A process evaluation of a Training of Trainers (TOT) model of men’s health training

A process evaluation of a Training of Trainers (TOT) model of men’s health training Abstract This study set out to identify the mediators of diffusion of a Training of Trainers (ToT) programme; focusing on ENGAGE, Ireland’s national men’s health training programme, we explored the process (planning, implementation and maintenance) of using a ToT model of training to affect change in gender sensitive health and social service provision for men. Our findings indicate that an experiential learning approach in combination with mechanisms for feedback and fostering peer-based support during training and beyond are key strategies that foster individual (Trainer), community (of Trainers) and organizational (Trainer workplaces) level ownership. Moreover, by adapting in response to feedback, ENGAGE was able to remain relevant over a number years and to different cohorts of Trainers. As such, core strategies used by ENGAGE could be used to inform new models of health training elsewhere. Training of Trainers, institutionalisation, sustainability, men’s health INTRODUCTION Background In recent years, the spotlight focused on men’s health has highlighted the excess burden of ill-health, mortality and premature death experienced by many men, and poorer men in particular (European Communities, 2011; White et al., 2013). Since 2008 national men’s health policies have been published in Ireland, Brazil and Australia prompting calls for an increased policy focus on men’s health more generally (White et al., 2011). Central to this increased focus on men’s health have been calls for a greater provision of gender sensitized health-related services for men (Department of Health and Children, 2008; Department of Health and Ageing, 2010; European Communities, 2011). Engaging men in health-related services, however, poses unique challenges to service providers who often see men as ‘hard to reach’ (Wilkins and Savoye, 2009; Caperchione et al., 2012). Many service providers struggle to identify men’s health needs, how to effectively reach men and the type of services to which men might respond (Hobbs, 1995; Barton, 2000). The importance of appropriate training (initial and ongoing) for those involved in men’s health work has been previously identified in research as key to successful health interventions for men (Robertson et al., 2013, 2015). In recognition of the need for services providers need to be supported to adopt gender sensitive work practices, Ireland’s national men’s health policy recommended the development of men’s health training targeted at front line service providers. ‘ENGAGE’, Ireland’s National Men’s Health Training programme, was developed by a partnership of statutory, academic and community sectors, to meet that recommendation. ENGAGE is a comprehensive 1-day training that aims to increase participants’ understanding of best practices in engaging men with health and social services and aims to address what many would regard as the current deficit in gender sensitive service provision for men. The Diffusion of Innovations Theory (Rogers, 2003) informed the approach used to implement the ENGAGE training programme. ‘Diffusion’, in this case, describes the process by which an ‘idea’ (i.e. gender sensitivity in service provision) spreads to a specific population (i.e. service providers), with the intended end result being that service providers adopt a new behaviour (i.e. gender sensitive work practices). A ‘Training of Trainers’ (ToT) cascade model of delivery was adopted; individuals from key organizations were recruited to the ToT training to become Trainers of the ENGAGE 1-day training programme for service providers. Trainers committed to deliver three ENGAGE training programmes. With respect to diffusion, a total of 57 Trainers were trained in three cohorts from 2012 to 2014. At the end of September 2015, 62 training events had taken place that were attended by 810 front line service providers. The purpose of this study is to investigate the process by which the ToT model was developed and implemented in order to effect maximum diffusion. Specifically, this study aims to understand both the mediators of diffusion, and the underlying theoretical assumptions (as articulated by Birkmayer and Weiss, 2000) that were used in the planning and implementation stages of the ENGAGE programme so that generalisable strategies can be identified that may inform how models of training may be implemented in the future. An overview of the development and implementation of ENGAGE The process of developing, delivering, and maintaining the ENGAGE training is detailed in Figure 1. The ENGAGE training [both the TOT and the 1-day training for service providers] was overseen by the ‘ENGAGE team’ [n = 7]. Four organizations partnered to create the ENGAGE training; a Facilitator from each organization developed the training and was responsible for its delivery and maintenance. An editor was responsible for creating the online discussion forum. The Coordinator fulfilled an administrative role and was responsible for communicating with the group of Trainers. A researcher led an outcomes