Publication
Promoting health improvement and tackling health inequalities: Local authorities perspectives - Evaluation of a pack for trainers
| Contents: | Executive summary 1. Introduction 2. Pre-training findings Acknowledgements 3. Post - training findings 4. Conclusions and recommendations Appendices |
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.
4.2 ?Operational? findings and recommendations
4.2.1 Pre-course activities for both training and participants? pre-course work- Introductory guidance for trainers
At the beginning of thepack, it was felt that an introductory message should emphasise the importanceof the 'spirit' of the HI agenda and how training delivery can reinforce thisspirit (i.e. focusing on improved service delivery and actively seeking outjoint approaches to delivery). Itshould also be emphasised at the outset that trainers should use the pack andguidance flexibly, by focusing on the learning outcomes and tailoring trainingstyle and delivery to match participants' needs. It is not anticipated that this will result in thirty tworadically different versions of the pack, but nor is it the purpose of thetraining pack to limit flexibility and encourage slavish conformance to theexact approach recommended. Trainers should exercise judgement on this and seekout local HI support or national guidance, if necessary. Additionally, trainers should be encouraged- as far as possible - to relate the different activities and sessions over theday to participants' experience. Thiswill serve to engage participants and encourage them to consider how the key'messages' relate to their work and experience, as opposed to learning about arange of general and non-specific themes. Some definitions of what is meant by 'health inequalities' were felt tobe necessary in order to offer trainers a clearer context, as well as dealingwith participants' questions regarding this term.
- Pre- and post-course reading
The pre-course readingrequested of participants requires to be made clearer within the pack anddistinguished from the post-course reading, which is recommended. As currently recommended within the pack,participants should be directed towards the COSLA papers which set out thelocal authority role, within the wider national policy context. Post-trainingreferences should be set more clearly against a backdrop of participantsalready having a basic 'grounding' in HI.
- The pre-course questionnaire and ice-breaker activities
The pre-coursequestionnaire was also felt not to fulfil its current objective as an effectivewarm-up / introductory activity. It wasfelt that the questionnaire could be revised to include more focused questions relatingto current experience and awareness of what activity is taking place withinservice areas. This could then bereturned early to trainers in order that they can gauge the level ofparticipants and to 'pitch' the workshop accordingly. Participants should only be encouraged to share and discuss theirquestionnaires following an effective ice-breaker' session which would prepareparticipants for the interactive nature of the workshop.
4.2.2 Detailed changes to the training work- The presentation of the support materials in thepack - the transparencies, the format and the organisation of the pack
It was generally felt thatthe format of the presentation should be changed to powerpoint, in order to'fit' with corporate branding and to allow for easier updates to the content.However, it is not entirely clear that all local settings will have access topowerpoint equipment and, as such, materials should also be available for anoverhead presentation. There was a suggestion that, in the future, the trainingshould be e-enabled to allow for wider access. The transparencies were felt to contain too much information and it wasproposed that this information should be shortened, with any additionalinformation being transferred to supplementary handouts, for laterreference. It was also suggested thatsome of the information could be displayed in a diagrammatical or pictorialway, instead of lots of text, which can be off-putting. The pack, itself, was felt to contain agreat deal of extremely useful background information and general guidance fortrainers. However, the currentorganisation of the pack meant that trainers often had to flick backwards andforwards to find all the relevant detail for the different sessions. As such, trainers suggested that the packshould be reorganised according to the materials required for delivery of eachsession.
- Balance between trainer-led and group work sessions
Overall, this balance wasfelt to be right although there were some aspects where trainer-led content wasdeemed to be a bit heavy ('History of Public Health' and the statisticssession). Relatively minor adaptations to these could rectify this balance
- Delivering the pack over one day
Initial concerns aboutcovering all of the proposed content in one day proved not to be whollyfounded. However, timings were tight,according to all the detail and content within the pack. As such, trainers have suggested that someof the actual content within some sessions could be removed, to allow focus ononly the key issues and learning points and to allocate more time to thediscussion and debating sessions, which often had to be cut short.
