Introduction
The aim of this paper is to demonstrate how the principles and methods of participatory appraisal (PA) were used to engage and consult with the wider public health workforce (Department of Health, 2003) in order to develop and launch a virtual organisation called the Centre for Enabling Health Improvement (CEHI) (CEHI, 2003). This paper critically analyses how the workshops adopting PA methods were organised and enabled the launch event to deliver its objectives on the day and to consult on future organisational plans.
Gateshead Primary Care Trust serves the population of a metropolitan borough in North East England which has some of the worst health outcomes in the country (Lambert, Reference Lambert2003; Department of Health, 2004a). It has worked in partnership with the local council, university and population to tackle public health workforce development (one of the supporting strategies in Choosing Health (Department of Health, 2004b) by developing a virtual organisation called Gateshead Centre for Enabling Health Improvement (Lambert, Reference Lambert2003; CEHI, 2003).
The strategic vision, goals and values of CEHI which are summarised in Box 1 underpinned the choice of methods used to launch CEHI in July 2004.
Box 1 Strategic goals, objectives and values for CEHI
Vision statement
Gateshead Centre for Enabling Health Improvement (CEHI) aims to support all those people who are responsible for improving public health and reducing inequalities for the Gateshead population, to recognise and develop the contribution those individuals and groups can make so that they can use high-quality accessible tools and intelligence, work in truly integrated multi-agency and multi-disciplinary partnership, and constantly evaluate and develop their practice so that every contact is a high-quality evidence and needs-based health improvement contact
Working values and philosophy
Working with the workforce and the public in a participative way
Creativity and innovation
Willingness to take risks
Recognising different ‘tiers’ of the workforce i.e. strategic, expert, operational/delivery, public
A Commitment to ehealth, Innovation theory, complexity science, transformational management
Multi-agency partnership approach
Evidence-based practice
Delegating organisational leadership to promote ownership, involvement and sustainability
Strategic goals
1 CEHI aims to help develop skills and knowledge in health improvement so that the public health workforce can:
• Understand national and local priorities for action and focus their work according to these priorities
• Recognise and understand their public health role
• Deliver evidence and needs-based health improvement
• Participate in health improvement research and development
• Audit and evaluate their health improvement activities
• Use appropriate occupational standards for public health as part of career planning
• Make every contact a health improvement contact
2 CEHI aims to develop and facilitate access to resources for Health Improvement in Gateshead so that the public health workforce is:
• Clear about the resources that exist and are available to help them
• Able to easily and routinely use resources to inform their work
• Able to routinely use resources to improve the quality of their practice
• Influence the development of new resources
• Can make every contact a health improvement contact
3 The Centre aims to develop and facilitate opportunities for the public health workforce and the public to network, share practice and learn from each other so that
• Sharing practice whether innovative or routine is adopted as an essential activity to improve services, deliver health improvement and promote research and development
• Every contact is a health improvement contact
The launch event was held in the borough leisure centre and aimed to use participatory methodology to demonstrate how members of the public health workforce can be part of initiatives and contribute to the development of future plans about health improvement.
The objectives of the event were:
• To provide a networking opportunity for staff in the borough who are interested in health issues.
• To collect information about the perceptions of the public health workforce concerned with health issues in the borough in order to consult and shape CEHI’s draft strategic plans and to inform its future action plans.
• To use methods which emphasised and promoted CEHI values of multi-disciplinary and multi-agency working and using the existing and combined resources of the wider public health workforce.
PA workshops formed the basis of the event. PA methods, established in the developing world, enable people who have an identity with their community to become involved in planning processes that affect their daily lives (Dockery and de Kooning, Reference Dockery and de Kooning1996 in De Kooning and Martin, Reference De Kooning and Martin1996; Kemmis and McTaggert, Reference Kemmis and McTaggert2000). According to the North American Primary Care Group (1996) participatory research is useful for groups of people who do not necessarily see themselves as part of a community. According to Lazenbatt and McMurray (2004:178) PA culminates in the formation of action plans that contribute to the overall development of future work. Typically in organisations, the workforce is not consulted in future organisational plans and in addition members of the public health workforce tend to see themselves as members of a professional group or an organisation rather than being part of a wider community.
