery the input and influence of the HI officer role is crucial.			Comments: the input and influence of the HI officer role is crucial
Structure of the workshop - guidance provided	+ content is broken-up well - language very wordy and sometimes ambiguous - concerns about lack of clarity for future updating of materials	+ provides good direction - confusing; not logical; requires 2-3 readings being becoming clear; more preparation time due to poor structure ~ should be grouped by topic throughout, according to sessions and not by different areas of trainer support	+ good direction and detail; provides reassurance and consistency - language sometimes a bit technical - sequence is not always logical	~ should be grouped by topic throughout, according to sessions and not by different areas of trainer support
Structure of the workshop - adequacy of information	+ good reference material	- you would require a basic'grounding' in HI before pack would make sense	+ national policy context is clear	~ too much background reading required of trainers and participants; off-putting
Structure of the workshop - relevance of aims	-'Role of Local Authority in Addressing HI Agenda' - not clear	- aims clear but learning points are a bit ambiguous	~ will require some'ad-libbing' to get across the key learning points	+
Structure of the workshop - content addresses aims	+	+ due to prescriptive nature of pack	+	~ Our HI plan is still not tangible enough for participants, which is beyond the control of the pack
Activities and Content - pack lends itself to information giving, discussion and sharing ideas and experiences	information giving - too much (-) sharing ideas - group might not know each other well enough (-)	information giving - quite academic (-) discussion - too presenter-led (-) sharing ideas - difficult to regionalise / contextualise (-)	information giving (+) discussion (+) sharing ideas - will need to allow opportunity to reflect and follow-up through'Phase 2' (~)	information giving (+) discussion (+) sharing ideas - not enough time; this could be destructive to workshop where participants begin to get to this stage and then it has to be cut short due to lack of time (-)
Activities and Content - effective'warm-up'	+ pre-course form and 'Overheard on the Bus' ~ scene setting is very important	+'Car Park' exercise ~ Group will not need a warm-up activity	- the pre-course form is good but there is no scope to fully explore. - lack of'ground rules' to ensure participants understand format and the need for fair and active engagement	- the pre-course form could be quite threatening if not used carefully - seems to go straight into theory without appropriate warm-up
Activities and Content - unnecessary / repetitive	+ (none)	- Ottawa Charter is unnecessarily detailed - historical development is too long	- historical development is too long (but the rationale is important)	+ (none)
Activities and Content - too simplistic	+ (none)	- Not clear if the'What is Health?' section is perhaps too simplistic	+ (none)	+ (none)
Activities and Content - too complicated	- Ottawa Charter - pm strategy planning session	- Ottawa Charter exercise is confusing	- weighting process ('What Influences Health in Your Locality - Session 2) - pm strategy planning session	+ (none)
Activities and Content - training methods balanced	+	- perhaps too much presenter-led	+	- too information-intensive in am sessions
Activities and Content - good examples and case studies	+	-'Overheard on the Bus'- objectives unclear - Overhead 2 (medical approach to health) is confusing	+ Broad Street Pump is a good example	+
Timing	- will have to cut short some of the discussions exercises - statistical evidence and measuring deprivation needs will require more than 10 minutes	~'added' time through adapting start and finish times, plus altering breaks	~ presence of Councillors close to election times could be difficult to manage, due to'discussions' which emerge during workshop - will have to cut short discussion sessions but unclear where other areas could'lose' some content	- will be tight
Scope for change / improvements	~ pre-course work could include an introduction to Community Planning / partnership working ~ group size should be 12-16 ~ training needs to link with planning structures in own area ~ perhaps pace training over a longer period to allow for consolidation and reflection, as opposed to overwhelming with information	~ group size about 12 ~ re-order pack as per earlier suggestion	~ awareness letter from the Chief Executive would send the right signal ~ future targeting will require to get through'gatekeepers' in order to raise awareness of training and wider agenda ~ group size about 14 ~ more time required ~ guidance / pack should be available on disk, to allow for easy searching ~ more use of diagrams / pictorial formats on transparencies and handouts, to demonstrate key points ~ more use of local examples	~ re-organise pack as per above comments ~ some guidance on how to use existing HI Groups for further dissemination of key messages ~ Group size about 12 ~ take training out to areas where it would be logistically difficult to come to a central location ~ training should be integrated into corporate training
Targeting Participants	~ messages within the pack are more relevant for strategic groups than operational groups ~ pre-course form (adapted) could be returned prior to training in order for trainers to get a better idea of pitching the training	~ difficult due to current internal reorganisation ~ could develop more impetus through an introductory session from the chief executive	~ the current group who meet might change membership following the training	~ could participants be encouraged and guided to use Health Impact Assessments at the end of the workshop, in order to provide focus for action?
Strengths, Weaknesses, Gaps and Difficulties Strengths, Weaknesses, Gaps and Difficulties (continued)	+ good mix of activities - challenge to make it more than an end in itself - more time to deliver and allow for reflection - Ottawa Charter is very new and quite complex - NHS role and involvement appears to be a gap - difficult for delegates to connect to their own roles ~ only 2 trainers will be required if participants are less than 15 ~ training needs to be placed within a Community Planning context	+ lots of excellent detail in pack - inflexible and not localised ~ will need to make it more relevant and'punchier'	+ impressed with breadth of coverage + clear consideration of group work and group dynamics + pack is a great start - too much detail - requires follow-up / 'Phase 2' - difficult to get beyond the theory (especially when there is no'How To' manual) - real barriers to sustainability of agenda include funding ~'Ownership' of the HI agenda will be crucial ~ training is a direct challenge to local government culture; managing change ~ staff do feel overwhelmed by change and this new agenda might further contribute to that ~ challenge to make agenda sustainable	+ pack is coherent - action planning stages will be challenging - should include use of heath impact assessments - will be difficult to cover all content in 1 day ~ internal plans for further roll-out are still unclear
Event Organisation	- training is not currently connected to wider corporate planning and therefore feels 'parachuted' in ~ difficult to incentivise attendance for more operational groups who are currently further'removed' from the HI messages ~ because of internal knowledge and experience of trainers, it was easier to target the key relevant staff	~ due to the current internal reorganisation, a less strategic group was targeted, with some reluctance to attend	~ well-planned and orchestrated but took lots of time and required both administrative and corporate support (resource implications)	~ well-supported at senior and corporate levels
Future Delivery / Used as'Stand-alone'	~ will require significant background work and planning for future trainers ~ will require co-facilitation ~ current uncertainty concerning how this will link to wider Community Planning agenda ~ too early to make confident links between this training and wider capacity building for HI	~ will require HI support for future delivery (advice, guidance)	~ understanding the local Community Plan is a pre-requisite for trainers ~ models of health require lots of work for clear understanding ~ need to consider learning objectives for different groups in the future	~ lots of background work required ~ it would be very difficult for a trainer without a background in HI to deal with information / knowledge based questions ~ trainers require strong overview of local culture and where HI sits within the local authority, in line with wider Community Planning
Co-Training Guidance	+ might be useful for future trainers but contained nothing new for current trainers	+ might be useful for future trainers but contained nothing new for current trainers	+ might be useful for future trainers but contained nothing new for current trainers	+ might be useful for future trainers but contained nothing new for current trainers

