PEARLS full document

Transcription

PEARLS (Person-based Evidence And Real Life Stories)
Health Behaviours Insight Summary 2014.
Contents
Key documents
1. Overview of PEARLS
2. Key questions to help you use insight effectively
3. Key insights summary
4. ‘Exploding rainbow’ showing key insights into what helps and hinders behaviour
change
5. ‘Exploding rainbow’ showing key insights into what helps and hinders
engagement with services
6. Health behaviours summary of facilitators (what helps) and barriers (what
hinders) to behaviour change
7. Summary of facilitators (what helps) and barriers (what hinders) to engagement
with services
Appendices
Appendix 1: PEARLS Project Outline
Appendix 2: Methods
Appendix 3: Report structure for marketing/ insight/ qualitative research
Appendix 4: How to critique qualitative research
Appendix 5: Gap analysis
Appendix 6: Summary of reports used
Appendix 7: Turning data/ intelligence into insight diagram
Appendix 8: Process for updating PEARLS with new insights
Appendix 9: Public Health Outcomes Based Accountability Toolkit
Useful links
Joint Strategic Needs Assessment (JSNA)
Joint Health and Wellbeing Strategy (JHWS)
Social Marketing and the Commissioning Cycle
Kirklees Council Involve tool
Social marketing big pocket guide
Social marketing benchmark criteria
1
1. Overview
This suite of documents is the result of a synthesis of findings from local qualitative
studies commissioned by Kirklees Public Health between 2008 and 2011. It consists
of a number of key documents that provide a useful summary of findings and key
insights relating to facilitators (what helps) and barriers (what hinders) of behaviour
change (document 6) and engagement with health and social care services or
interventions (document 7). The findings and insights are structured in line with the
rainbow model1 of health which identifies the various personal, social, cultural and
economic factors that influence a person’s individual health and wellbeing.
Several reviewers were involved in scrutinising and discussing the findings from
twenty-four reports (see appendix 6) to develop a robust set of cross-cutting themes
and issues (see document 6 & 7). Three independent reviewers then identified and
summarised the key insights into what helps and hinders people to change their
health behaviours or engage with services (documents 3, 4 & 5).
The ‘exploding rainbow’ diagrams¹ (documents 4 and 5) have been created to
visually represent key insights into what helps or hinders behaviour change and
engagement with services and how these reflect different layers of the rainbow. The
green bubbles represent things that help and the pink bubbles represent things that
hinder. A summary (document 3) also shows the key insights from the synthesis in
an alternative quick-to-read word format.
The two main reports (documents 6 and 7) show more comprehensively what helps
and hinders behaviour change and engagement with services. To bring the findings
to life we have included quotes from the original qualitative reports showing real
examples of what people in Kirklees think. These illustrative quotes are an important
aspect of the insight but it is important to remember that they should not be used out
of their particular context (i.e. the population group and specific focus of the study).
A number of appendices are included alongside the key documents outlined above.
These will help you to make the best use of current and forthcoming qualitative
studies, research findings and insight for planning or commissioning.
1
Dahlgren G, Whitehead M 1991. Policies and Strategies to Promote Social Equity in
Health. Stockholm, Institute of Futures Studies.
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2. Key questions to help you use insight effectively
Outcomes Based Accountability (OBA) Population Accountability questions
(See appendix 9 for more information)
Does the insight inform?

The quality of life conditions experienced by children, adults and families who live
in your target community?

How they want to experience these conditions?

The causes and forces at work that explain people’s experience?

Who else should be involved in doing better?

What works to do better?

What you propose to do next?
OBA Performance Accountability questions
In determining whether you need further qualitative work to help you develop ‘insight’ into the
effectiveness of your interventions, have you identified:

Who your target population/group are?

How you can measure if your target group are better off?

How you can measure if you are delivering/commissioning services well?

How you are doing on the most important of these measures?

Who are your partners that have a role to play in doing better?

What works to do better?

What you propose to do?
Answering these questions can help you to decide what approach is needed and whether
you need to derive further ‘insight’ from your target groups.
Page 1 of 2
‘Quantitative’ approaches can help you answer the question “how much have we done?”
‘Qualitative’ approaches can contribute much more to answering the questions:

What should we do?

How should we do it?

How well did we do it?

Is anyone better off?

If so, how?
Strategic Questions Framework from Kirklees Joint Health and Wellbeing Strategy
(JHWS)1
In deciding on an approach to take to providing interventions, the first question to answer is
“What difference are we trying to make for whom?”
Once decided, then deriving insight can help us answer these questions:
1

What are the factors that cause the difference we are trying to make?

What actions will be effective in tackling this difference?

Who else should we be working with, including the local people themselves?

How are we supporting local people to take control and have choice?

Are we using resources according to the different needs of local people?

How will we know if we have made a difference and to whom?
Kirklees Council (2014) Joint Health and Wellbeing Strategy
Page 2 of 2
3. Key insights summary
Services insight
Insight 1: Person centred approach
Start with where the person is at:
 Just ask me how I am and what I need.
 One size does not fit all.
Culture
 Cultural requirements need to be taken into consideration and promoted.
Age, gender and ethnicity
 Women only… but not always.
 Don’t forget dads!
 Lack of control, fear of reprisal.
Continuity of care/holistic/whole person approach
 Look at general whole person issues such as self-esteem rather than bits of
the body or by disease.
 Treat the person not just the symptom/illness/defective body part.
Insight 2: Delivery and design of service
Format/’Feel’ of session
 Show me don’t tell me.
Interpersonal skills of provider
 Listening is key - ‘listen to me and I’ll listen to you’.
 The population do still, on the whole, value and respect clinicians but they
must be non-judgemental and demonstrate empathy.
Access and convenience
 Time: opening hours and waiting times.
 Place: ease of contact with service (e.g. efficient telephone manner and online
tools to manage appointments), easy to get to, child-friendly or childcare
provision and car parking requirements.
 Costs (real and perceived) - money, time off work, self-confidence needed to
interact with the service.
 Childcare arrangements, travel and opening times.
 Being creative about service provision: providing support in different ways
such as online and in local community groups to provide services at more
convenient times. However, people do find that one to one support with a
clinician is beneficial.
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Lack of awareness of services available


You don’t know what you don’t know and it is not always obvious what to look
for or where to look.
It is important that people are given consistent and clear information about
what services are available to them including where and when they can
access this support.
Behaviour change insight
Insight 3: Easier and nicer to do the unhealthy behaviour
 The exchange1: tangible benefits of stopping/reducing versus enjoyment from
unhealthy behaviours.
 Does the cost of adopting the healthy behaviour outweigh the perceived
‘benefit’ of unhealthy behaviour? I.e. competition (see social marketing
benchmark criteria¹).
 Why would I change what makes me happy or my life easier?
 If it ‘aint’ broke why fix it?
 The environment: obesogenic/alcogenic - it’s easy to do the ‘bad stuff’
 Freedom of choice? Without support, skills and money healthy ‘choices’ aren’t
seen as ‘choices’.
Insight 4: Life gets in the way
 Life is complex; impact of responsibilities (e.g. children, job and impact of
daily pressures).
 Lifestyle and social norms of population groups such as young people.
Insight 5: Health literacy (health knowledge)
 People need to be provided with quality information on how to make healthy
choices and be given support to maintain change.
 It is important for people to understand the advice they are given so they can
build the skills and confidence to support themselves.
 Mistrust in government advice/lack of awareness/conflicting
advice/misconceptions.
Insight 6: Influencers/decision makers: family, social and community networks
 Families can shape you, make you or break you. Family can provide support
and a positive role model but can also provide conflicting advice or a negative
role model.
 Key life-stage transitions are significant for better or worse.
 Lack of control - Who’s in charge? Who makes the rules? Important to
consider influencers and decision makers (don’t just target individuals).
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
Social connectedness - supportive and strong relationships are a key
influence on personal resilience, coping and control.
Insight 7: Resilience, confidence and self-belief
 It is important for people to understand the advice they are given so they can
then build skills and confidence to support themselves and maintain change.
Confidence is a key barrier to change e.g. healthy eating.
 Fear of the unknown - How else would I cope?
 Why should I? You need to understand the barrier to identify the motivators
(e.g. being more active helps you feel less stressed).
 Negative feelings and embarrassment about previous attempts need to be
addressed so people feel comfortable to attempt change again.
 Seeing change (including in other people like them, importance of peer case
studies) improves confidence.
1
French and Blair-Stevens (2006) [adapted from the original benchmark criteria
developed by Andreasen (2002)] Social Marketing – National Benchmark Criteria.
London: National Social Marketing Centre.
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4.Insight into what helps and
hinders behaviour change
Helps….
‘Obesogenic’/
‘alcogenic’
environment
It’s easy to do
the bad stuff
Level of knowledge about
health (health literacy) &
Learning through
observation
Hinders….
Work is hard/ tiring
Unhealthy food and
alcohol is cheap and
cheerful
Keep it convenient
Negative role
models,
unsupportive,
discouraging
Social norms,
positive role
models, support
and
encouragement
‘Cost’ of healthy
behaviour
outweighs ‘cost’
of unhealthy
behaviour
What’s in it for
me?
How long until I
see change/feel
better?
Give me the tools I need
Motivation, motivation, motivation!
“show me don’t tell me!”
Life stage transitions are turning points
Who is the
decision maker?
Who Is in control?
“Who rules the
roost”?
How else would I
cope?
What’s the point?
It’s embarrassing to
talk about
Diagram adapted from
Dahlgren & Whitehead 1991
Helps….
Keep it in the
community
Is it local,
convenient,
childfriendly?
5. Insight into what helps and
hinders accessing and engaging with
services or interventions
Do as I do not as I say
(learning by observing)
Work patterns
Hinders….
It’s not really a
choice if I can’t
afford it in the first
place e.g going to
the gym
Families can
hold you back
Fit with family
commitments?
Flexible provision
(formats, venues, times)
How will I
get there?
How much
of my time/
money will
it cost?
Start with where
I am at
Listen to me,
don’t judge me
One size
does not fit
all
See me as a whole
person not just
defective body
parts
I can’t do this
on my own
1-2-1 support
with an ‘expert’
helps
Knowledge is power
Tell me what’s on offer
What if…?
Access to Women only services
is great…but don’t forget dads!
One size does not fit all!
Lack of control
Fear of reprisal
Diagram adapted from
Dahlgren & Whitehead 1991
6. Summary of barriers and facilitators to behaviour
change
Introduction
The tables, starting on page three, summarise the key findings from a range of local
qualitative evaluations and research projects designed to provide insight (see
appendix 7) into the experience of local people about their health behaviours.
Specifically, the summary identifies the barriers (i.e. what hinders) and facilitators
(i.e. what helps) that can influence healthy behaviour change. It is important to note
that perceptions of barriers and facilitators vary depending on the individual and their
circumstances; some of these are amenable to change and others are not.
Predicting what triggers and maintains behaviour change towards a healthier lifestyle
is complex, dynamic and needs to be tackled in a variety of ways. Individual
motivation is only one aspect of this.
The value of the tables is determining whether the barriers and facilitators apply
regardless of the type of behaviour, to prompt commissioners and service providers
to promote the facilitators and address the barriers when designing, commissioning
and delivering services or interventions. It is important for those planning health
improvement interventions to be clear about the outcomes they are seeking to
achieve, any relevant contextual changes that need to be made, and the level at
which the intervention will be delivered (individual, community or population).
The extent to which an intervention can directly bring about, influence or contribute
to behaviour change must also be considered. This will help to attribute (or not)
behaviour change to a particular intervention and contribute to our local evidence
base on what does and doesn’t work for whom and in what circumstances.
Document 2, key questions to help you use insight effectively provides a series of
questions which could be helpful in determining this.
Page 1 of 16
An example of how to read across the table:
Barriers
Demographic
Desired Behaviour(s)
group(s)
Cost