evaluation that will be reported elsewhere [see corresponding author]. In addition to these human resource costs, core funding of €35 000 was secured to implement the ENGAGE programme. Fig. 1: View largeDownload slide ‘ Engage’, National Men’s Health Training Programme: development, delivery and maintenance process methods adopted. Fig. 1: View largeDownload slide ‘ Engage’, National Men’s Health Training Programme: development, delivery and maintenance process methods adopted. A plan for sustaining the diffusion of ENGAGE underpinned the implementation process and was based upon an adaptation of Shediac-Rizkallah and Bone’s (Shediac-Rizkallah and Bone, 1998) conceptual framework that includes: Project design and implementation factors ENGAGE was piloted over a 24-month period to a variety of service providers (see Figure 1). Based on feedback from the pilot phase and personal reflections from Facilitators, the ENGAGE training content and methodology was adapted and refined before delivery to Trainers. The five ENGAGE Units include: an overview of men’s health, gender and social determinants of health; strategies for practitioner support; guiding brief interventions with men; strategies for engaging with men; and mechanisms for men’s development groups and sustained engagement. Using experiential and interactive methodologies, opportunities were created for Trainers to connect with the subject matter on a personal level to promote a deeper integration of their learning. Upon completion of the training, Trainers were resourced with an ENGAGE training folder that consisted of session plans, handouts, audio-visual aids and a promotional flyer. Mentoring and technical assistance was offered to Trainers post training in the form of opportunities for co-facilitation, regular email and phone communication, two refresher meetings and an online resource repository that was continually updated. Factors within the organisational setting Following a wide marketing strategy, Trainers were selected based on four specific criteria: the strategic relevance of their representative organization to men’s health; having a remit to deliver training; having facilitation experience; and having knowledge of men’s health. It was endeavoured to achieve a wide geographical spread and, over time, to recruit two or more participants from the same organization. Factors within the broader community environment (i.e. community of Trainers) All Trainers underwent two 2-day residential training blocks delivered 1 month apart. Experiential methodologies prompted the sharing of experiences and knowledge between Trainers. Consistent with adult learning theory, Trainers were also given the opportunity to practice using the skills and information that they had received by co-facilitating a workshop to their peers (Spencer and Jordan, 1999). At the end of training, Trainers were formally certified as ‘ENGAGE Trainers’ and networking amongst the community of Trainers was encouraged via an online discussion forum and offline via the sharing of contact details. METHODOLOGY Informed, written consent was given by all participants in this research, which was approved by Waterford Institute of Technology’s Research Ethics Committee (Ref: 14/HSES/05). All data represented in this study have been de-identified and made anonymous. The ENGAGE team and ENGAGE Trainers comprised the study population. All Trainers consented to be contacted for this evaluation via email at recruitment. This study overlapped with the training of the 2014 cohort, and only one 2014 Trainer delivered training within the study timeframe (end of December 2014; 42 training days delivered to 571 service providers). Therefore, a total of 39 Trainers were invited by the authors directly to participate in this study. Three Trainers were no longer active in their organizations, and could not be reached, thereby reducing the study population to 36 Trainers. Using data from the parallel outcome evaluation, Trainers were categorized as very active (≥3 trainings delivered), active (1–2 trainings delivered) and inactive (0 trainings delivered); the activity level of Trainers who participated in this study is representative of the activity levels of all ENGAGE Trainers (see Table 1). Table 1: Activity of trainers as of the end December 2014 Year  Trainers (number)  Very active trainers (≥3 trainings delivered)   Active trainers (n = 1–2)   Inactive trainers (n = 0)   n  %  n  %  n  %  2012  18  5  28  8  44  5  28  2013  20  1  5  12  60  7  35  Total  38  6  16  20  53  12  31  2014  19      1  5  18  95  Total  57        Year  Trainers (number)  Very active trainers (≥3 trainings delivered)   Active trainers (n = 1–2)   Inactive trainers (n = 0)   n  %  n  %  n  %  2012  18  5  28  8  44  5  28  2013  20  1  5  12  60  7  35  Total  38  6  16  20  53  12  31  2014  19      1  5  18  95  Total  57        Multiple data collection tools were adopted in order to fit the needs and preferences of participants; a semi-structured, qualitative interview guide was used with participants in telephone and in-person interviews and was then modified into an online survey. Some 16 Trainers self-selected to do the online survey (n = 5) or an interview (n = 8 telephone and n = 3 person-to-person). Participation was a challenge for this study because Trainers work full time and many were on vacation during the data collection period. While the participation rate was lower than desired, the sample of Trainers was representative of the diverse activity level of Trainers and participants provided adequate insight into their experience of ENGAGE. Five members of the ENGAGE team (focus group) participated in the study. The first author conducted, transcribed verbatim and coded the data, using qualitative thematic content analysis, from all in-person and telephone interviews. Codes were created based on both unique language and from previously identified points of interest (e.g. mechanisms of support). Once transcripts were coded, thematic memos were created from both the interviews and online survey data to illustrate how key excerpts were categorized into major and sub themes. Themes from both data sources were consistent. The fifth author (ENGAGE team member) then reviewed the coded transcripts and the theme memos in order to ensure consistency in the analysis. Themes and codes were discussed openly and used to guide a final reading of the transcripts and development of a comprehensive list of themes. The authors then worked collaboratively to write the final manuscript. RESULTS All participants reflected broadly on their experience of the ENGAGE training programme and specifically the ToT model that was used in this health training. Responses were captured by several overarching themes, including: individual and organizational buy-in, collaborative approach, professional and personal practice and peer-based support. In particular, issues of trust, clarity, reliability and confidence emerged from interviews as key mechanisms that instilled this sense of buy-in and ownership among Trainers at each stage of the programme. Both Trainers and ENGAGE team members unanimously identified that mechanisms of support were the backbone of the training programme, and the catalysts for diffusion. This section will outline in detail the factors that contributed to the perceived strengths and challenges of the ToT model. Individual and organizational buy-in The notion of ‘buy-in’ was understood by participants as the degree to which the training aligned with values, “moral compasses”, or goals either on an individual or organizational level, and was salient in the responses of both Trainers and ENGAGE team members. Trainers discussed applying to the Engage training with some initial sense of buy-in based on a perceived synergy between the training objectives and their own personal or professional interests and values. These factors also facilitated the Trainers’ sustained involvement in ENGAGE over time and their motivation to deliver training. Trainers commonly noted the application of training material with their practice, and actively took it upon themselves to advocate on behalf of ENGAGE and share the lessons they learned from their experience. Commonly, buy-in was discussed in terms of participants’ own understanding of the importance of such training, and their enthusiasm to be involved. As one participant described, “My sense from working in the community is there's a real need for this, for this particular training. That would have been reflected within the amount of people when it was put out to all HSE [national health service] users, is the interest of people around it.” – Emma Similarly, members of the ENGAGE team discussed that congruence between organizations and prospective Trainers was an intentional strategy used in the recruitment phase and was paramount to the diffusion of ENGAGE. The ENGAGE team commented that all Trainers were deliberately recruited. Those just “looking to put something on their C.V.” were intentionally avoided. Prospective Trainers who intended to influence organizational practices related to the engagement of men in health services, were deemed a better fit for the training. The focus group unanimously concluded that this strategy was an important first step in ensuring that the incoming Trainers would have some degree of buy-in, and would therefore be in a realistic and strategic position to deliver training. Moreover, their existing experience and interests would align with the content and ethos of ENGAGE, making the training both enjoyable and beneficial. Organizational-level buy-in was discussed by participants as an important factor that either enabled or prevented Trainers from participating fully in the ENGAGE training, and upholding their commitment to training service providers. Initial organizational support enabled Trainers to take time off of work to participate in and deliver training, and attend refresher sessions. Some Trainers noted that their organizational affiliation further enhanced their ability to deliver training because the particular brand or reputation added extra credibility. “I was more privileged than most in that [Organisation] is my work, and I had been doing a lot of training and I had a lot of contact with different groups. So, I actually went back to some of the groups I already did training with and I said, ‘You know the training I