2.2 Summary of pre-training findings

Fromthe above table, the following key issues seem to be the most relevant atpre-training stage:

2.2.1 Skills required and self-ratings of skills

The key skill areas which weredeemed to be very important for trainers were presenting to senior audiences;pitching delivery appropriately; dealing with difficult issues; presentingeffectively and facilitating group work. Self-ratings tended to vary quite a bit with the lowest self-ratings forthose with no / limited training experience. This suggests that even where a'trainer' possesses a HI background, this might not - by itself - compensatefor a lack of training experience. However, the HI role and input were also deemed to be very important

2.2.2 Structure – guidance

Thepack offers good content and general direction, providing trainers withreassurance and consistency. However, it does need reorganising, in order tolink information related to each topic for delivery, and not according to thedifferent areas of trainer support (as is currently the structure)

2.2.3 Structure – adequacy of information

Very good in relation to policyissues and reference material. Someconcerns that the amount of information could be off-putting / daunting forfuture trainers and that a certain'grounding' in HI would be necessary inorder not to feel overwhelmed

2.2.4 Structure – relevance of aims

Generally very good although moreclarity might be required relating to learning points. (This might be partiallyovercome with pack reorganisation.)

2.2.5 Structure – content addresses aims

Yes, but much is dependent onparticipant'readiness' to engage with the material, which relates to how'close' participants are already to the HI agenda and how this is progressingwithin the local setting

2.2.6 Activities and content – information discussion andsharing

Lots of very good information butperhaps too much. Discussion ideas arevery good but, due to timing, trainers might have to cut short some of thesesessions, which might defeat the purpose of the training. Participants might not be comfortable enoughwith each other to share ideas, depending on how well they already know eachother. However, the material was felt to be sufficiently geared towardsenabling'the penny to drop' with participants i.e. over the course of the dayparticipants would be able to make the relevant connections between what theydo in their jobs and the links to the health improvement agenda. One trainer described an analogy whichexplains this very well:

"When youbuy a red car, you always see red cars"

2.2.7 Activities and content – warm up

'Ground rules' are perhaps requiredto set off the day and more extensive use of the pre-course form is necessary(which currently appears not to address the issue of'ice-breaking').'Overheard on the Bus' was felt to be a goodinteractive activity, as well as the'Car Park' activity in the afternoon

2.2.8 Activities and content – unnecessary/repetitive

Too much time spent on, and detailwithin, the Ottawa Charter

2.2.9 Activities and content – too simplistic

None, although the'What isHealth?' session might be perceived this way if not facilitated well

2.2.10 Activities and content – too complicated

The Ottawa Charter, the weightingprocess from'What Influences Health in Your Locality?' and the strategyplanning session at the end of the day. All felt to require more guidance for effective delivery, focus andfacilitation

2.2.11 Activities and content – training methods balanced

Yes, but perhaps lesspresenter-led focus and less information throughout would offer a betterbalance

2.2.12 Activities and content – examples/case studies

Very good but some level ofuncertainty as to what the objectives are for'Overheard on the Bus'

2.2.13 Timing

Felt to be tight so some sessionsmight have to be cut short, especially discussion sessions

2.2.14 Changes/improvements

The pre-course questionnaire couldbe more focused and used more effectively in the first session, as well asincluding areas within it about partnership working / Community Planning. More time was felt to be required overalland the pack reorganised. Ideal group size would be twelve to sixteen. Early training promotion from the chiefexecutive through a letter to delegates was suggested as well as using thedelegates in the future for wider promotion of the event. There was felt to be a clear need to ensurethat training is'mainstreamed' into the corporate training calendar, as wellas clear linkages to overall internal planning frameworks. The pack might be more easily updated andused by trainers if on disk and some presentation aspects could includediagrams / pictorial formats, instead of just text. Local examples could also be inserted into material.'Phase 2' or follow-up sessions were felt tobe important in order to consolidate learning and begin to build capacity. It was felt that simplified versions ofhealth impact assessments might also supportthis

2.2.15 Targeting

This was made easier by the'ready-made' groups for training, where these existed. Earlier return of a more focused pre-coursequestionnaire would allow trainers to'pitch' the training more appropriately