- Clarity of learning outcomes
In line with the above, itwas often felt by trainers that the learning points of some sessions were notclear enough for trainers to be sure how to guide these sessions and whatoutcomes they were aiming for. Clearerdefinition of the learning outcomes for each session should be provided,with separation from the learning points, which could be described asthe 'training process'. This lack of clarityseemed to be especially apparent withthe afternoon sessions, where linkages from one session to the next were notfelt to be obvious, thus impacting on participants' understanding of how thevarious HI components fit together.
4.2.3 Specific changes to the training pack content- The introductory session
Aims and objectives forthe day should be presented on the transparencies to focus thinking. Thereshould also be one or two transparencies which demonstrate in diagram formathow the HI agenda links to the wider, national policy agenda.There should be scope at a local level toadd local details within this diagram and so make the context of the trainingmore 'real' for participants. Additionally, it will be important not to overwhelm participants andthis could be addressed by setting out what is already being achieved at alocal level and how it will be important to build on this work. The addressingof the HI agenda will not be about starting with a 'blank sheet' andparticipants need to understand this message.
- 'Overheard on the Bus'
This session was not feltby all trainers to be a particularly effective session, partially due to a lackof clarity of the learning outcomes and partially because this session comesright after the introductory session which seems to lack an effectiveice-breaker activity. The inclusion ofan ice-breaker is likely to assist in ensuring that participants engage withthe 'Overheard on the Bus' activity in the way intended.
- The statistics session
The statistics session wasfelt to be somewhat 'dry' and there was a view that this could be addressed byre-defining the objectives and learning outcomes of this session and reducingthe information on the transparencies. It was also felt that the addition of local statistics would add a morerelevant dimension, as already suggested in the pack. Whatever statistics are used in this session, it was felt thattrainer guidance should be provided which offered clear sign-posting to wherestatistics can be sourced. The trainer guidance requires to specify in clearerdetail that the purpose of this session is not to analyse the variousstatistical sets but to understand how statistics can be used to offer insightsand evidence of health improvement / health inequalities issues and thatstatistics can be subject to different interpretations. As such, the inclusion of extra sets ofstatistics will not, by itself, achieve the desired learning outcomes.
- 'Car Park' activity
This was felt to be enjoyable and energising afterlunch, with clear links to health inequalities. There was a suggestion that the 'characters' might be updated andreviewed and an indoors format should be considered, since it will not alwaysbe possible to undertake outdoors. Byplotting the 'results' on grid paper, this would offer a strong focus for thefollow-up discussion exercise, rather that trying to come together and re-tracetheir steps
- The debating activity
This was felt to requiremore effective facilitation and emphasis that the key learning is through thediscussion and not who actually 'wins' the vote.
- 'What Influences Health?'
The weighting processattached to 'What Influences Health?' was felt to be complex and could beeasily simplified by working towards a consensus of the 'top five' issues.
- 'History of Public Health'
This session was also feltto be too long and could be readily condensed and limited to only the keylearning points, with supplementary material provided on an additional handout.
- The Ottawa Charter
This session requiressignificant background reading and planning for trainers. Reference materialsfor trainers, relating to the Ottawa Charter should be provided. Additionally,some of the terminology used in this session was felt to be quite alien to thelocal authority environment (e.g. 'food market'). As such, this should berevised. It was also felt that the real value of this session was inunderstanding how to use the model and not necessarily to complete thepro-forma
- Strategy Planning Sessions
The strategy planningsession at the end of the day was felt to be the most important part of the daysince this was about putting into perspective both what had been achieved overthe day and how this would be taken forward in the local service area. As such,trainers require to be clear on the objectives for this session and how thesemight be different for more operationally-focused groupings than for strategicgroups. A lack of focus in this session could produce incomplete outcomes andthis could be disappointing for participants at the end of, what has been, avery busy day. Regular summarisingsessions throughout the course of the day might support more focused efforts at this stage, as wellas clear linking to the introductory sessions where the national and localcontexts are presented and the 'duty' (through the Local Government (Scotland)Act, 2003) to engage with the HI agenda is made clear.
4.2.4 Post- training activities and support to participants- Using previous participants to promote futuretraining sessions
As well as usingparticipants to engender support and interest from future participants, theymight also play a key role in identifying where the 'gatekeepers' might existwithin the service areas. As part ofthe overall strategic plan to roll-out this training, some consideration shouldbe given to how to deal with 'gatekeepers' who are less willing to raiseawareness at a service area level. This could have quite a significant impactupon how the training is both 'perceived' and 'received' within serviceareas. It was also suggested thatprevious participants might be willing to support local awareness-raisinginitiatives, through for example the local press. This is something which localauthorities might wish to consider in relation to their own local plans.