Fresh food and physical
NEET
Healthy eating
activities including gym
YO
Increasing physical
membership are perceived to
Students
activity
be too expensive.

This tells us that the perception of fresh food as too expensive (i.e. cost) is a
barrier to healthy eating for 16-18 year olds not in employment, education or
training (NEET), young offenders and students.

The table above describes the barriers and facilitators to health behaviours e.g.
physical activity or healthy eating, for the particular demographic group(s), where
this has been identified in the original research.

The table uses the Rainbow model of health1 as a framework for understanding
barriers and facilitators to health behaviours. This insight can therefore be used
to update and enhance the existing set of exploding rainbows developed as part
of the Kirklees Joint Strategic Needs Assessment (JSNA)2.

Please note that it is not possible to identify from the synthesised research
findings which facilitators and barriers have more or less impact than others.

The tables on the following pages provide a synthesis of the findings. For more
detailed information and context, please ask the Public Health Intelligence Team
for the full reports.
Key to abbreviations for demographic groups:
LGBT
Lesbian, Gay, Bisexual, Trans-gender
NEET
16-18 year olds Not in Employment, Education or Training
WoCBA
Women of Child-Bearing Age
YO
Young Offenders
R&M
Routine and manual workers
BME
Black and minority ethnic groups
Page 2 of 16
General socioeconomic, cultural and environmental conditions
BARRIERS
“You’ve got the teenagers in the park and they’re all drinking … they’re taking drugs; you find needles
in the parks and that puts you off a bit as well … but there’s nothing for them really to do up here, aside
from the rugby club; if you’re interested in rugby it was there but if you’re not interested in rugby there is
nothing else for the people on this estate (the kids) to do”. (PAR01)
“Diet is very important. I always try to get my five a day of fruit and veg. Even if I eat 20 packets of
crisps, I will always try to eat ‘five a day’. So at least I’m doing one thing. But, there’s always new stuff
that’s coming out: Omega 3! What the blooming hell is that? I’m unemployed at the moment and I try to
eat right but if you go for this low cholesterol margarine it’s, like, £6 a tub! I mean £6 for some
margarine!” (ALC01)
“There’s a cinema, but it’s £7 to go….you could get pi**ed on a £7 bottle of vodka”. (ALC01)
“You eat five fruit five a day, it is expensive. So tell me how single mums are supposed to afford those
expensive fruit and veg. You are not able to…” (WOC01)
Barriers
Demographic group(s)
Changing Government Advice

General
Reducing alcohol intake
Fresh food and physical
NEET
Healthy eating
activities including gym
YO
Improving diet
membership are perceived to
Students
Increasing physical activity
Fresh food takes longer to
Students
Healthy eating/improving
prepare.
LGBT
diet
Lack of time for physical
WoCBA
WoCBA
Improving diet
Adults
Mistrust and confusion about
alcohol units.
Cost

be too expensive.
Lack of time


activity due to childcare, jobs
or study.
Lack of understanding

E.g. about a balanced diet
Availability of drugs and alcohol

Alcohol available 24 hours.
Adults

Cannabis widely available.
Young adults
Limiting drug use
Page 3 of 16
Barriers
Lack of restriction:

Outdoor drinking (“alcogenic
Children
environment”) and smoking.
Limiting tobacco use
Cheap alcoholic drinks promotions &
Students
limited non-alcoholic alternatives.
Adults
Unhealthy food provision in canteens. Students
Improving diet
(further and higher education)
Unemployment.
YO
Improving mental health
NEET
Lack of money.
YO
NEET
Being a young carer.
Young carers
FACILITATORS
“Anything that can teach you to cook better is great”. (OBE12)
“It has got to be something you are interested in for you to continue to do it, because if you find it boring
it’s going to be on the bottom of the list. If you enjoy it you will make it your priority”. (OBE12)
Facilitators
[Some] social workers.
Care leavers
Availability of social activities in the
Children
Students
Improving diet
Obese Adults
Improving diet
community.
A place to eat own food rather than
buying it.
Clear food labels and symbols.
Facilitators
Developing cooking skills.
Students
Improving diet
WoCBA
Having a job.
18-24 year old vulnerable groups
Limiting drug use
Access to money.
Young adults
Page 4 of 16
Family, social and community networks
BARRIERS
“My mum can drink eight cans of bitter in one night and not get drunk. I say, ‘Mum aren’t you drunk?’
and she’s like, ‘No. I’m 47 and I’ve been drinking for 27 years”.(ALC01)
“Like in high school some of them smoke. But half of them their Mum’s tell them to smoke...
Their Mums tell them to smoke? Yeah. Their Mums say you can smoke”. (TOB01)
“When I was living at home my mum always did everything for me. Now I live away from home
everything falls on me, I can’t be bothered so I get takeaways. That’s why I’m putting weight on”.
(OBE08)
Barriers
Family and friends as negative role
Students
models.
Children
Healthy behaviours
Young carers
Parents enable unhealthy
behaviours:

Buying cigarettes or alcohol for
Children
their children.
Young people
Children and teenagers
18-24 year old vulnerable
Limiting drug use
groups
The social ‘norm’ for first year
Students
university students to drink to
Adults
excess and young offenders to
Children
smoke cannabis.
YO
Peer pressure.
Socially acceptable ‘unhealthy’
behaviour

Limiting drug use
Social events, holidays, freedom from Students
Reducing alcohol
families (are associated with
Healthy eating
Young carers
unhealthy behaviours).
Weight management
Hectic social life.
Students
Weight management
Young people
Bonding (certain unhealthy
Students
behaviours are felt to aid bonding).
Children
Page 5 of 16
Barriers
Pressure of catering for family tastes
WoCBA
Healthy eating
Asian WoCBA
WoCBA
(Asian women only)
(especially partners).
Lack of control over own life.
Healthy eating
Improving diet
Pressure from families.
Young South Asian
Young carers
Breakdown of relationships.
NEET
YO
Being unable to discuss mental
Young adults
health with family and friends.
(Carers, YO and NEET)
Competing commitments on time.
Asian WoCBA females
Weight management
FACILITATORS
“My mother’s support really did help [to attend Weight Watchers]. And it does work, and I did enjoy it
but it was just the commitment. It just tapered off. I really got into it then I just lost my willpower”.
(OBE08)
“I drink a lot less now than I did before I had my little girl (who’s now one year old)…because I’m up
all night with her; it just takes up all my time. It’s very demanding”. (ALC01)
“My son is my conscience. [He says] Mum, you don’t want to be doing that, it will kill you
eventually. It’s like an NHS advert on my shoulder”. (TOB01)
Facilitators
Demographic group/s
Desired Behaviour/s
Family role models.
Children and families
Limiting alcohol intake
Weight management
Peer pressure.
Children
Reducing smoking
Young carers
Limiting drugs
Adults
Limiting alcohol
Students
Social norms.
Students
Limiting alcohol
YO
Limiting drugs
Page 6 of 16
Facilitators
Demographic group/s
Desired Behaviour/s
Family responsibilities
 Pregnant and having children to
look after.
Adults
WoCBA
 Not wanting to let parents or
partners down.
Having children and grandchildren to
Obese Adults
Weight management
be around for.
R&M Smokers
Friends as positive role models.
Children
Family support.
Adults
Young people
Students
Weight management
Good relationships with family,
Young adults
friends, colleagues, community.
(YO, BME and NEET)
Experiences of family illness or death
R&M Smokers
related to smoking.
Children and Young people
Skills gained through adopting
healthy behaviours