Process methods
This section explains the different methods and processes involved in the preparation for and delivery of the CEHI launch. The collection of the empirical material and its analysis involved three workshops each with two stages: firstly the collection of the empirical material, and secondly the analysis of the empirical material. The management of the workshops required the facilitators to work together as a team (Pretty and Hine, 1999). The launch was planned in detail by a multi-agency team of 13 facilitators from the primary care trust (4), the local authority (6), the university (2) and an MSc student. The team met fortnightly over a three-month period prior to the launch to visit the venue at the leisure centre and to plan appropriate workshops. The planning process itself assisted in familiarising the team members in participatory methods as well as alleviating anxieties about whether PA methods were appropriate or not for the launch of CEHI. For example, the launch team piloted the questions for the workshops with a local authority community heath team in order to trial the questions and ensure that the questions facilitated participation and created empirical material that reflected people’s opinions about the location of the their work, their day-to-day working experiences and how they perceived the changes over time.
Managing the launch
The launch team collected empirical material from different sources, firstly, on arrival using the information summary sheet which was a large piece of paper on the wall at the entrance to the leisure centre. A receptionist asked each delegate to complete the summary sheet that sought information about place of work, length of time spent working in the borough of Gateshead and whether the participants were male or female. Secondly, empirical material was created in the workshops, mapping, your working day and the timeline. The welcome pack included a number and a colour which represented designated workshops for each delegate. This pre-planned approach ensured an even distribution of delegates to each of the three workshops during the first half of the launch and the analysis workshops during the second half.
The workshops
Each workshop had two facilitators who were responsible for ensuring the delegates knew about each task and managing the empirical material. One steering group member was responsible for timekeeping and moving delegates on to the next appropriate workshop.
Each workshop had two stages: (i) spending 10 minutes to generate and record empirical material and (ii) spending 30 minutes to analyse the material. Every delegate participated in the first stage of all three workshops and the second stage of one of the workshops.
The mapping workshop
The aim of the mapping workshop was to ask about delegate’s workplace in terms of the location. Delegates found their workplace on a map of Gateshead and answered three questions about the locality they worked in:
a) What is special about your locality?
b) What are the problems?
c) What are the solutions?
The delegates wrote their responses on one side of flags made from coloured post-its and cocktail sticks. On the other side of the flag, they wrote the location of their workplace. The delegates used Blu Tack cones to stand the flags on the appropriate area on a map of the borough. A specific but different colour for each question facilitated the sorting of the material in the second stage of the workshops. Green post-its indicated special features, pink for problems and yellow for solutions.
The your-working-week workshop
The aim of your-working-week workshop was to explore comments about how delegates managed their day-to-day work. In stage one of this workshop, the delegates answered the following questions about their working week:
a) What is special about your work?
b) What messes up your working week?
c) What are the solutions?
Again, different coloured post-its were used to correspond to each question. The participants wrote their responses onto the post-its and then placed them onto a long sheet of paper.
The timeline workshop
This workshop aimed to explore historical influences on delegates’ working lives and what they would like to see in the future. A large piece of paper displayed the decades 1960s, 1970s, 1980s, 1990s, 2000s and 2020s and delegates recorded their responses on colour-coded post-its corresponding to each decade. The Library and Archive department in Gateshead Council provided photographs to illustrate scenes of Gateshead during the different decades. To assist in the empirical material collection process the following themes were displayed: government policy, local issues, self-development, career opportunities, diversity, access, transport, education and training.