2.2.16 Strengths, weaknesses, gaps and difficulties

A good mix of content andactivities which are pitched well to meet a range of needs and learning styles.The strategy planning session was felt to be challenging, as was keeping totimings throughout and working through the Ottawa Charter materials. There was felt to be a need to include localexamples and statistics and to consider how the NHS might contribute to futuresessions.'Phase 2' / follow-up sessions were felt to be crucial, against abackdrop of strong internal'ownership' of the agenda and a clear vision forhow the HI agenda and training are to be made sustainable at local levels

2.2.17 Event organisation

Senior support was felt to benecessary in both promoting the training and ensuring its sustainabilitythrough the corporate training calendar. Such support was available to the fourtest sites through a corporate / HR role, either directly through one of thetrainers and / or through more strategic support, whereby trainers reportedback on needs and progress. The'proximity' of the'lead trainer' role (i.e. the HI officer role) to corporatesupport and / or the chief executive's office was felt to be very important inboth organising the training event and in providing longer-term support for thetraining.'Insider knowledge' of the culture, contacts and internal processesfor gaining support were felt to be essential. This links to providing appropriate incentives for participants and alsogetting past'gatekeepers' within service areas who might consciously orunconsciously present barriers to wider participation

2.2.18 Future training/standalone

Co-facilitation was felt to beessential, combining HI expertise with wider training experience. Trainersshould also have a strong grasp of the internal culture and knowledge ofprogress and plans for Community Planning. Sufficient time for building knowledge and planning the training werealso important. Given that this'mix'of skills and abilities is not likely to be common within local settings, thereis probably limited scope for these events to be delivered as'standalone'. A process of buildingcapacity to achieve the skills and behaviours mix mentioned above is likely torequire planning efforts, with resource implications

2.2.19 Co-training guidance

Trainers generally felt that therewas little new in this guidance since most of them came from trainingbackgrounds and had co-facilitated in the past. However, it was felt to beessential for future trainers without co-facilitation experience

Acknowledgements

The project commissioning team and the researchers would like to thank the seven pilot local authority sites, who contributed to the research.  Their support and enthusiasm were invaluable to the project.  These local authorities were:

Dumfries and Galloway Council
East Ayrshire Council
East Renfrewshire Council
Fife Council
Highland Council
Inverclyde Council
Perth and Kinross Council

3. Post - training findings

This chapter is based upon the findings from the questionnaire returnsfrom the seven test sites and the one-to-one interviews in the four test siteswhich took place, following training delivery in each local area. Unlike the focus group results, where foursets of findings were produced, the post-training one-to-one findings consistof 16 separate sets of findings. Assuch, the second part of this chapter has been structured by highlighting thekey themes which emerged across these sets of findings. In order to provideclear connection and comparisons to the pre-training findings, thepost-training findings have been grouped in the following way:

• issueswhich remained significant at both pre and post-training stages
• issuesat pre-training stage which were not found at post-training stage
• newissues which emerged at post-training stage

3.1 Summary of the key issues at post-training stage

The results which follow summarise all key issues which were capturedat post-training stage, through both the questionnaire and one-to-one interviews:

• akey theme running through responses was that some general 'tweaking' would berequired to the pack but that it was a very effective starting point, providinga good base of information and activities for introducing and developing the HIagenda in the local setting. It wasalso felt that a level of local flexibility will always be required to get thebest results. This will includeadapting timings, ordering the sequence of events, flexibility around how longis spent on each individual activity and the provision of local examples andanecdotes
• onlyone local authority delivered the training to two separate groupings while theothers delivered to only one group
• thetraining was targeted at a predominantly senior audience across local settings,although some participants across settings spanned a strategic and operationalrole context
• therewas a mix of views from trainers regarding the 'pitching' of materials,including views that it was at the right level, too simplistic and toochallenging. This relates to thedifferent sessions and how different participants related to the variousactivities
• overall,views on the effectiveness of the pack were very positive, through its generaldirection and quality of materials. Itwas felt that the pack should be reorganised to group activities and theirassociated guidance together. Thereshould be less detail on the transparencies and more consideration of thelikely energy of the group over the day will be necessary in terms of how muchinformation should be included. Theguidance in its current format was felt to be a bit didactic / prescriptive /inflexible. However, for the purpose ofthe pilot process, this was necessary. Flexibility is desired for the future
• adaptationsrequired were felt to be relatively subtle. Some trainers wish to include different health models, local statistics,the use of powerpoint (instead of transparencies), some changes to timings andthe actual presentation of the transparencies / powerpoint (not content). The pm session of 'Challenges andOpportunities' might already be covered through the earlier sessions. In which case, trainers might wish toconsider summarising this session and build on any further areas for development
• howthe training will be integrated into wider training provision is an area whichis still a bit unclear in most local areas. There are some plans to make thetraining part of wider corporate training induction or mainstreamed into thecorporate training programme. Again,the 'proximity' of the lead trainers / HI officers to senior level corporatesupport was deemed to be necessary to progressing the training in this way.There were also some suggestions of making the training part of a widerprogramme for Councillors. This willrequire senior, internal support as well as perhaps guidance from COSLA withregard to how to make the training sustainable. It was also felt that 'train the trainer' support would benecessary, given the particular mix of skills and experience required of thistype of training delivery
• seniorand / or strategic planning support will be necessary to secure the future ofthe training internally, together with a HI officer 'presence' in providingeither guidance and support or direct 'hands-on' support to the delivery of thetraining (although this will have resource implications, especially in light ofthe wider strategic role of HI officers)
• 'What Is Health?' - the pre-coursequestionnaire could be adapted to encourage participants to prioritiseactivities. Information relating towhat the local authority / service areas already do in line with HI could belinked to the last session of the day to provide more impetus. This could be designed for easy completionin a grid response format. Design couldalso include asking participants about their role - if any - in working on theJHIP. This questionnaire was largely not considered to be an effective'ice-breaker' but a warm-up activity would be needed, in order to encourage amore interactive format from the beginning of the day. Many participants were felt to be reluctantto discuss views at an early stage and it was felt that this might be overcomeby introducing some early warm-up activities
• 'Overheard on the Bus' - there were mixedviews, here, with some sense that more clarity of the purpose of this sessionis required as well as offering trainer prompts to support this earlyparticipant-led session. Reluctance to engage at this stage could have beenrelated to ineffective warm-up activities. The impersonal nature of this exercise was felt to be a positive issueas participants need not feel exposed about expressing their own personal viewsbut rather focus on those of others
• 'Brief History of Public Health' - some mixedviews but a general feeling that this session needs to be shortened, with someof the surplus information provided as a separate handout. This would be made clearer by a strongeremphasis on the learning points which were felt to be a bit ambiguous. Because this session is quite presenter-led,it will be important to ensure that it is not 'too dry'. This could be addressed by shortening thesession, transferring some of the detail onto a separate handout and providinglocal examples
• 'Approaches to Health: Medical and Social' -very mixed views, here. It was felt tooffer clear guidance and was relatively easy to deliver where the links couldbe made obviously to 'Overheard on the Bus'. This session seemed to work lesswell with more operationally-focused staff, where more time was required tocover the complexities. It was alsofelt to be important to ensure that that the session does not lose focus andattempts t o draw conclusions that the medical model is 'bad' and the socialmodel is 'good', or vice-versa. Thissession requires to focus on generating awareness of the two models.
• 'What Influences Health in Your LocalAuthority?' - the guidance was felt to be unclear, here, and the scoringcomplicated. Some trainers appeared tobe unclear as to the purpose of the session. Handout two requires to be changed to remove the reference to tobaccoadvertising, which is now obsolete
• OttawaCharter sessions - these were generally positive sessions if a littlecomplicated and perhaps better suited to more senior audiences. The wider resonance of the Charter to localuse, beyond the health improvement agenda, is something which could beemphasised. There was some feeling thatextra time might be required to prepare this session but that the benefits wouldbe in the support and structure of delivery. For the Food Programme example, more background is required and / or awider range of examples used. ThePhysical Activity example was felt to work quite well but was challenging. It also required quite a bit of trainersupport. It will be important fortrainers to emphasise that the focus of the exercise is based on localauthority activity and not national initiatives or their own, personal issues.This will depend on the strategic ability of the group.
• 'Car Park' activity - this was felt to begood fun and energising after lunch, with clear links to healthinequalities. There was a suggestionthat the 'characters' might be updated and reviewed and an indoors formatshould be considered, since it will not always be possible to undertake outdoors. By plotting the 'results' on grid paper,this would offer a strong focus for the follow-up discussion exercise, ratherthan trying to come together and re-trace their steps
• statisticalevidence session - this was felt to be quite a 'dry' session and could beimproved by shortening to only the very necessary details and including localstatistics (which can be taken from the NHS Health Scotland web-site), as wellas statistics from Europe and high performing countries, as a focus fordiscussion. Clarity of objectives wasalso felt to be lacking, resulting in less focused prompting by sometrainers. There were felt to be sometyping errors on the associated overhead. Finally, it was requested that the North Karelia experience could beadded to provide more focus to this session. However, a cautionary note is required, here, regarding the overallobjective of this session. The key learning outcome relates to engendering anunderstanding with participants that statistics are often used for differentpurposes and are subject to different interpretations. As such, it might be confusing to use anextensive range of statistical sets, where participants might become focused onthe statistics themselves, rather than the process of use and interpretation
• measuringdeprivation - objectives were felt to be unclear concerning whether thissession was about the statistics themselves or the tools to measure andinterpret these. This session couldalso explore how such tools support policy making and linkages to the socialmodel and health inequalities. There was felt to be generally limiteddiscussion during this session, suggesting that trainers should focus on thekey learning outcomes and adapt the discussion to participants' needs
• groupdebate - this was felt to be good for re-energising the group and generatingfocused discussion (coming in the middle of the afternoon). Trainer preparation is required to prepareand structure the session and consider timings and the rules and format fordebating. The pack should also include ideas of how to support both argumentsif the group is short on ideas. Thedebating format should be flexible to accommodate needs - e.g. using only twodebaters while the others ask questions and then vote, or get participants tostay in 'character' from the Car Park exercise and to work through the debateon this basis
• roleof LA - felt to be a very good exercise for information sharing and providingreassurance to participants that many areas are already being exploredlocally. Clarity of objectives of thissession is essential and objectives will change depending on the level ofparticipants. For example, some lessstrategic groupings might be expected to 'list' key local activity associated withthe HI agenda while more strategic groupings might be expected to move beyondthis to exploring future plans and added value in partnership working. Since this session is a crucial part to thewhole day, enough time needs to be allocated to exploring views and developingthoughts. This will also go some way todetermining whether participants reach a satisfactory conclusion from thissession, and so work towards finishing the day on a positive, confident andforward-looking note. Trainers mightrequire to offer prompts in order to encourage focused thinking and to checkknowledge and understanding
• roleof LA in partnership working - some trainers felt that this had already beencovered in the previous session and was therefore superfluous. The last twosessions - in particular - will require quite specific objectives, depending onthe groups participating, in order to end on the right note and with the keymessages. This will be challenging dueto the complexity of this session together with participants already feelingquite tired by this stage. Somesuggestions for change here included linking this session to the first amsession to review how views and ideas might have developed over the course ofthe day. Using 'post-its' to gather anddisplay ideas was also felt to offer a clear focus, especially since thesecould be moved around to accommodate new ideas and views. One trainer suggested that a handout wasmissing from this session, in line with what had been described in the pack. In providing a focus for further action, itwas suggested that participants could be given a basic version of a healthimpact assessment. As well as beingguided as to its purpose, use and benefits, they could be asked to use theseback in their service areas to provide a baseline and focus for wider action. Since undertaking the research, it has beenrevealed that health impact assessments are being dealt with in the HI agendathrough an evaluation module. Therefore, in the interests of ensuring that a fuller understanding ofits objectives and application can be achieved at local level, it has beendecided not to include this area in the training pack for this project, but toleave all references to this for the evaluation module
• aimsand learning points - some confusion existed among trainers as to whetherlearning points could be more usefully defined as learning outcomes. These werefelt to require more definition and clarity and could perhaps be included inthe presentation to alert participants to intended outcomes
• facilitatorguidance - this was felt to be generally very helpful, but that its currentposition in the pack does not give it enough prominence. As such, it was felt to be somewhat lackingin coherence, due to its lack of integration in the pack with the rest of theassociated material (as detailed earlier in the report)
• transparencies- the content of these was thought to be of a very high quality, but there wassome feeling that the detail on some transparencies will be required to beshortened and to be presented in powerpoint format
• facilitatorbackground notes - in line with pack reorganisation, these could be improved.There was also some feeling that guidance was somewhat inconsistent in itsavailability across all sessions. Thesessions on inequalities were felt to require clearer guidance by way ofintegrating these sessions and so emphasising the key learning points. Despite the detail in the background notesthere was some feeling that this might not prepare trainers for participants' questions. This is whereHI knowledge is essential and could not be addressed by someonewithout an HI background
• handouts- as noted earlier, local statistics and other, additional material from thetransparencies could be transferred onto handouts
• readinglists - it was suggested that it is perhaps unrealistic to expect that a non-HItrainer would read all materials on the reading list, in addition to thecontent of the pack. This could be off-putting and daunting. There was also some lack of clarityregarding what participants should be encouraged to read prior to attending thetraining. The pack proposes that participants could be asked to make themselves familiar with the COSLAdocuments, in order to provide a basic level of grounding, prior to attendance.However, there was some confusion regarding what was requested for participantpre-course reading and post-course reading. This will require to be made clearer in the pack It was also notclear if participants would actually read the suggested pre-course, backgroundreading before attending the training.