- Reinforcing the learning from the training
It was suggested by atrainer that the Dahlgren and Whitehead model of health could be given toparticipants as a 'post card' at the end of the workshop, to remind them of thekey messages from the training and to encourage consideration of this modelback in the workplace. This is an issuewhich could be further explored at a local level.
- Simplifying health impact assessment tools for useat service level
There was also asuggestion that a simplified version of health impact assessments could beexplored with participants at the end of the workshop, for use back in theirservice areas. It was felt that thismight offer some short-term momentum for the training and a step towardprogress with the HI agenda. However,it has been recognised at a national level that awareness and application ofhealth impact assessment tools might differ at local levels and that this willbe addressed through an additional evaluation training module for HI. Therefore, in the interests of consistencyand being mindful not to over-burden trainers with peripheral training tasks,this is an issue which will be explored more fully outwith this project.
- Suggested need to undertake some follow-up work withparticipants
A 'Phase 2' or follow-upsession was advocated by many of the trainers. There was some concern aboutflagging energy levels at the end of the workshop and the extent to whichparticipants would be able to give of their best during this last session. As such, a follow-up session does offerscope to re-visit these issues and explore further. Here, any typed-up notes of the discussion sessions / outcomescould be distributed as a basis for further discussion. It will be important to consider and definethe objectives of such a follow-up session, otherwise it could becomeunfocused. This is something whichmight be pursued at a local level, whilst seeking national advice if necessary.
- Sustaining momentum at a local level
In the interim, it will be important for HI officersto take back the key messages of this evaluation study to their local sites, inorder to sustain momentum for future delivery and integration with the HIagenda, and to explain why it is necessary for all sites to wait till the finalversion of the pack is ready. Another proposed mechanism for sustainingmomentum locally was to provide regular 'update' reports to appropriate localcommittees. National guidance could beoffered, here, but local mechanisms are likely to vary significantly across thecountry. At this stage, update reportsmight focus on the outcomes of the pilot exercise and emphasise the importanceof strategic level involvement and commitment.
4.3 ?Strategic? findings and recommendations
4.3.1 Skills of trainers and future support for trainers- Trainer skills, experience and competencies
In addressing the issue ofwhether this pack could be delivered as 'stand-alone', it is important torecognise that trainers felt that significant training and facilitationexperience would not - by itself - be sufficient to deliver this HI trainingpack. It was felt that, in combinationwith this training / facilitation background, trainers would require at least abasic level of knowledge of the HI agenda (in terms of the national, policyperspective and history), current local plans and progress and a widerunderstanding of how HI 'fits' with the wider Community Planning agenda. A lack of knowledge or understanding ofthese issues could leave trainers feeling 'exposed' during training sessionsand could impact upon the credibility of the training. Additionally, trainersfelt that it would be essential for future trainers to possess a goodunderstanding of the local authority culture and the specific culture of thelocal setting. Given that specificskills, competencies and experience will differ across all local settings, inrelation to the future training role, it would be impossible to offer a 'onesize fits all' development guidance programme. This was evidenced by the significantly different ratings which trainersassigned to themselves when asked about their specific skills and experience indelivering the training. As suchtrainer capacity building at a local level is likely to require quite differentsolutions across each of the local settings. Nonetheless, national guidance which recognises this can offer advice onhow local settings can develop their capacity by learning from each other andlooking further afield to both other local areas and to more formalised and'external' learning development support. There was strong endorsement for the pack to be delivered by twotrainers. Complementary skills setsshould be identified, here, in order that the collective skills within thetrainer pairing offer a close 'match' to those proposed in this report
- The role of the HI officer in taking forward localHI training
As noted above, it wasfelt that it would be unlikely that this skills and experience 'mix' wouldexist in all local authority settings and that some form of learning supportmight be required to assist a set of 'core' trainers. The role and 'presence'of the HI officer in taking this forward was unclear although it was felt thatcurrent HI officer remits would not allow for significant time to be spent inthis way. However, there would be aneed to ensure that the HI officer has clear links to the training by way ofguidance, support and updating the materials in the pack. The relationship between future trainers andHI officers will require some definition and clarity, in order that asystematic approach to reviewing and updating the training takes place. As such, there appears to be a need fornetworking and the development of partnerships, to support both trainers and HIofficers, specifically for the training. This is required to take place at local and national levels.Such networks and partnerships could alsoassist in promoting the importance of good practice examples. It was felt that - despite the absence of acurrent 'bank' of such examples - these do exist, and a more systematicapproach to identifying and sharing these could offer significant support tofuture trainers. Examples need not belimited to the HI agenda but could include instances of partnership working,where the parallels can be readily understood.