Learning team building skills and
NEET
discipline in the gym.
Young women
Page 7 of 16
Personal behaviours
BARRIERS
“It [alcohol] makes me feel relaxed and makes me forget about my worries for a bit”. (ALC01)
“I start panicking if I haven’t got one [a cigarette]…I’d love to stop its just finding it hard to stop”.
(TOB06)
“It’s like a relaxation, a hobby. [smoking] is where you go and you relax like you go to gym
and it makes you relaxed, you go swimming and it’s relaxing and you got outside for a fag and
it’s just like my time for me”. (TOB01)
Barriers
Demographic group/s
Desired Behaviour/s
The perception that drinking makes
Adults
you happy.
WOCBA
The perception that drinking gives
Adults
confidence.
WOCBA
The perception that drinking solves
Adults
Children
problems.
[Unhealthy behaviours are] fun,
exciting, enjoyable.
Limiting drug use
Improving diet
The perception that drinking
Children
facilitates sexual and social activity.
Young people
[Use of food] as a reward after a bad
WOCBA
Improving diet
R&M Smokers
Adults
Students
Weight management
day.
Habit/addiction.
Low motivation.
Adults
NEET
WOCBA
Page 8 of 16
Barriers
Demographic group/s
Desired Behaviour/s
Not interested/don’t like the desired
Students
Weight management
behaviour.
Adults
NEET
WOCBA
Low levels of skills/confidence about
Practitioners perspective
ability to change.
All groups
Improving Diet
Weight management
The fear of trying something new.
WoCBA
Improving diet
Time and effort involved.
Students
LGBT
Improving diet
Young men
NEETs
YO
Improving diet
Time spent on screen-based,
sedentary activities (e.g. X-box).
Expense (perceived or actual).
Students
WoCBA
“Me time” is associated with
Female R&M Smokers
Young adults
unhealthy behaviour.
Embarrassment/self-consciousness.
(LGBT & NEET)
Sense of “working class” right.
R&M Smokers
Drinking and smoking go hand in
R&M Smokers
hand.
Adults
Unpleasant experiences when try to
Adults
change unhealthy behaviour.
R&M Smokers
E.g. weight gain, anger and tension
when stopping smoking.
Page 9 of 16
FACILITATORS
“Socialise while you lose weight”. (OBE08)
“[Lose weight] to look better”, “To look attractive”, “To feel better in yourself”. (OBE08)
“It’s quality of life, we just feel like going to the gym. Sometimes you don’t go, you don’t feel that
satisfaction. You feel that sense of achievement; you know when you’ve been to the gym. You look at
yourself. People are telling you you’re looking better. Generally you just look at yourself, you feel
better”. (CLiK NEET)
“Well physically, if you’re eating healthily it makes your body healthy, and you meet up with friends.
That’s your emotional as well as your social. Everything has a way of interlinking together”. (CLiK
Care leavers)
Facilitators
Physical appearance.
Demographic group/s
Desired Behaviour/s
Students
Weight management
Adults
Improving diet
Obese adults
Having alternative interests.
Children
Reducing unhealthy
Adults
behaviours
Interest in food and healthy eating.
Care Leavers
Improving diet
Undertaking physical activity.
Children
Care leavers
Awareness of links between
Young carers
Improving diet
unhealthy behaviours and impact
NEET
Improving physical activity
on health.
Care leavers
Weight management
Adults
Limiting drug use
Knowledge of health
benefits/health literacy:

Page 10 of 16
Physical and emotional health and wellbeing
BARRIERS
“Being overweight knocks your confidence”. (OBE08)
“When I go and stand outside a pub you can hear coughing and wheezing. And I think he’s
obviously older than me, but I just think, God is that what it’s going to do to me. But then I just
carry on doing it”. (TOB01)
“You can tell me it will give me lung cancer at some point, but until I go to the hospital and they
say right okay, that’s it, I just think it’s not going to happen to you”. (TOB01)
Barriers
Demographic group/s
Desired Behaviour/s
Lack of knowledge about
Adults
consequences for long term health.
Young carers
Obese adults
Weight management
Children and young people
Adults
Weight management
Students
Weight management
Obese adults
Improving diet
Obese adults
Low motivation.
Emotional ill health/depression.
Mobility & other health problems.
FACILITATORS
“I know smoking has given my grandmother asthma and she has inhalers twice a day. I couldn’t cope
with that”. (TOB01)
“[Going to the gym is] a massive stress release. It’s like a burden come off. Like if you’ve been really,
really stressed out really upset throughout the day, you feel really good about yourself. I think like I
said, coming back to the point, that you feel that sense of achievement, like you haven’t done nothing
throughout the day and you feel like you’ve achieved something, you’ve been in there”. (CLiK NEET)
“I have a car but if it is local I walk now, I leave my keys and just get out. I used to feel more tired
when I used the car. I go shopping and I carry everything. Since I moved I’ve started doing that
even though I’ve got a car”. (WOC01)
Facilitators
Demographic group/s
Desired Behaviour/s
Short-term negative physical and
WOCBA
Limiting alcohol
mental effects.
Adults
Stopping smoking
Young BME males
Limiting drugs
Awareness of long-term health
Adults
Limiting alcohol
problems.
Obese adults
Weight management
Page 11 of 16
Facilitators
Demographic group/s
Fear of additional risk associated with Adults
Desired Behaviour/s
Limiting alcohol
unhealthy behaviour e.g. having drink
spiked.
Individual or family member having a
Adults
Limiting /stopping smoking
health scare.
Children (smoking only)
Weight management
Recognition of positive effects of
NEET
physical activity to relieve stress.
Resilience, coping and control
BARRIERS
“Wednesday night is student night - £1 a bottle and so easy for them to drink and get a takeaway
rather than going home and cooking some fresh vegetables”. (OBE11)
“Because we are addicted and smoking for me is part of my life and I couldn’t imagine life
without a cig”. (TOB01)
Barriers
Demographic group/s
Desired Behaviour/s
Appeal of unhealthy behaviours

Socialising, relaxing, cures
Children
boredom, enjoyable, reducing
Adults
Reducing drug use
stress, habit.
Young adults
Improving diet
WoCBA
Students
Make light of, ‘bravado’ in relation to
Students
Weight management
Adults
Stopping smoking
condition or behaviour.
Anticipated negative impact of
stopping the ‘unhealthy’
behaviour.