Stage two – empirical material analysis
Each delegate participated in the second stage of one of the workshops as indicated in their welcome pack. The methods in each workshop were similar in that the delegates analysed the empirical material generated during the first stage by reading, interpreting, sorting and counting post-it’s in order to establish the main results. The delegates sorted the material in each workshop by using the categories listed in Box 2 and by writing what was written on the post-it’s in the most appropriate category on a large sheet of paper.
Box 2 Categories for analysis in each workshop
Categories in the mapping workshop
Physical infrastructure
Environment
Health and illness
Community
Partnership
Categories in the your working week workshop
Environment
People
Tasks
Time
Demands
Funding
Categories in the time line workshop
Education and training
Government and local policy
Career opportunities
Transport
Diversity
Environment
Culture and leisure
Self
The preparation of the final report was carried out by the principal researcher (Griffin) (Griffin, Murphy and Reid, 2004). This work involved transferring the written material from the stage two workshop onto a computer.
At the end of the sorting workshop the facilitators asked their group of delegates to identify the three main results from all of the available empirical material. One of the speakers at the launch presented the important themes during the final plenary session.
Validating the results
The facilitators and delegates confirmed the results in two ways. Firstly, at the plenary of the launch, themes identified by the delegates in the mapping workshop, for example, inequalities of services, your working week workshop, for example, responding to government led demands and timeline, for example, regeneration of the area, were fed back orally with opportunities for comments. A week later, every delegate and facilitator received a draft copy of the report summarising the results and was given the opportunity to make comments about its content. No comments were received.
Outcomes
The information collected about delegates indicated that 89 delegates (27% male and 73% female) attended the launch with the majority working in primary care (48%), the local authority (38%), mental health trust (6%), voluntary sector (6%) and higher education (2%). A large proportion (57%) of the workforce had worked in the borough for at least 11 years.
The workshops generated a vast amount of empirical material and only summary data can usefully be presented here. The main themes from each workshop were fed back during the plenary session and included the delegates’ working knowledge about the location of their work such as: the diversity of the communities in which they worked; problematic access to facilities and the inequalities of services in the borough.
Table 1 represents the delegates’ knowledge of their workplaces and their client groups as collected during the mapping workshop. Their special comments refer to the delegates valuing partnership working and the diversity of the client group. The problems show the same trend of identifying issues about the workplace such as lack of investment and the difficulties associated with the client groups such as the crime and vandalism associated with young people. In terms of solutions, the delegates identified the website as being an opportunity for staff working across all sectors to improve their team working as the website can communicate successful interventions. The delegates’ solutions for their client groups sought to improve housing and facilities.
Results from the mapping workshop which explored special features, problems and solutions in localities represented by delegates
Table 2 presents the results from the working day workshop. Delegates found the diversity of work special because they had an opportunity of helping people of all ages and seeing progress. There was some overlap in that delegates found there was too much traffic and insufficient parking. These issues could be associated with location. Nevertheless, they emerged as issues that impacted on delegates’ working day in that they contributed to a poor working environment. The solutions pointed towards more investment in terms of being able to share good working practices.
Results from the working week workshop exploring delegates’ special issues, problems and solutions
Delegates identified aspects of what they would like to see in the future for themselves as well as improvements to the borough. Table 3 illustrates what the delegates valued, including the special features of Gateshead for the future, such as the regeneration of their area such as the quayside. The delegates cited specific schemes such as SureStart as examples of opportunities of offering equal access to healthcare and a step towards reducing the number of children growing up in poverty.
Key results from the timeline workshop exploring influences on delegates’ work over time and identifying what they would like in the future
Discussion
The participatory methodology facilitated collaboration between participants and organisers of CEHI through the visual methods including maps and photographs which stimulated discussion and recorded written opinions. PA methods facilitate negotiation and consensus concerning meaning and interpretation of the empirical material.
Using PA methods at the launch generated new information about the workforce and local issues in terms of the participants’ day-to-day working practices. This is congruent with the principles of PA as the exchange of ideas between the organisers and the participants prompt new insights into day-to-day issues (Pretty and Hine, 1999; Lazenbatt et al., Reference Lazenbatt and McMurray2001).