3.2 Issues which remained significant at both pre- and post- training stages

Almost all of the issues identified bytrainers at pre-training stage remained significant following trainingdelivery. Some of these issues wereexpanded upon, to provide new insights and these have been listed in section3.4 below. The key issues whichremained the same related to:

• aparticular skills 'mix' is required of this type of training delivery, inrelation to facilitation skills, knowledge and understanding of the HI agendaand wider 'insider knowledge' of the culture and structures at a local level,as well as a clear grasp of the Community Planning agenda at national and locallevels
• theneed to reorganise the structure of the training pack and to simplify some ofthe language on the transparencies and in the handouts
• adequateinformation in the pack regarding the policy context of HI and references
• theneed for sufficient time to plan and prepare the Ottawa Charter session, inorder to provide clear direction and information to participants
• thepack contains very relevant aims but the learning outcomes need to be moreclearly defined, particularly for the discussion and debating activities. For example, where the pack states 'ask thegroup to discuss, there needs to more direction provided to trainers of whatthey should expect from participants. This issue perhaps stems from the terminology used in the pack, where'learning points' is used instead of 'learning outcomes'. As such, there might have been a tendencyfro trainers to confuse the training process with results
• theobjectives of the last session require careful consideration and should takeaccount of the abilities of the group. Whilst more operationally-focusedparticipants might be more comfortable in 'listing' activities, morestrategically-oriented participants need to move beyond this to consider whatshould be happening next at a local level
• somediscussion sessions did have to be cut short, in the interest of sticking totime, especially where there was some initial reluctance of participants toshare ideas
• thepurpose of the pre-course questionnaire remains quite unclear and requiresclearer guidance and direction. It wasnot deemed to be an effective warm-up activity and whilst it should be used atthe beginning of the day, a warm-up activity should precede it. Additional questioning and earlier return ofthe form for prior consideration by trainers, would make its use more effectiveand focused
• boththe historical development session and the Ottawa Charter sessions should beshortened, to focus on only the key points, while the remainder of the materialcould be transferred to additional handouts
• noneof the content was deemed to be too simplistic although 'What is Health?' requiresmore focused direction and objectives
• theweighting process activity attached to the 'What Influences Health in YourLocality?' session requires to be simplified through an easier and fasterscoring system and which results in a general overview of the 'top 5'priorities
• aswell as condensing the Ottawa Charter sessions, the completion of thepro-formas should focus only on the key principles and not a 'task-driven'exercise based on 'filling in the boxes'
• thetraining methods are well-balanced but there should be a slightly lesspresenter-led focus. This is likely tobe addressed by shortening some of the sessions
• theobjectives of 'Overheard on a Bus' require some clarity, as well as prompts fordirection
• oneof the key challenges of the training will be to get beyond the intellectualargument of the need for the HI agenda and to prompt action for futuredelivery. This will depend on the skills and level of the participants, as wellas the extent to which senior level support (from a corporate and / or HRperspective) for the training and the wider HI agenda exists at a locallevel. The barriers of local authoritycultures and traditions will be a key influence, here
• further,national support for the future delivery of the training will be required. Otherwise thirty two variations of the HItraining might exist with no common themes or 'core' learning points
• theco-training guidance was not found to be especially useful to the majority oftrainers, who were generally experienced in this area but will be necessary forless-experienced future trainers
• co-trainingrelationships worked very well, largely due to the time spent on planning andpreparing for training delivery in a very structured way. This was conducted through face-to-facemeetings.