Increased stress levels,
depression, impact on loved ones. R&M Smokers
WoCBA
Page 12 of 16
Weight management
FACILITATORS
“Support [from friends] – that is essential. You need that definitely for young people, so to have
friends around”. (OBE11)
“[Weight loss support] They won’t take the mickey out of you and you will make new friends and
when you see the results it will boost your confidence”. (OBE03)
Facilitators
Demographic group/s
Recognition of loss of control and
YO
Desired Behaviour/s
Limiting drugs
functional ability with some unhealthy
behaviours.
Good relationships with family,
Young adults
friends, colleagues, community.
(BME, YO and NEET)
Facilitators
Demographic group/s
Exercise reduces stress and tension.
Young adults
Desired Behaviour/s
BARRIERS
“If I am not there, [my husband] can’t get everything done for himself in time so I have got to be there
for him, I think that is my priority”. (WOC01)
“It has got a lot of fat in, it’s not healthy, that’s why we’re not healthy. That’s what it is. It is very
difficult to change your lifestyle when it is set, we have been brought up with it”. (WOC01)
Barriers
Demographic group/s
Desired Behaviour/s
Denial, ignorance about health and
Young males
Weight management
not prioritising health.
Students
Transition years e.g. from school to
Students
Young adults
college.
Pressure from families.
(Asian and black females)
Belief that physical activity is only for
Asian females
Asian females
WOCBA
Cancer screening uptake
men.
Knowledge about health.
Page 13 of 16
Barriers
Reduced opportunities for instigating
Demographic group/s
Asian females
healthy behaviours.
Lack control over diet as food is
Desired Behaviour/s
Improving diet
Reducing physical activity
Asian females
Improving diet
prepared by other family members.
FACILITATORS
“Yeah women only gyms” “You don’t get guys gawping at you…you feel more self-conscious if there
are guys there don’t you?” (WOC01)
“Sometimes in the evening twice a week or three times a week I would like to do some sort of
exercise, as women together, just for an hour two times a week” (WOC01)
Facilitators
Demographic group/s
Desired Behaviour/s
Concerned about weight
Female students
Weight management
Women-only gym/exercise sessions
WoCBA
Summary and Conclusion
As the tables on the previous page demonstrate there are many wider factors which
influence health behaviours and this subject has been researched extensively over
the decades. Within Kirklees, although improvements have been made in various
health behaviours over time (e.g. tobacco use, physical activity levels in older people
specifically) as identified by the Current Living in Kirklees (CLiK)3 survey; the most
deprived groups still have the poorest health behaviours and highest levels of
morbidity and mortality.
It is worth noting that the barriers and facilitators of one health behaviour (i.e. limiting
tobacco use) are similar to the barriers and facilitators of multiple health behaviours
(e.g. reducing alcohol intake or drug use)4. Also, when people make one change to
their health, they gain the confidence to make others5.
Commissioners, programme managers and service providers can make an important
contribution to reducing inequities in health and wellbeing outcomes by addressing
barriers and promoting facilitators for healthy behaviour change, such as positive
role models and family support. Although it is important to support individual
behaviour change appropriately, commissioners and providers also need to
recognise and address what else is within their gift or remit to make the environment
or context more supportive (see exploding rainbows¹).
Page 14 of 16
For example, working in partnerships, communities can be supported to identify
those barriers and facilitators to their health behaviours, identify shared solutions and
participate in the design and delivery of interventions to more closely meet their
needs6.
References
ALC01: Kirklees Partnership (2008) Exploratory Research in Alcohol-Related
Behaviour in Kirklees. Prepared by 20/20 Research Limited.
CLiK Care leavers: Kirklees Council and NHS Kirklees (2010) CLiK Qualitative
Research: Care Leavers (18-24 year olds).
CLiK NEETS: Kirklees Council and NHS Kirklees (2010) CLiK Qualitative Research:
Young Adults aged 18-24 Not in Education, Employment or Training (NEET).
OBE03: Kirklees PCT (2008) A Qualitative Insight into Obesity Children’s Service
Users. Enventure.
OBE08: Kirklees PCT (2008) An Investigation into Attitudes and Perceptions of
Overweight and Obese Students in the Kirklees area of Huddersfield. Survey &
Marketing Services Ltd.
OBE11: Kirklees PCT (2008) An Investigation Into Kirklees PCT Stakeholders
Attitudes In Relation to 16-25 Year Old Students Attending Further and Higher
Education In the Kirklees Area of Huddersfield. Survey & Marketing Services Ltd.
Overweight and Obese students aged between 16 – 18 years living at home with
their parents in the Kirklees area of Huddersfield. Survey & Marketing Service Ltd.
PAR01: COI Leeds/NHS Kirklees (2009) Support for Parents. Andrew Irving
Associates.
TOB01: NHS Kirklees (2008) Smoking in Kirklees. Accent.
TOB06: NHS Kirklees (2009) “To test and develop, with the target audience, the
proposed service design and promotion to inform the development and
implementation of the pilot programmes planned (to reduce smoking rates of R & M
workers in the Batley and Huddersfield South areas).” Blue Republic.
WOC01: Kirklees Partnership (2008) Exploratory Research into Health of Women of
Child Bearing Age. Prepared by 20/20 Research Limited.
Page 15 of 16
1
Dahlgren G, Whitehead M 1991. Policies and Strategies to Promote Social Equity
in Health. Stockholm, Institute of Futures Studies.
2
Kirklees Joint Strategic Needs Assessment (JSNA)
3
NHS Kirklees and Kirklees Council, Current Living in Kirklees (CLiK) Survey 2012.
4
Buck, D., & Frosini, F. (2012). Clustering of unhealthy behaviours over time.
Implications for policy and practice
5
Dixon, A. (2008). Motivation and confidence: What does it take to change
behaviour. London: The Kings Fund.
6
WHO (2011) Closing the gap: policy into practice on social determinants of health:
Discussion paper for the World conference on Social Determinants of Health.
Page 16 of 16
7. Summary of barriers and facilitators to service access
Introduction
The tables starting on page two summarise the key findings from a range of
qualitative evaluations and research projects designed to provide a deeper
understanding (insight) into service users experiences of a range of services and
programmes (appendix 7). Specifically, the summary identifies the barriers (i.e. what
hinders) and facilitators (i.e. what helps) to uptake and access to services and
interventions.
The tables describe the demographic group to which the experience applies, where
this has been identified in the original research. The tables also list services to
which the experience applies, again where this was clear and specified in the original
research.
The value of the tables is to determine whether the barriers and facilitators apply
regardless of the service and whether commissioners and providers of services can
increase their knowledge of how to address barriers and promote facilitators when
designing, commissioning and delivering services.
Document 2, key questions to help you use insight effectively, provides a series of
questions which could be helpful in determining this.
How to read the tables:

Read across the table. The example below tells us that an understanding and
non-judgemental trainer is an important facilitator to help young girls to access a
dance class.
Facilitators
Service(s)
Personality of trainer is
critical:

‘Someone who
Teenage girls
understands’.

Non-judgemental.
Page 1 of 12
Dance class
 The table uses the Rainbow model of health1 as a framework for understanding
barriers and facilitators to services. This insight can therefore be used to update
and enhance the existing set of exploding rainbows developed as part of the
Kirklees Joint Strategic Needs Assessment2 (JNSA).
 Please note that it is not possible to identify from the findings which barriers and
facilitators have more or less impact than others.

The tables on the following pages provide a synthesis of the findings. For more
detailed information and context, please ask the Public Health Intelligence Team
for the full reports.
Key to abbreviations for demographic groups:
LGBT
Lesbian, Gay, Bisexual, Trans-gender
NEET
16-18 year olds Not in Employment, Education or Training
WoCBA
Women of Child-Bearing Age
YO
Young Offenders
R&M
Routine and manual workers
BME
Black and minority ethnic groups
General socioeconomic, cultural and environmental conditions
BARRIERS
“There isn’t like any community centre that we can all go to and do stuff together, like on a Friday
night, Saturday night. There’s nothing like that around here”. (CLiK BME)
“For adults like us obviously, like I said earlier, it’s got to do with money. I don’t think many parents
could afford to do stuff like that. I’d love to, you know, if I had money I’d do the swimming pool and
stuff like that”. (PAR01)
“I’m always going to start going to the gym! I just never get round to doing it, can’t afford it”.
(ALCO01)
“I thought that big [maternity booking in] appointment would be to answer my questions... and she
just, she seemed that whenever I asked a question she looked at me like I was inconveniencing her”.
(MAT05)
“I wanted to go but there was only two, and I think I just missed them. I know I wanted to go, but I
didn’t go. They were written down, so it’s a case of I just forgot sort of thing, she (the midwife) didn’t
warn me that it was coming up or anything”.(MAT05)
Page 2 of 12
Barriers
Service(s)
Unfriendly or unhelpful facilitator:

Not being listened to.
General

Not treated with respect.
E.g. WoCBA

Perception that GPs are not
All services
approachable.

Provided with leaflets instead of being
able to speak to someone.
Lack of access to and timings of services.
R&M Smokers
Chronic pain
Obese adults and children
Smoking cessation
Weight management
Perceived general lack of services in
Kirklees for:

children aged five plus
Young people

youth and teenagers
Parents
General
An expectation that schools will pick up on
issues.
Low awareness of what services on offer
Disadvantaged families
locally.
18 – 24 year olds
Financial cost of attending e.g. transport.
Parents
Weight management
Weight management
Physical activity e.g.
swimming
Awareness or availability of services:


Perceived lack of smoking cessation
Children and teenagers
Smoking cessation
services for children and young people.
Obese adults
Weight management
Practitioners not aware of obesity
Obese children
management.
Page 3 of 12
FACILITATORS
“I don’t know anything about them [Children’s Centres]. I would.....do you know like places where you
can go and there’s stuff for your kids to do and you can talk to the parents and that...I would go to all
of them me... because apart from coming here [Home Start] I’m at home 24/7, I don’t get out”.
(MAT05)
“Have a little place where you can go somewhere. I don’t know if I’d like it to be school. I just
don’t know why. But if you could go somewhere and talk to them about it [the issue] then that
would be better. What sort of a person do you want to talk to though? Someone who’d keep it
confidential, and keep it to themselves”. (TOB01)
“It’s got to be friendly as well and they’ve got to understand we are smokers and ideally if
people could run it that had been smokers, and then they’d understand then”. (TOB01)
Facilitators
Service(s)
Personality of health professional is
critical.

Someone who understands.
Teenage girls
Dance Classes

Non-judgemental.
Parents
Maternity
Smokers
Stop Smoking
Pregnancy

Adults
General
Generally non-clinical atmosphere.
Adults
General
On-line and face to face support
Adults
Out of school support.
Children
Being able to see the right person at the
right time.