A participatory approach positively encourages people to construct their perceptions of their everyday work and issues in an active and consensual way. The methods signal to individuals that the difficulties they experience in their own daily lives are not isolated events and that sharing experiences can lead to more scope for changes. The process shows how a diverse group of people still share common challenges and problems. In the context of CEHI, this means scope for improving the co-ordination of the support and delivery of health improvement resources in Gateshead.
Researchers adopting PA methods acknowledge that people know and can articulate their day-to-day experiences in order to shape future policy; however, the ordinary people, in this case the delegates are not usually included in any planning events (Annett and Rifkin, Reference Annett and Rifkin1995). Having stated its commitment to consult the public health workforce in planning the future of CEHI, the event was a visible demonstration of the steering group’s commitment to provide a networking opportunity for staff and to involve frontline staff in the planning process. The process emphasised the value of multi-agency and multi-disciplinary working and the resources of the wider public health workforce. The workshops provided experiences that drew people together and this was exemplified by the sustained effort displayed by the delegates.
In proposing solutions the delegates brought new information to the issues they face everyday. Their solutions provided insight into how plans might develop. For example, the solutions in ‘your working week’ are clear in their direction such as a move towards increased inter-agency working, transparent targets and networking of services. These features identified by the delegates are congruent with CEHI’s objectives and reinforced them.
The concept of what is special is a key to understanding positive aspects of peoples’ working lives. Special features represent a different way of exploring ideas, for instance, asking for positive elements moves away from a negative deficit model of planning. Arguably, building on positive aspects brings momentum and a different perspective to the planning process. CEHI was able to respond quickly to the delegates requests, such as, more multi-disciplinary training events, for instance, health needs assessment seminars (Centre for Enabling Health Improvement, 2003).
During the process of the workshops, there was a high level of concentration with delegates engaging in discussions and collaboration. For example, in the analysis workshops, it was necessary for the delegates to focus their attention on interpreting and sorting the post-its into categories. This meant that there was co-operation and negotiation taking place. The process modelled the skills required for problem solving and planning services. In addition, the process exemplified how issues and solutions can be shared with all members of staff.
Despite the advantages of PA, there are criticisms and difficulties. The main criticism concerns the levels of interpretation of the empirical material. The first level of interpretation involved the delegates who read, sorted and transcribed the post-its onto large sheets of paper. The second level of interpretation was by the principal researcher who transcribed the large sheets of empirical material onto spreadsheets. In the third level, the co-ordinator and the facilitators validated the results by endeavouring to capture the momentum of the workshops in the final report. The interpretation of the empirical material means that the data is sorted and counted. This process added quantitative data to the qualitative written statements by recording the post-its, counting their frequency and identifying the three main issues from each workshop. Nevertheless, Silverman (Reference Silverman2006) observes that the results from counting can be different from the observations made by other sources such as epidemiological data from tighter controlled sources, such as the annual public health report. Therefore, the results from the launch are one source of information that CEHI consulted in their planning.
Also, each different organisation has its own agenda and the delegates did not necessarily provide a representative sample of the wider public health workforce in Gateshead. Not everyone completed the optional delegate summary sheet so that our information about the delegates is likely to be incomplete. There are also practical difficulties. The PA workshops were challenging to organise and required significant co-operation and commitment on the part of facilitators, steering group members and leisure centre staff. Without a high level of commitment and collaboration a participatory approach is problematic (Pretty and Hine, 1999). Ethically, there were concerns about asking staff about issues that fall beyond CEHI’s ability to influence, for example, improving roads. Nonetheless, the steering group could take a lead in developing methods of working that reduce the need to travel, for instance, by increasing the use of ehealth information, distance learning and other new computer technologies to avoid unnecessary travel.