3.3 Issues at the pre-training stage which were not founded at post-training stage

There were only two issues which fell into this category:

• initialconcerns by some trainers that the strategy planning session at the end of theday would be too complicated were not founded with strategic groupings, whowere clearly ready to engage in this type of discussion. However, perhaps because trainers had notexpected this, these sessions were probably not as focused as they could have been. This is an important issue as the effectivenessof this last session is likely to be the key focus for participants inassessing the overall value of the training. A lack of focus at this stagecould tarnish the reputation of the training. In contrast, less strategic groupings might not be able to address theseobjectives. If this session is felt tobe too taxing for them, this could lead to disappointment and, again, couldtarnish the reputation of the training. Trainers will require to consider theintended outcomes of this session very carefully and perhaps be prepared toadapt objectives as the day unfolds and they gain a stronger grasp of what thegroup can achieve by the end of the day. The overall energy levels of the group, at this stage, will also be akey influence
• despiteconcerns about timing and fitting everything into the day, trainers found thatit was possible to cover all areas. However, this did mean cutting short the discussion sessions and it wasfelt that a more effective approach would be to cut back on the presenter-ledsessions, as detailed earlier, and to provide more time for the discussionsessions

3.4 New issues which emerged at post-training stage

A range of issues emerged here, largely building on what had alreadybeen recorded at pre-training stage:

• trainerskills - in defining the skills and abilities which trainers require fordelivery of the HI training, it is important to determine whether the ultimateobjective of the training is to challenge or inform participants. From the detail in 3.2 and 3.3 above, thiswill largely be determined by the specific needs of the group, as well asprogress being made at a local level. It is probably true that both of these issues are relevant to thetraining objectives. Future trainersshould be made aware of this from the outset, in order to determine whethertheir skills and experience are appropriate. It is very likely that a 'train the trainers' workshop will be requiredfor future trainers, with input from the HI officers
• pre-coursereading and scene-setting - participants should be encouraged to undertakebackground reading relating to the policy context of the HI agenda (through theCOSLA papers). This should bereiterated at the introductory session, at the outset of the day. Additionally, this should be discussedwithin the wider context of the community planning agenda and the LocalGovernment Act (2003), in order that participants can place the rationale forthe training in an appropriate context and understand the 'duty' element of theHI agenda. This could be achieved through diagram representationon a transparency, with scope for local information to explain progress andplanning structures which are particular to their local setting. This could act as a very powerful pre-cursorto the training and offer a clear context for incentives to engage with thetraining. Additionally, furtherstructure to the day could be created by the inclusion of some earlytransparencies which detail both the structure of the day, the key aims andlearning points. This will provide focus and a 'framework' for working over thecourse of the day
• further'scene-setting' guidance - at the 'scene-setting' stage (or perhaps earlier inpromoting the event and 'recruiting' participants) it would be useful toreassure participants that the HI agenda is not about starting from a 'cleansheet' and adding to current workloads. The message should be emphasised that a great deal of work at a locallevel already exists and that the training provides some prompts and focus forfuture direction. This could assist inreassuring participants of the value of the training, as well as offeringincentives to attend. It will beimportant that participants do not perceive the training message as HI beingsimply 'another hat to put on', in addition to current workloads. Some local authorities are already makingprogress with the Scotland's Health at Work (SHAW) initiative. From an operational perspective of 'healthimprovement' this is a real example which participants will be able to relateto. As such, where relevant to thelocal setting, this could be discussed at the scene-setting stage. However, this is only a small part of the HIagenda and should not form the focus of the scene-setting. There was also asuggestion that if participants sign a 'confidentiality agreement' at theoutset of the training, this might set the scene for encouraging open andhonest discussion throughout the day, as well as meaningful sharing ofexperiences. Whilst this type of'scene-setting' could be helpful, a confidentially agreement might be seen tobe daunting and intimidating. It shouldbe noted that the 'open learning' style of this training event might be quitenew to some participants. This will make scene-setting all the more important
• identifyingand 'recruiting' future participants - It was also suggested by some trainersthat service directors and / or heads of service will have a key role to playin promoting the training within their service areas. Where they have personally attended the training, thispromotional message is likely to be more powerful. These groupings are probably best placed to be able to identifywho the next 'layer' of target participants should be
• barriersto understanding and engaging with the HI agenda - it was also identified bysome trainers that the 'named person' culture which often operates within thelocal authority setting could act as a barrier to wider understanding of howeveryone has a role to play in contributing to the HI agenda. Traditionally, local authority staff have'single focus jobs', whereby performance and accountability are defined throughtheir service area. The HI agendarequires that staff work across service areas for added value in servicedelivery. This 'joined-up' approach topartnership working is still quite new to the local authority setting and willpresent challenges to both participants' understanding of the HI agenda, aswell as the incentives to engage and deliver in this way. Indeed, the planning structures to how thiscan be achieved are still quite unclear at a local level
• lackof current 'how to' examples - this current lack of clarity relates to thenewness of the HI agenda and, as such, there are few examples of what otherlocal settings are currently doing which could be disseminated across localauthorities. This will, of course,change as progress is made and as experiences are captured and shared through afocused approach to networking. However,in the interim period, participants might feel uncomfortable about exploring anagenda where both processes and parameters are still unclear
• clearerstructure to the pm strategy planning sessions - the last pm sessions relatingto the role of the local authority require a structural context, whichsummarises the national and local HI context. This could be presented as a summarised version of the structuresidentified in the introductory session. There should also be scope for each local setting to include details oftheir local planning structures and progress. This could be presented in diagrammatical format linking the SocialJustice Milestones to the Community Planning and HI agenda. These sessions might also benefit from thegroup undertaking a SWOT analysis, in order to focus thinking and to moveforward from mere 'listing' of current activity
• inclusionof 'ice-breakers' - the pack should contain a range of options for trainers touse as 'ice-breaker' activities. Trainers could choose from these options, in line with participants'needs and what is likely to appeal to the group. Indeed, the effectiveness ofthe 'Overheard on the Bus' session seems to be dependent upon successfulcontext-setting through the prior session - 'What is Health?' In the absence of an ice-breaker session,followed by effective context-setting, it follows that the 'Overheard on theBus' session might fail to stimulate discussion in the way in which it isintended
• the'Car Park' activity - this activity appears to have been very successful andwas very much enjoyed by participants, by way of both an afternoon 'energiser'and challenging their own views and perceptions. As detailed earlier in this chapter, the discussion which takesplace after the activity could perhaps be more focused by mapping out 'movements'from the activity and discussing these. Also, one trainer suggested that the 'character' which a participantmight be asked to assume could present some personal discomfort. In this setting, the participant might notget as much out of the activity as intended. To address this, a few extra characters could be set aside andparticipants could be encouraged to change their character if they wish to
• proposedchanges to the 'What Influences Health in your Locality?' session - setting upthe debating activity will require an element of planning. In one of the localauthorities, participants were asked to choose their stance and, in practice,too many opted for one line of argument to the detriment of setting up a fairdebating session. It might be best toeither assign roles at the outset of the activity or encourage only a fewindividuals to take part in the debate while the others observe, ask questionsand then vote. Alternatively, there wasa suggestion that participants resume the 'character' whom they were assignedduring the car park activity and take their perceived stance during thedebate. This would make the activitymore impersonal. Importantly, it will be necessary to establish that theobjective of this session is not for the debate to be 'won' but that the valuelies in the discussion and complexities which will arise during the course ofthe debate. To this end, the actualvoting stage is much less important than the process
• trainingfollow-up - the importance of a 'Phase 2' or follow-up session was raised bymany of the trainers. This would serve a range of purposes: it would allow for reflection of the keymessages from the training; it would encourage a 'next steps' approach to HIand sustain momentum for the HI agenda; it might encourage participants toprogress their thinking from a more intangible level to a practically-focusedapproach in considering what each service area can contribute to theagenda. This follow-up session couldalso be preceded by providing participants with the outcomes of the one-daytraining session. This could be done by typing up the key outputs anddistributing these either in advance of the follow-up session or at thebeginning of the session. Trainers should bear in mind that by the last pmsessions of the training, participants' energy levels are likely to belower. As such, a follow-up sessioncould produce more focused direction and outcomes
• trainingfollow-up - at the close of the session, it was suggested by one trainer that a'post card' of the Dahlgren and Whitehead model of health could be distributedto all participants. This could act asa powerful reminder of the key messages of the training and participants couldbe encouraged to take this back to their service areas for personal use or forwider discussion with colleagues
• suggestedchanges to statistics sessions - the statistics session could be condensed notjust by removing some of the information but by presenting the key data on oneoverhead which allows for easier comparison. There was some feeling that the 'connections' between the data presentedon different transparencies might have been lost due to these being presentedin different formats
• trainingdelivery over one day or two half days - whilst most trainers felt that aone-day delivery format was the most appropriate, there was some feeling thatdelivery over two half days, within a two week period might be moreeffective. This is because of theamount of information within the training and a view that this was too much toretain in one day. This might be overcome by commencing the second half daysession with a recap of the first half day. However, the disadvantage of two half days is that it is often difficultfor staff to commit to this and some fall-out might occur with someparticipants only attending the first half day. For this reason, a one-day format appears to offer the bestapproach, but with a more considered approach to the actual amount ofinformation over the course of the day
• regularsummary sessions - in order to ensure that participants remain focusedthroughout the day, it might be useful to undertake short summary sessions ofwhat has been achieved so far, perhaps before or after break times. These could be presented on flipcharts andthrough the co-training approach, where the less 'active' trainer could takenotes of progress during each session
• updatingmaterials and sustaining the training - as well as follow-up sessions forparticipants, it will be necessary to ensure that the training content staysupdated and that experiences are shared across local settings of the trainingitself, as well as local HI activity. There will clearly be a role here fornational co-ordination and overview, as well as how HI officers and futuretrainers input to this process. (HIofficers who took on a training role for the pilot exercise were keen to ensurethat any future inputs to the training are considered within the wider contextof the HI officer role.) It has been suggested that networking activity will benecessary for this to be made sustainable. This could be achieved in a range of ways, including web-access.Sustainability will require direction,planning and resourcing, with a clear view of what the objectives are for thetraining and how this links not only to the wider HI agenda, but also to thenational Community Planning agenda. Itmight be through this route that further resourcing and dissemination of goodpractice takes place. Capacity buildingwithin the HI agenda will be largely dependent upon how such networkingprocesses are established, in line with the national context. There was someconcern expressed by trainers that the sustainability of the agenda will bestrongly related to the sustainability of the currently short-term funded HIofficer posts
• relationshipsbetween trainers and HI officers - related to the above point is the need toensure that future relationships between trainers and HI officers are clearlydefined, in order that communication takes place on a regular and systematicbasis, as opposed to ad hoc updates, where important information ismissed. Such information will includeHI updates from HI officers to trainers and training updates from trainers toHI officers
• futureevaluation of the training - building on the baseline of information generatedfrom this report will be extremely important. As such, it will be important toconsider how the training and the processes which support the training will beevaluated in the future. This isparticularly important on considering that the pilot sites for this trainingwere self-selecting and are, perhaps, not typical of how the training might bereceived across all local settings
• thetiming of the training - with forthcoming elections, there was a general viewfrom trainers that the timing of this training is extremely important. In order to raise the profile of the HIagenda and ensure that its place will become embedded in future, localactivity, it must be incorporated into service plans, as well as workingtowards mainstreaming the training through the corporate training calendar andinduction training
• roll-outof training to partners - beyond embedding the HI agenda at a local authoritylevel, it will be necessary for the other partners of the JHIP to engage in asimilar process of awareness raising. This training could provide a strong framework for taking this forwardand, as such, there was general agreement that the parameters of the HItraining should not be limited to the local authority setting
• e-enabledtraining format - as well as considering how web-access could support thesustainability of the training, this medium should also be explored for wideravailability of and access to the training. This would allow for fasterupdating of materials as well as ensuring that a larger base of participantscan engage with the training. There areimplications, here, for the training format and the relationship between thetraining objectives and the delivery formats. This might be some way off but it was suggested by one interviewee thatthe HI agenda could be at the forefront of the E-Government component of theModernising Government agenda. It isclear that considerable commitment would be required to achieve this and,whilst being an important area for consideration, the implications are beyondthe scope of this particular piece of work
• thetitle of the training - despite recognising a need to review the title of thetraining, most areas simply used the same title as the pack - 'Promoting HealthImprovement and Tackling Health Inequalities'. This was felt to be too long and there was some concern that the word'promoting' might be misleading , given the established Health Promotion roleof NHS Boards
• whathas / will the training achieve? - there was strong consensus that a great dealhas been, and will be achieved by the training. Examples include: raisingthe profile of HI at a local level; encouraging partnership working through theactual training event; gearing up and preparing for completion of and deliveryof the JHIP; providing reassurance and information of what has already beenachieved at a local level; encouraging participants to make the effective'linkages' to take forward the agenda; tackling the 'myths' which existregarding what HI is and the local authority's role in addressing the agenda.Where training has been targeted at the local HI group ( as was the case withsome of the pilot sites), this offers a new opportunity for a relativelynewly-formed group to meet outwith their normal meeting format and so worktogether in a way which might offer new insights and ideas. The last of these issues seems especiallyimportant as partnership working contexts are often difficult and challenging,partially due to the partners not knowing each other very well and beingconstrained in addressing this through the normal 'meetings' format. Indeed, itwas observed by one trainer that their local group who have met since thetraining seemed to be working together in a more relaxed and productive waythan before the training
• nextsteps for the training pack - of the four test sites who were closely consultedin this study, two appear to be ready to move forward with the training in theshort-term. The other two sites are still planning how this training will fitwith wider integration of the HI agenda. After careful consideration, it hasbeen decided that no sites should use the pack in the interim period, prior torevisions being made. There are severalreasons for this: only the pilot siteshave currently had access to the pack and, as such, it would be unfair to limitshort-term usage to only these sites; in the absence of over-arching andfinalised guidance regarding pack content and delivery, there might be atendency for local variations to be developed. Under these conditions, quality assurance will be difficult to monitor;related to this issue, there is a clear need for consistency in content anddelivery across all local authority settings - accepting that local planningstructures and mechanisms must be accounted for; in the interests of ensuringthat the pack is sufficiently robust for future sustainability, there will be aneed to provide national guidance to support local areas in achievingthis. This guidance has yet to bedeveloped and will require careful consideration of balancing local flexibilitywith overarching national support. Since the pack does not contain any majorflaws, the revisions required are of a relatively minor nature. As such, the timescales for revision shouldbe quite short
• revisingthe training pack - a few trainers suggested that it might be useful to includea trainer in the process of revising the pack. This seems important in order to retain a practical approach to makingrevisions