More continuity of care with each service
having an understanding about other
services that can provide help.
Page 4 of 12
Family, social and community networks
BARRIERS
“I think there should be a group that is more based on activities where you can go to a social, for the
social side of it but then you can also get advice. Because then people might not necessarily think ‘I
don’t want to go to a support group because I don’t want to be seen to be needing support’, whereas if
they go into a social group you think ‘oh, I can just pick up a leaflet while I am there’ or ‘I can just
speak to someone while I am there’ then that kind of opens up for whoever wants to go”. (CLiK LGBT)
“I’m out of that age bracket now, but when I was applying to university or if I had any problems with
housing, it’s more than just a careers advice service. The one that I went to it was like a hub for young
people to actually sit and do something. I think its lacking that, and it shocked me that there isn’t one
quite central”. (CLiK BME)
Barriers
Strong informal networks of close knit
Service(s)
Disadvantaged families
General
BME
Organised physical
friends and family
Lack of appropriate childcare
activity e.g. gym classes
FACILITATORS
“They [pregnant pupils/school age pregnancy service ] do different things every time, like crafts and
arts, they do talks to mums and drink cups of tea- chill out really, just to socialise with other mums and
so you’ve got friends with babies – share experiences and stuff”. (MAT05)
“It’s [the exercise] so enjoyable. You don’t really realise you’re losing weight because you’re having so
much fun”. (OBE03)
“There’s also another one called Chestnut Centre, that’s like all in one place, where you can get a
check-up done, get condoms. You can also get check-ups at the royal infirmary and Boots pharmacy”.
(CLiK BME)
“Discussion boards and chat things....they offer a chance to be in a community in a way that a street
might not...obviously it’s different but it can certainly be rewarding and you feel close to people”. (CLiK
LGBT)
Page 5 of 12
Facilitators
Childcare or place to bring children.
Service(s)
Pregnant women
Maternity
New mums
All services
Parents
Informal support services situated in
local communities:

Buddy schemes.
Obese Children
Community health

Volunteers involved in running services.
New mums
centres
Young people
Maternity
Weight management
Social support via online channels e.g.
Young people
Facebook.
Students
General
Personal behaviours
BARRIERS
“I’ve got no one to go [to the gym] with and you feel intimidated going by yourself..... because I’ve got
this belly now”. (WOC01)
“I used to bottle my problems [stress] up and then I had a big thing because I used to self-harm as
well and that’s what I used to do I just used to keep it all to myself, I just bottled it up and bottled it up
until it got bad one time but now I have got a lot of people helping me and I’m a lot better”. (CLiK
NEET)
“I was actually quite proud of myself ‘cos the person who was taking the dancing said I could become
a leader of the dance group. I were proud of that, but after that I thought I’m fed up of this, I can’t do it
no more”. (WoCBA dance evaluation debrief)
Barriers
Demographic group/s
Services/s
Lack of confidence:
WOCBA
Physical Activity

Shy and self-conscious.
Students
Cooking classes

Sensitive to criticism.
NEET
Dance classes

Being judged by others.
Young women

Failed in the past.
Page 6 of 12
FACILITATORS
“It was fun, welcoming. The dance teacher, she was all like ‘Come dance!’ so I was like okay!”
(WoCBA dance evaluation debrief)
“It was ok having them there. It didn’t make a big difference really. They just watched us and some of
them joined in after seeing how easy it actually were”. (WoCBA dance evaluation debrief)
“Group session, led by an ex-smoker to assess your lifestyle, habits and give you ways to break the
cycle of smoking”. (TOB06)
"I thought about what I wanted to cook, I got the ingredients, and then the instructor came and
showed me how to cook it". (WOCBA food evaluation report)
Facilitators
Observing someone else.
Service(s)
Teenage girls
Cooking classes
WoCBA
Dancing
R&M Smokers
Physical activity
Stop smoking
Physical and mental wellbeing
BARRIERS
“I’d only go to doctors only if I had to. I don’t like causing a fuss. Because a few times when I have
caused a fuss it’s turned out to be nothing. So I rather not just cause a fuss”. (CLiK Carers)
Barriers
Service(s)
GPs are not perceived as someone to talk to NEET
GP
about mental health problems.
Primary Care
Young carers
Young BME
YO
LGBT
FACILITATORS
“My friend said it was a good way of keeping children out of trouble and keeping them fit”.
(WoCBA dance evaluation debrief)
“I stopped [smoking] for health reasons. Two years ago I was diagnosed diabetic and I’m insulin
dependent. So you go to your doctors and you must do this, do that. I got the patches. I get free
prescriptions now I can just go and get what I want when I want. Big patches and they worked great”.
Page 7 of 12
Physical and mental wellbeing
BARRIERS
“I’d only go to doctors only if I had to. I don’t like causing a fuss. Because a few times when I have
caused a fuss it’s turned out to be nothing. So I rather not just cause a fuss”. (CLiK Carers)
“It would take a lot of stress off me if I could cook something I know he would eat." (WoCBA food
evaluation report)
Facilitators
Service(s)
Prescriptions:

Reduction or exemption for prescription
People with chronic pain
Chronic pain
charges.
R&M Smokers
Stop smoking
Formal or one to one and intensive support
Male smokers
Stop smoking
with a clinician is seen as necessary and
YO
Primary Care
helpful.
Young Carers

Help with attaining prescriptions.
Resilience, coping and control
BARRIERS
“If you go to the gym, you see all those big guys that make you feel even worse”. (OBE12)
“I want to get fit myself, most of it is actually motivating myself. If I’ve got someone to kick me up the
bum then I will do it. … if I had a friend or partner then we’d do it together and then we’d motivate
each other along the way”. (WOC01)
Barriers
Humiliation at weigh-ins
WOCBA
Service(s)
Weight management
Obese adults
Obese children
FACILITATORS
“My health visitor was brilliant, I knew her on first name terms and had her mobile number stored, I
knew I could call her any time of day”. (PAR01)
“She’s [the Midwife] nice. She talks nice and she listens and she tells you everything that you need to
know and checks to see if there is anything you’re worried about. She’s like talking to your mum or
something like that, she’s brilliant, yes, I’ve never had any problems with her whatsoever”. (MAT05)
Page 8 of 12
“I don’t have many friends but I have good friends, when they need my help I help them and when I
need help they help”. (CLiK Care leavers)
“I’m a lot more knowledgeable [about mental health issues], because I’ve looked after my mum and
helped raise my sister and stuff like that”. (CLiK carers)
“They [other members of the group] won’t take the mickey out of you and you will make new friends
and when you see the results it will boost your confidence”. (OBE03)
Facilitators
Service(s)
Advice on coping with stress and emotional
WoCBA
Maternity
support.
Pregnancy
Weight management
Care Leavers
Mental health
Carers
NEET
Obese Children
BARRIERS
“Even if you are married some women don't like to see male doctors because I wouldn’t”. (CLiK BME)
“A lot of the GPs are Indian or Muslim and I feel myself I couldn’t go to him for support, I know myself
in their culture it is not acceptable and I would feel like he would think of me in a completely different
way and treat me completely differently”. (CLiK LGBT)
Barriers
Racial sensitivities in terms of diet (halal)
BME
and accessing services.
Service(s)
General Health
Gyms
Too busy or hectic lives and no spare time
Young people/students
General
Cultural issues:
Young south Asian adults
GP

Young South Asian adults voicing
Young south Asian
concern over South Asian GPs and
females
confidentiality.