Collectively, the results from the launch are a source of community knowledge that supplements national statistics and other epidemiological data. One of the strengths of using PA at the launch of CEHI was that it provided an opportunity for a workforce to make a contribution to future plans. The results constitute descriptive qualities that require interpretation and PA is not a value-free process (Annett and Rifkin, Reference Annett and Rifkin1995). The principal researcher recorded all the comments as written by the delegates. This means that the same feature might appear as a special, issue or solution statement. This need not be viewed as a problem but rather as an attempt to capture different elements of everyday life.
In using the results, the steering group focussed on issues which were consistently cited in relation to all localities and intends to use locality-based results to guide more detailed local consultation in the future. Delegates identified the need for better networking and communication and further insights into these areas are cited in the issues and solutions. For example, the results indicate that team working, better partnerships and more multi-agency working is a solution in workshop 1, 2 and 3. Other feedback indicated that participants felt that they needed more support to enable multi-agency working and networking. These results provided further validation for the CEHI goals and objectives. Subsequently, CEHI has developed an interesting and up-to-date internet website and blog (www.cehi.org.uk) and provided a wide range of multi-agency opportunities for staff development (CEHI, 2003). Delegates identified a need for more opportunities to work with a range of disciplines. This points towards providing opportunities for multi-disciplinary and multi-agency working in order to increase the public health capacity of all people working in Gateshead.
Since launch, CEHI has facilitated a series of networking events related to the ‘Choosing Health’ (Department of Health, 2004b) agenda. These events have used PA methods to engage staff in the construction of the web log and to involve staff at all levels and disciplines in planning health improvement interventions. CEHI also adopted PA methods to develop local plans for health trainers becoming one of the 12 national early adopter sites to implement Health Trainers nationally (CEHI, 2003; Department of Health, 2004a).
The PA results indicated that the workforce identified the need for organisational development activity to support health improvement activities in the borough. CEHI was established to provide this support thus, we were able to conclude that the workforce welcomed and supported the creation of CEHI and its strategic goals. The CEHI steering group recognised that the PA results were also relevant to other groups and agencies concerned with planning for health improvement in Gateshead. Therefore, the results have been disseminated in CD format to key groups, such as neighbourhood management committees, and are also available on the CEHI web blog. Consequently, the views of the workforce can be used to influence other plans in the borough. Local area executive committees are already using these results.
Conclusions
The PA methods provided a concrete networking opportunity for the local health community and encouraged joined up working regardless of agency or discipline. This builds on the cross-disciplinary approach that the senior teams in the PCT and Local Authority are taking in order to tackle health inequalities in Gateshead.
The workshops visibly and actively demonstrated that CEHI is committed to involving frontline staff in its plans, to use the combined resources of the wider public health workforce and to provide concrete experiences to bring members of the Gateshead health community closer despite their different goals and experiences. The PA results provided validation of CEHI strategic goals and have been used to inform future plans. Top-level endorsement at the event, combined with the PA workshops signalled the major changes in the culture of health improvement in the borough.
This paper highlights some of the challenges and benefits of using PA methods. In our experience, PA provided a wealth of information generated by staff that had clear understanding and expert knowledge of the issues and solutions affecting them in their work. It enabled the CEHI steering group to get a better understanding of the issues and solutions by consulting and involving people who were not usually involved in planning. We would encourage other groups to use PA methods as a way of drawing workforce communities together and ensuring that relevant experience and knowledge can be used in the planning process.
Acknowledgements
We are grateful to every member of the Centre for Enabling Health Improvement steering group and the facilitators who helped to make this project so successful. We extend special thanks to Pat Elms, Nicoll Loyd, Adrian Smith, Amanda Potts, Jayne Norwood, Trevor Hopkins and Ian McGowan for their role in helping to develop the workshops and who were instrumental in making it all happen. Barbara L Griffin acted as the principal researcher leading the design of the workshops, collecting and reporting on the results.