- The co-training role and relationship
Finally, it was also madeclear by trainers that the pack should emphasise the importance of aco-training approach (with two trainers delivering to an audience of betweentwelve and sixteen participants) and that trainers should be encouraged to setaside quite a bit of time to undertake individual and joint preparation fordelivery of the training.
4.3.2 Local strategic planning mechanisms- Local, strategic planning of the 'fit' betweenhealth improvement and community planning
The local authority HIagenda should not be considered in isolation of the wider partnership working /JHI and Community Planning agendas. Inthe interests of sustainable capacity building, any approaches to networkingshould link with these agendas. It wasalso anticipated that a national co-ordinating / overview role would berequired to support such networking, with clear links to the 'operational 'context of the on-going use and application of the training pack and the wider'strategic' context of making the HI agenda sustainable at local and nationallevels through clear linkages to the Community Planning agenda and otherrelevant, local initiatives. In the longer term, there might be scope todevelop an e-enabled approach to such networking, in order to ensure speed ofinformation exchange and dissemination of good practice, as well as appropriateaccess.
- Strategic planning for roll-out of local training
In encouraging attendanceat the training sessions, it will be necessary to consider a strategic plan for'training roll-out' which fits with the overarching, local HI plan. Most areas have suggested that anincremental approach to roll-out will be undertaken, focusing on senior staffacross service areas and then encouraging such staff to support widerengagement within their service areas. For some areas, these senior staff already contribute to a'purpose-built' HI Group, which would seem to be the logical target group forinitial attendance. This group couldhave a key role to play in supporting wider promotion and awareness-raising ofthe HI training and in encouraging others to attend, within their serviceareas. It was also felt that a letter / introductory session from the chiefexecutive might also assist in setting the strategic context for the training,as well as sending a clear message to staff about the importance of thetraining. Inclusion of the HI training within the corporate training calendarwas felt to be important in both boosting the image of the training andsupporting its sustainability. Effective targeting of future participantsrequires careful consideration, in order to achieve a high degree of perceivedrelevance of the training. The packclearly specifies that local settings should consider this issue carefully andwould, perhaps, benefit from a reinforcement message that the relevance of theHI agenda should be considered before seniority, as a key, targeting criterion.The benefits of bringing different service groupings together in one sessionwere felt to be significant, in that the holistic nature of the HI agenda and'joined-up' working are likely to add value to service delivery.
- The importance of senior management support
Effective implementationand sustainability of the HI agenda are likely to be highly dependent uponon-going support from senior management. Where the HI role is 'positioned' within the local authority setting wasfelt to be extremely important in how others will perceive this agenda (e.g.positioned within a service-specific setting or having a more corporate-basedimage by being placed in the Chief Executive's office)
- Evaluating the training - nationally and locally
It is anticipated thatguidance for local training evaluation will be necessary - in terms of both the'operational value' of the pack (e.g. the content and delivery guidance), aswell as the 'strategic value' of the pack (e.g. the impact which the trainingis having on service delivery, in line with health improvementobjectives). These could be defined astraining outputs and outcomes. As wellas local level evaluation work, there will be a need to assess what has beenachieved nationally as a result of the training. This is likely to form part of the national training guidancerole. It will also be necessary to undertake regular training evaluations, aspart of incremental assessments of what is being achieved through trainingdelivery. The baseline of informationfrom this report should support future evaluations
The operationalconclusions and recommendations detailed above will support the development ofthe revised training pack, in order to make it 'fit for purpose'. The strategicissues require considered reflection at a national level and might assist COSLAin developing strategic training guidance for the health improvement agenda