Unease of going to male GPs.
Page 9 of 12
FACILITATORS
“Yeah women only gyms. You don’t get guys gawping at you…you feel more self-conscious if there
are guys there don’t you?” (WOC01)
“l liked that boys couldn’t go, that added a lot to the group...”. (WoCBA dance evaluation debrief)
“The people there were very nice, they didn’t speak to us like we were children, they spoke to us like
adults. That made us feel a bit special cos we weren’t being treated like little kids no more”. (WoCBA
dance evaluation debrief)
“I would like an age range like 18-25, 25-40, 40+, different age groups, women only. And having
crèche facilities as well”. (WOC01)
Facilitators
Service(s)
Female or male only support services in
South Asian women
Gym
certain circumstances
Female smokers
Dance classes
Obese males
Stop smoking
WOCBA
Male only weight loss
programmes
Mixed groups encouraged in some
Dads
circumstances
Including Dads in
maternity services
Summary and conclusion
Instead of reducing inequities in outcomes between populations, communities and
groups, services can make them worse by providing poorer access and quality of
care to segments of society with comparatively greater need. Ensuring that services
reduce rather than increase inequities requires equitable access to and provision of
services to all groups in society, at all stages of care, proportionately provided based
on needs and access to resources (assets). Such assets include communities and
volunteers as well as state provided services.
Once it is known which groups benefit from which services and, more importantly,
which groups do not access, benefit from or receive poorer-quality services, the
reasons for these discrepancies can be considered and the barriers and facilitators
of access to quality care services for these groups can be identified.
Page 10 of 12
Services and their commissioners can make an important contribution to reducing
inequities in outcomes by addressing those factors within their control - removing
barriers and facilitating access to services, such as the funding, location and timing
of services and the attitudes, skills and competencies of workers (including unpaid).
Working through partnerships, communities can be supported to identify those
barriers and facilitators to their participation in services, identify solutions and
participate in the design and delivery of services which are, by definition, readymade to meet their needs3 .
References
ALC01: Kirklees Partnership (2008) Exploratory Research in Alcohol-Related
Behaviour in Kirklees. Prepared by 20/20 Research Limited.
CLiK BME: Kirklees Council and NHS Kirklees (2010) CLiK Qualitative Research:
BME Black Young Adults
CLiK Care leavers: Kirklees Council and NHS Kirklees (2010) CLiK Qualitative
Research: Care Leavers (18-24 year olds)
CLiK Carers report: Kirklees Council and NHS Kirklees (2010) CLiK Qualitative
Research: Young Carers (18-24 year olds)
CLiK LGBT: Kirklees Council and NHS Kirklees (2010) CLiK Qualitative Research:
lesbian, Gay, Bisexual & Transgender (LGBT) 18-24 year olds.
CLiK NEET: Kirklees Council and NHS Kirklees (2010) CLiK Qualitative Research:
Young Adults aged 18-24 Not in Education, Employment or Training (NEET)
CLiK BME: Kirklees Council and NHS Kirklees (2010) CLiK Qualitative Research:
Black and Minority Ethnic 18-24 year olds - Asian
CLiK Young Offenders: Kirklees Council and NHS Kirklees (2010) CLiK Qualitative
Research: Young Offenders (18-24 year olds)
MAT05: Kirklees NHS (2009) An Evaluation into The maternity Services Available to
the People of South Kirklees. Planning Express.
OBE03: Kirklees PCT (2008) A Qualitative Insight into Obesity Children’s Service
Users. Enventure
Overweight and Obese Students in the Kirklees area of Huddersfield. Survey &
Marketing Services Ltd.
Page 11 of 12
OBE11: Kirklees PCT (2008) An Investigation Into Kirklees PCT Stakeholders
Attitudes In Relation to 16-25 Year Old Students Attending Further and Higher
Education In the Kirklees Area of Huddersfield. Survey & Marketing Services Ltd
Overweight and Obese students aged between 16 – 18 years living at home with
their parents in the Kirklees area of Huddersfield. Survey & Marketing Service Ltd.
PAR01: COI Leeds/NHS Kirklees (2009) Support for Parents. Andrew Irving
Associates
TOB01: NHS Kirklees (2008) Smoking in Kirklees. Accent
TOB06: NHS Kirklees (2009) “To test and develop, with the target audience, the
proposed service design and promotion to inform the development and
implementation of the pilot programmes planned (to reduce smoking rates of R & M
workers in the Batley and Huddersfield South areas).” Blue Republic
TOB08: Kirklees (2010) Optimisa Toplines from Women Stop Smoking Club.
WOC01: Kirklees Partnership (2008) Exploratory Research into Health of Women of
Child Bearing Age. Prepared by 20/20 Research Limited.
WOCBA food evaluation report: NHS Kirklees and Kirklees Council (2010)
Evaluation of Food Pilot. Define Research & Insight Ltd.
WOCBA Dance Evaluation final report: NHS Kirklees and Kirklees Council (2010)
Evaluation of Dance Pilot. Define Research & Insight Ltd.
1
Dahlgren G, Whitehead M 1991. Policies and Strategies to Promote Social Equity
in Health. Stockholm, Institute of Futures Studies
2
Kirklees Joint Strategic Needs Assessment (JSNA)
3
WHO (2011) Closing the gap: policy into practice on social determinants of health:
Discussion paper for the World conference on Social Determinants of Health.
Page 12 of 12
Appendix 1
Public Health Intelligence – PEARLS project outline
Programme Name
Overall aim
Objectives
Rationale
Stakeholder involvement
Health Intelligence (PEARLS)
Generate insights into key themes (e.g. life course as per
Marmot report) through the analysis and synthesis of findings
published in local qualitative research reports
 Address gaps in understanding and information about the
needs of target population groups.
 Identify any research gaps.
 Enhance intelligence to underpin behaviour change work*
 Enhance understanding of barriers and motivations to
behaviour change and levers for change.
 Inform service design/redesign and commissioning
decisions to meet the needs of the target audience.
 Produce insights and ‘end-products’ in an accessible format
(Link with NHS Hull re potential formats (CT to make link)
so that people use and understand them and do not
duplicate effort (either commissioning research or designing
services that aren’t insight led).
 Develop a quality assurance ‘tool’ or approach than can be
used by other stakeholders to assess, review and ensure a
‘minimum standard’ for qualitative methodologies, findings
and reports.
Understanding needs better leads to better developed planning
and commissioning by:
(a) Addressing barriers to behaviour change and drivers of
behaviour change.
(b) Linking to wider factors (social determinants of health
(SDH)) and the context of people’s lives and
circumstances (to compliment/enhance existing
exploding rainbows).
The output will be used to communicate and influence
commissioners, planners and frontline staff across the health
and social care system.
It will be part of Kirklees Evidence Network (KEN); Wellbeing
and Health Inequalities Steering Team (WHIST); and Joint
Health and Wellbeing Strategy (JHWS) development and
implementation.
Key products, outputs and Outputs
outcomes
 Synthesis of key insights organised into life course/
exploding rainbows, population group/ SDH issues as
appropriate.
 Key themes, keywords (e.g. to log on Involve tool),
qualitative indicators and cross-cutting issues identified.
Page 1 of 2
Appendix 1




Links with local and
national priorities?
Resources needed
Insights produced/ presented in a meaningful way for a
range of stakeholders.
For example use real case study example, link to each
stage of the commissioning cycle.
Template for logging/ recording qualitative studies and
social marketing projects. This might build on the SDH
‘case studies’ template proposed by the Institute for Health
Equity (IHE) and should complement the Involve tool.
Quality appraisal checklist (or equivalent) based on the
NICE Quality appraisal checklist for qualitative studies but
adapted for local (Kirklees/ KEN) context and with a clearly
defined SDH element.
Outcomes
 Insight led commissioning across the system.
 Shared learning about behaviour change.
 Shared learning about qualitative methods (to undertake
research and to analyse) evaluation, qualitative indicators
and SDH.
 Key element of local PH Function Paper and MOU to
Commissioning systems.
 Informs local priorities.
 Key aspect of PHI work programme.
 In-line with Cabinet office Behavioural Insights Team
recommendations.
 Key element of the JHWS implementation.
 Health and Social Care Act 2012 ‘no decision about me
without me’.
 PHI specialist to lead/ project manage (estimated no.
hours?)
 B6? Support (estimated no. hours?)
 Admin support (estimated no. hours?)
Helpful resources

One Stop Shop (OSS) – national resource and YPHO resource (might help
with structure)