3.5 Key issues at post-training stage

This chapter has detailedthe results of both the post-training questionnaire returns across the sevenpilot sites and the results of the one-to-one interviews at post-training stagewith trainers and senior managers in four pilot sites. The findings very much build upon trainers'views at pre-training stage and add clearer insights for both how the trainingcontent can be improved and what might be required to make the trainingsuccessful and sustainable in the future. The key themes which have emerged can be grouped under the followingthemes:

• skills of trainers and future support for trainers
• pre-course activities for both training organisationand participants' pre-course work
• detailed changes to the training pack
• post-training activities and support to participants
• next steps in taking forward the training pack
• current challenges to successful delivery of thetraining and future sustainability

4. Conclusions and recommendations

This evaluation study has exploredthe utility and sustainability of a training pack which was specificallydevised to raise awareness of the HI agenda within local authority settings.The pack was piloted in seven local authority areas - four of which contributedto intensive consultation regarding the training pack at pre and post-trainingstages. All individuals who contributedto the research did so with great enthusiasm and against a backdrop ofconsiderable preparatory and planning work. It should be noted that those test areas involved in the project werevery keen to be part of this pilot and might not be entirely representative ofall other local authority areas.

The key findings andrecommendations below have been separated into 'operational issues' and'strategic issues'. This is becausethere is a range of relatively simple changes which can be made to the pack inthe short-term, which would make the pack easier to use and deliver fortrainers. (For example, the structure of the pack, the content of thetransparencies and the specific nature of the various activities.) Such 'operational' issues can be addressedwithin a relatively short timescale and through the guidance provided in thisreport. 'Strategic issues' relating tothe training pack's future sustainability - e.g. the pack's 'fit' with localplanning structures and the need to consider how the training will berolled-out at a local level (to whom and by whom) - will require furtherconsideration. This is because many of the issues which were raised during theresearch phase of this project require to be considered within the context of acomplex and dynamic operating environment. As such, there is a need fornational training guidance to be devised, to support this.

4.1 Key findings and recommendations

Findingsat pre and post-training stages have been combined in order to identify the keythemes which emerged across the study. These findings have been listed below, together with recommendations forhow both the training pack could be improved ('operational issues') and how thetraining could be made sustainable in the future ('strategic issues'). Additionally, a research findingspresentation session to trainers and senior managers from the pilot sites wasdelivered. This resulted in a range of further suggestions and considerations,which have been factored into the report's findings and recommendations. Again, some of these were based on'operational issues' and other were based on more 'strategic issues'. Findingsand conclusions have been generalised to identify the key, overarching themesfrom the research phases of the project. As such, the details below will not reflect exactly the views of any onepilot site or individual. Given thatfour pilot sites provided more substantial contributions to this project, it islikely that most of the issues identified below have been drawn from thesesites, although the key themes from the other three pilot sites have also beenincorporated.