NSMC case studies

Marmot report

NICE (or equivalent) quality appraisal checklist
*link to JHWS behaviour change questions.
Page 2 of 2
Appendix 2
PEARLS Method
Many organisations have produced detailed processes and guidance documents for
how to systematically review data from both a quantitative and qualitative
perspective. Organisations such as The National Institute for Health and Care
Excellence (NICE) 1 and The Cochrane Collaboration2 produce high quality guidance
documents of evidence and systems. Table 1 shows the organisation, the type of
guidance they provide and a link to their websites.
Table 1: Guides and processes for systematically reviewing data.
Organisation
Type of guidance
Evidence for Policy and Practice
Tools and methods for carrying out
Information and Co-ordinating
systematic reviews.
Centre (EPPI-Centre)
3
Provides condition specific guidance
NICE¹
setting standards for high quality
healthcare.
The Cochrane Collaboration²
Provide guidance for completing
systematic reviews and holds a
database of completed systematic
reviews.
Critical Appraisal Skills
Programme (CASP)
4
Provides guidance to use research
evidence in professional practice.
However, these guides were not entirely fit for purpose or practice when examining
the local reports/documents/insights because the reports varied enormously in
writing style and publication formats. This particular qualitative synthesis required a
different approach to extracting, summarising and synthesising the findings. The
framework proposed by Harden et al5 was used to deconstruct (break down) then
reconstruct (put back together) each ‘views’ study (defined as a study which places
people’s own voices at the centre of its analysis) in a systematic way.
Page 1 of 3
Appendix 2
Twenty-four local (see appendix 6) reports from work commissioned wholly or jointly
by NHS Kirklees between 2008 and 2011 were reviewed (see Appendix 6 for details
of individual reports). The majority of these were related to the facilitators and
barriers to health behaviours. Each study was broken down using the data extraction
tool shown on page 3 (Table 1). It was then reconstructed in a standard format
according to its particular topic area and assigned a quality score between 0-18, with
0 being the lowest quality and 18 being the highest quality score.
Key findings relating to behaviour change and engagement with services were
summarised and structured according to the Rainbow model6. Facilitators (things that
help) and barriers (things that hinder) to both behaviour change and engagement
with services were identified as the most appropriate way to categorise the key
findings from the synthesis. A gap analysis (i.e. identifying what issues or population
groups require further study/exploration) was also undertaken from both population
group (age/sex/ethnicity) and programme (e.g. mental health, sexual health, obesity)
perspectives (see appendix 5).
Several reviewers were involved in scrutinising and discussing the findings to
develop a robust set of cross-cutting themes and issues. Three different reviewers
then identified and summarised the key insights into what helps and hinders people
to change their health behaviours or engage with services
1
The National Institute for Health and Care Excellence (NICE)
2
The Cochrane Collaboration
3
The Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre)
4
Critical Appraisal Skills Programme (CASP)
5
Harden, A., Garcia, J., Oliver, S., Rees, R., Shepherd, J., Brunton, G., & Oakley, A. (2004).
Applying systematic review methods to studies of people’s views: an example from public
health research. Journal of Epidemiology and Community Health, 58(9), 794-800.
6
Dahlgren G, Whitehead M 1991. Policies and Strategies to Promote Social Equity in
Health. Stockholm, Institute of Futures Studies.
Page 2 of 3
Appendix 2
Table 1: Data Extraction Tool
(Grey shaded areas were used to create a quality assurance score)
Title of Project
Notes
1
Type of report
Pilot/Evaluation/ Social
Marketing
2
Location
3
4
Date
Sample description
5
6
7
Sample size
Sample characteristics
Sample Recruitment
Geographical location of
participants/study
Date report published
e.g. pregnant
women/smokers
N=?
Age/sex/ethnicity
How was the sample
recruited? e.g. word of mouth
8
Issues of consent/
confidentiality
Explicit theoretical
framework and/or literature
review
Clear description of the
context/ justification for the
report
Methods of data
collection/analysis
Aims/objectives clearly
stated
9
10
11
12
Page 3 of 3
Score
0 = no information/evidence
1 = limited information/evidence
2 = sufficient
information/evidence
Appendix 3
Template report structure
(for commissioning marketing, insight and qualitative research)
Refer to appendix 8 before undertaking new research or consultations.
Each report you receive or produce should contain:
1. Title
2. Date
3. Authors
4. Postcodes of the participants.
5. Location of the focus groups/interviews.
6. How the sample was recruited.
7. Well written aims and objectives (SMART) which are linked explicitly to the
results, discussion and conclusion.
8. Brief introduction incorporating background to the issue which is being
explored and justification for this piece of work.
9. Materials and Methods (i.e. what type of data collection tool utilised – e.g.
focus group discussions/semi-qualitative questionnaire/including any ethical
considerations) and justification for the methods chosen.
10. Results (including sample description: numbers/age/sex/ethnicity/any other
demographics) and a summary of the clear themes identified.
11. Sufficient inclusion of original information or quotes to help identify where/how
the themes arose.
12. Discussion of results (themes) in context of other key research or evidence.
13. Conclusions (should summarise all of the above information with some clear
‘Take home messages’).
14. Recommendations for practice and further research.
Once the research is complete, refer to appendix 8 for the process of updating
the qualitative synthesis with new findings.
Page 1 of 1
Appendix 4
How to critique qualitative research
There are many useful resources, checklists and guidelines available to help service
commissioners and providers appraise the quality of existing qualitative research
studies. Whatever model, framework or approach is adopted, it is important to be
transparent, consistent and systematic in your appraisal of qualitative studies so that
it is clear how and why you have come to your conclusions.
When commissioning qualitative studies, it is also important that, regardless of the
size/ scope/ budget of the work being commissioned, a minimum standard of ‘quality;
is achieved. As a default ‘gold standard’, the eight universal excellence criteria
proposed by Tracy1 (see Table 1 overleaf) may help to guide the appraisal of the
research report and ensure that it is fit for purpose. Please refer to appendix 8 for the
process of updating the qualitative synthesis with new findings.
Greenhalgh’s2 paper and the Critical Appraisal Skills Programme (CASP)3 resource
listed below are also strongly recommended.
1
Tracy, S. J. (2010) “Qualitative Quality: Eight ‘Big-Tent’ Criteria for Excellent Qualitative Research”, Qualitative
Inquiry, vol. 16, no. 10, pp. 837-851.
2
Greenhalgh T. (1997) Papers that go beyond numbers (qualitative research). In: How to read a paper. The
basics of evidence based medicine. BMJ Publishing Group.
3
Critical Appraisal Skills Programme (CASP). Qualitative Checklist.
1 of 2
Appendix 4
Table 1: Tracy’s Eight “Big-Tent” Criteria for Excellent Qualitative Research
Criteria for
quality
(end goal)
Various means, practices, and methods through which to
achieve
Worthy topic
The topic of the research is:
 relevant
 timely
 significant
 interesting
The study uses sufficient, abundant, appropriate, and complex:
 theoretical constructs
 data and time in the field
 sample(s)
 context(s)
 data collection and analysis processes
The study is characterized by:
 self-reflexivity about subjective values, biases, and inclinations of the
researcher(s)
 transparency about the methods and challenges
The research is marked by:
 thick description, concrete detail, explication of tacit (non-textual)
knowledge, and showing rather than telling
 triangulation or crystallization
 multivocality [e.g. lots of voices]
 member reflections
The research influences, affects, or moves particular readers or a variety
of audiences through
 aesthetic, evocative representation
 naturalistic generalizations
 transferable findings
The research provides a significant contribution:
 conceptually/theoretically
 practically
 morally
 methodologically
 heuristically [empirically, experientially]
The research considers:
 procedural ethics (such as human subjects)
 situational and culturally specific ethics
 relational ethics
 exiting ethics (leaving the scene and sharing the research)
The study:
 achieves what it purports to be about
 uses methods and procedures that fit its stated goals
 meaningfully interconnects literature, research questions/foci,
findings, and interpretations with each other
Rich rigor
Sincerity
Credibility
Resonance
Significant
contribution
Ethical
Meaningful
coherence
2 of 2
Appendix 5
Gap analysis
The following gaps in local* qualitative research and insight have been identified** in
relation to current strategic priorities. Please refer to appendix 8 for the process of
updating PEARLS with new findings.
By Life course/Population group:

The elderly population

Mental health service users

Elderly perspective on food

Male perspective on food

Father’s perspective on parenting (in progress April 2014)

Specific ethnic groups

Children and young people with long term conditions

Adults with long term conditions (apart from chronic pain)
By topic:

Food production

Sexual health (in progress April 2014)

Parenting (in progress April 2014)

Resilience: individual and community (may be covered in the nurturing
Parents work)

Self-care

Long-term conditions (and the link with mental health, self care and other
health behaviours)
*to Kirklees Public Health Directorate
**accurate at April 2014
Page 1 of 1
Kirklees Public Health Qualitative Synthesis 2012-14
Appendix 6
Qualitative Reports used in PEARLS
BARRIERS AND FACILITATORS TO HEALTHY BEHAVIOURS AND ENGAGING WITH SERVICES
Appendix 6
Topic area
Title
A Qualitative Insight into Obesity Adult
Service Users March - April 2008
Document name
Location
OBE01
Kirklees
A Qualitative Insight into Obesity; Adult
Target Group
OBE02
A Qualitative Insight into Obesity Children's Service Users
Social Marketing Insight into Obesity –
the Health Practitioners Perspective.
OBESITY
An Investigation into Attitudes and
Perceptions of Overweight and Obese
students in the Kirklees area of
Huddersfield
An Investigation Into Kirklees PCT
Stakeholders Attitudes In Relation To 16
– 25 Year Old Students Attending
Further And Higher Education In The
Kirklees Area Of Huddersfield
An Investigation into Attitudes and
Perceptions of Overweight and Obese
students aged between 16 – 18 years
living at home with their parents in the
Kirklees area of Huddersfield
OBE04
OBE08
Kirklees
Kirklees
Kirklees
OBE11
Kirklees
Methodology
Focus groups
Obese adults (16+y) who were not currently
undertaking weight management activity at
2008 the time of interview or had not done so in
the last 12 months.
Interviews
5-18 years olds currently attending or
attended a specific weight management
2008 programme in the past 12 months.
Parent and child interviews
Focus groups
Workshops
GPs, Practice Nurses, Dieticians, Health
Visitors, occupational Therapists,
2008 Physiotherapists, Stroke Staff, Coronary
Heart staff.
Interviews
Facilitated discussion groups
2008
16 – 25 year old male and female overweight Focus groups
and obese students.
Telephone interview
2008
16 – 18 year old male and female overweight Focus groups
and obese students.
OBE12
Kirklees
OBE16
Kirklees
Exploratory Research into Health of
Women of Child Bearing Age
WOC01
Batley, Dewsbury, Huddersfield
North and Spen, Batley, Dewsbury
Topline feedback from Pregnancy
Development Days: PILOT IDEA
GENERATING
Topline feedback from Dance
Development Day (EVALUATION)
Sample
Obese Adults (16+ y) currently undertaking
2008 any weight management activity.
Stakeholders (students).
Evaluation of a Programme to Reduce
Obesity Among the 16-24 Student
Population
Topline feedback from Development Day
in Dewsbury Cooking Programme:PILOT
IDEA GENERATING
WOCBA
OBE03
Kirklees
Date
2008
16-24 year old students.
2009
Women of child bearing age aged between
2008 18-40 years.
Mothers aged 21 – 36 (3 Asian/6 white).
WOC02
Dewsbury
WOC03
Dewsbury
WOC04
Batley
16 – 24 year old women who were
2009 pregnant/had children or intending to
becoming pregnant (3 Asian/5 white).
15 – 17 year old females - White.
2009
Key front line professionals (midwives).
Kirklees
Focus group
Interviews
Focus group
2009
Maternity Care report: final draft Professional and community consultation
WOC08
Focus group
2008
Focus group
Focus group
Semi structured interviews with key
front line professionals
Semi structured focus groups with
community based groups
Page 1 of 2
Kirklees Public Health Qualitative Synthesis 2012-14
Appendix 6
Area
TOBACCO
ALCOHOL
Title
Smoking in Kirklees
“To test and develop, with the target
audience, the proposed service design
and promotion to inform the
development and implementation of the
pilot programmes planned
Document name
Location
TOB01
Kirklees
TOB06
TOB07
Batley and Huddersfield South
Optimisa Toplines from Women Stop
Smoking Club Overall evaluation of
experience so far (strengths)
TOB08
Batley and Dewsbury
Exploratory Research into AlcoholRelated Behaviour in Kirklees
ALC01
Kirklees
Final report of the ‘insight phase’ of a
social marketing campaign to reduce the
alcohol consumption of young women in
Kirklees
Exploration of the Relationship Between
First Year Students and Alcohol At
Huddersfield University
CLIK 18 -24 YEAR OLDS VIEWS CLiK Summary of qualitative outputs
ON HEALTH AND HEALTH
SERVICES
An evaluation into the maternity services
available to the people of south Kirklees
MATERNITY
ALC02
Chickenley, Dewsbury Moor,
Dewsbury East and West, Batley
ALC05
Huddersfield University students
N/A
Kirklees
Date
Sample
12 – 15 year old children plus
2009
Routine and Manual workers.
Routine and Manual workers aged 20 - 40.
2009
Women attending pilot 'time for me' sessions Combination of focus groups and 12-1 interview including telephone
2010
interviews
Young people 16-18.
2008 Students 18-24.
Adults 25-40.
18-24 year old white women;
25-35 year old white women;
2008 Asian women aged 25-35.
Young girls aged 15/16.
18 – 19 year old first year students.
MAT05
South Kirklees
Methodology
Friendship pair interviews
Mini focus group
Single gender focus groups
2008
Group discussions
Interviews
Focus groups
Vox pop at Batley Frontier club
Facilitated session at Earlsheaton
College
Focus group
Website blogs
18 – 24 year olds form disadvantaged
2011 groups.
Focus group
Women (pregnant or baby under four
2009 months).
Health Care Professionals.
Focus group
Interviews
CHRONIC PAIN
Engagement with Services (PowerPoint
presentation)
PAI02
Kirklees
2009
SUPPORT FOR PARENTS
Support for parents from disadvantaged
groups
PAR01
Kirklees
2009
Individuals suffering from persistent pain.
Discussion groups
Parents from disadvantaged communities.
Focus groups
Interviews
Page 2 of 2
Appendix 7
Turning data into intelligence into insight…
Quantitative
data &
information
What?
How much?
How many?
Things that we can
measure and count
Qualitative
data &
information
Why?
How?
In what way?
Experiences,
perceptions,
attitudes,
understandings
that aren’t
‘measurable’
Intelligence
Insight
What does this
all tell us?
What’s the story?
So what?
Explaining what’s
going on, making
sense of the
information
The deep truth that
strikes a chord with
people
Adapted from Government
Communications Network
Page 1 of 1
Process for updating PEARLS
with new insights
Start
Is the work logged
on Involve?
Log on Involve:
[http://www2.kirklees.gov.uk/involve/default.aspx]
No
Yes
Have you shared
with PHI team?
Discuss findings with
PHI lead for your
programme area
No
Yes
Have new insights been identified for a particular
population group, programme area, behaviour change
or service/intervention?
No
Share learning points
(positive and negative)
as appropriate
Yes
PHI colleagues to quality assure the piece of
work/report/results and new insights and update
qualitative synthesis (and other intelligence products)
as appropriate
Ensure PHI team has copy of report and that results
and outcomes are updated on Involve
PEARLS (Person-based Evidence
And Real Life Stories)
Health Behaviours Insight
Summary 2014.
Appendix 8
Page 1 of 1
Share with full
PH team
End of
process
Appendix 9
Outcome Based Accountability
Is made up of two parts:
• Population Accountability
about the well-being of
WHOLE POPULATIONS
• for neighbourhoods, communities, districts etc
• Performance Accountability
about the well-being of
CLIENT POPULATIONS
• for projects – agencies – service providers
1 of 10
The OBA™ Journey – From Talk to Action
ENDS (POPULATION ACCOUNTABILITY)
DESIRED
OUTCOME
Choosing the
INDICATORS
Drawing the
BASELINE (and the
CURVE TO TURN)
Choosing the
PARTNERS
REVIEW
Contributory
Relationship
The STORY
BEHIND THE
BASELINE
The ACTION
PLAN
Deciding WHAT
WORKS
PROCUREMENT
MEANS (PERFORMANCE ACCOUNTABILITY)
PERFORMANCE
MEASURES
How Much?
How Well?
Better Off?
(CLIENT OUTCOMES)
2 of 10
Population
Definitions
OUTCOME
• A condition of well-being for children, adults, families or
communities.
–
eg Being Healthy, Staying Safe, Enjoying and achieving, Making a Positive
Contribution, Economic Well-being ….
ENDS
INDICATOR
• A measure which helps quantify the achievement of an outcome
–
Performance
Ends to means
eg Rate of low-birth weight babies, Crime rate, Air quality index ….
PERFORMANCE MEASURE
• A measure of how well a programme, agency or service system is
working.
–
3 types
1.
2.
3.
MEANS
How much did we do?
Is anyone better off? = customer outcomes
3 of 10
The 7 Population Accountability Questions
1. What are the quality of life conditions we want for the
children, adults and families who live in our community?
(Outcomes)
2. What would these conditions look like if we could see them?
(Indicators)
3. How can we measure these conditions? (Baselines)
4. How are we doing on the most important of these
measures?
(The Story Behind
the Baseline)
5. Who are the Partners that have a role to play in doing
better?
6. What works to do better, including no cost/low cost ideas?
7. What do we propose to do?
(Action Plan)
4 of 10
POPULATION
Turning the Curve Report Card
OUTCOME
Population Accountability
INDICATORS
The Curve
to Turn
BASELINES
heartening and/or troublesome indicators
STORY
BEHIND THE BASELINES
Data
development
agenda
KEY PARTNERS
with a role to play
BEST IDEAS - WHAT WORKS
including: No/ low cost idea, Off the wall idea
5 of 10
Performance accountability
1. Who are our customers?
2. How can we measure if our customers are better off?
3. How can we measure if we are delivering our service
well?
4. How are we doing on the most important of these
measures?
5. Who are the partners with a role to play in doing
better?
6. What works, what could work, to do better?
7. What do we propose to do?
6 of 10
Service/ system/ project being
performance managed
Customer
Turning the Curve Report Card
Performance Accountability
Performance measure
The Curve
to Turn
Performance measure baseline
heartening measures / troublesome measures
Story
behind the baselines
Data
development
agenda
Key partners
with a role to play
Best ideas - what works
including: no/ low cost idea, off the wall idea
7 of 10
Service/ system/ project performance measures
QUALITY
EFFORT
QUANTITY
How much
service did
we deliver?
How well did
we
deliver it?
EFFECT
OUTPUT
INPUT
Least
important
How much
change/effect did
we produce?
What quality of
change/effect did
we produce?
Most
important
8 of 10
How much did we do?
Number of customers served
% Common measures
(by customer characteristic)
Staff turnover rate, staff morale, % of staff
fully trained, unit cost, customer
satisfaction: Did we treat you well? etc.
Number of Activities
(by type of activity)
% Activity Specific Measures
% of actions timely and correct, % of clients
completing activity, % of actions meeting
standards etc.
Is anyone better off?
Number / Percentage
• Skills/Knowledge
• Attitude/Opinion
Including customer satisfaction
Did we help you with your problems?
• Behaviour
• Circumstances
9 of 10
Draft Kirklees OBA based action plan
Population Accountability
or Performance Accountability
OUTCOME
Service/ system/ project being
performance managed
POPULATION
Customer
HEADLINE INDICATORS
Heartening
Indicators
Troublesome
Indicators
Data
Development
Agenda
Story behind the baseline
What will make
things better
Who will do it
Performance measures
Heartening
measures
Troublesome
measures
Data
Development
Agenda
What will make
things better
Who will do it
10 of 10
Appendix 9
Turning the curve report (performance accountability)
Service/ system/ project
being performance managed
Customer
The people whose lives are affected by the
actions of the programme
Performance measure
The 3-5 priority measures which identify in
particular how well we are doing and is
anyone (and who) better off?
(Remember the quantity/quality ; effort/
effect quadrant)
Performance measure
baseline
Remember the the quantity/quality ; effort/
effect quadrant
What’s going on here?
What do we know from social marketing:
Local intelligence?
Which target population(s)? (segmentation)
Insight?
Data development agenda
Do you have everything you need to
understand the story behind the headlines?
Do you have sufficient evidence of ‘the
problem’ or is there a genuine intelligence
gap? Have you asked the right questions/
looked in the right places? Do you need more/
better data to inform your indicators?
*Do you have evidence of ‘what works’?
Key partners
Who’s involved?
Does your stakeholder map need reviewing?
Are you genuinely involving the right people?
Who are the key influencers on your target
audience?
Who’s missing?
Best ideas – what works*
 Is it specific enough?
 How much difference will it
make?
 Is it consistent with our personal
and community values?
We could….
Idea 1
Idea 2
No/ low cost idea
 Is it feasible and affordable?
Off the wall idea
1 of 1
Appendix 9
Turning the curve report (population accountability)
Population
Outcome
A condition of well-being for people in a
place…
Indicator
A measure that helps quantify the
achievement of an outcome
Indicator baseline
Choose heartening and/or troublesome
indicators that have high communication
power (commonsense and compelling), high
proxy power (say something important
about the outcome and bring along the data
herd) and high data power (quality data
available on a timely basis)
The Curve to Turn
What’s going on here?
What do we know from social marketing?
Local intelligence?
Which target population(s)? (segmentation)
Insight?
Data development agenda
Do you have everything you need to
understand the story behind the headlines?
Do you have sufficient evidence of ‘the
problem’ or is there a genuine intelligence
gap? Have you asked the right questions/
looked in the right places? Do you need
more/ better data to inform your indicators?
*Do you have evidence of ‘what works’?
Key partners
Who’s involved?
Does your stakeholder map need reviewing?
Are you genuinely involving the right
people? Who are the key influencers on your
target audience?
Who’s missing?
Best ideas – what works*
 Is it specific enough?
 How much difference will it
make?
 Is it consistent with our
personal and community
values?
We could….
Idea 1
Idea 2
No/ low cost idea
Off the wall idea
 Is it feasible and affordable?
1 of 1

PEARLS full document

Transcription

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