did with you in the past, well now there’s a new training pack and it’s called ENGAGE’.” – Jack Yet, Trainers also expressed frustration with navigating managerial red tape or influencing internal organizational culture. Negotiating time off, getting support from upper management, and explaining the purpose of ENGAGE to “non-medical” or “pedantic” employers were frequently cited challenges. The ENGAGE team similarly noted that the frustration of going from a positive training experience to an unsupportive organization can smother momentum for delivering training or making any changes to practice. “I have to explain the value and why you would do this. I would have some really good people and […] I’ve other people going, ‘Well what does this have to do with caring for somebody?’ And […] they just were an admin person and they didn’t get it”. – Ciara “The biggest challenge is not getting lone individual visionaries […] The harder one is getting their organisational buy-in to do something with it afterwards […] The people who come away after four days training, who are buzzed to the nines, soon lose it when somebody’s saying, ‘no you can’t have time off to deliver that training’.” – John Participants also reflected on the unique challenge of facilitating organizational buy-in around the topic of men’s health. Many participants discussed the difficulty of demonstrating the importance of addressing men’s health, meaningfully engaging with men, and allocating funding to gender-based initiatives. Specifically, some participants commented that countering the relative invisibility of men’s health and persistent gender stereotypes at work threatened their ability to foster buy-in for the ENGAGE training, and influence organizational change more broadly. “When you say, ‘I’m doing the national men’s health training programme engaged with men’, I think that people don’t understand what you’re talking about initially because you know some people kind of say in a joking, ‘how to engage with men ha ha ha’.” – Sophie As Trainers were given the task of setting up their own ENGAGE training sessions and recruiting service providers as participants, they also found it challenging to generate external organizational buy-in in their role as Trainers. Promoting the training, selling the concept of meaningful engagement with men, and navigating training policies in other organizations were commonly cited obstacles that participants faced. For example, one participant found that influencing organizational culture related to sports, and specifically trying to facilitate buy-in around the value of promoting the wellbeing of male athletes, was difficult. “For training lads for football, they just weren’t grasping the concept that they had a role to play in helping that player’s health. […] They were there to train the player, and not to be wondering, ‘are they alright?’” – Rachel Ultimately, participants came to a similar conclusion that organizational buy-in—whether it was the Trainers’ own organizations or a prospective organizations to deliver training to—could make or break the ToT model. “The challenge starts then when you release [the Trainers]. If you release them and say, “Look off you go now you’re trained,” it’s doomed to failure really. So, you have to be realistic. […] We’ve learnt through experience, that you need to kind of mentor and support people once they completed the training. To get up and running and develop confidence, well through that, and delivery.” – Richard Collaborative approach All participants named the collaborative approach, both between ENGAGE team members and Trainers, as a significant component of the training that established trust, reliability and individual ‘buy in’ from Trainers. The initial collaboration between ENGAGE team members to integrate their diverse skills base to develop the content was commonly referenced as a success of the training. Many Trainers recognized the diverse skills and expertise of the Facilitators, and subsequently attributed the credibility of the training programme to the holistic (rather than biomedical) content and the well-researched and delivered information. “The fact that we were actually doing something around men’s training to try and engage men. […] Like what exactly is men’s health? What it comes down to, not just the physical aspects. It included looking holistically at the man.” – Rachel “You can see how the research […] it’s the backbone of what is actually being delivered. […] This isn’t just some willy-nilly thing that someone in a department thought of, this was you know a lot of research to show the need for this type of training. – Emma In addition to recognizing the strong collaboration between the ENGAGE team members, participants commented on the ongoing collaboration between team members and Trainers. All participants cited opportunities for feedback as a key aspect of the training. Trainers and service provider participants were invited to share oral and written feedback throughout their training sessions, consult privately with Facilitators, and comment specifically on initial versions of the resource pack as well as the training sessions. Trainers took pride in knowing that their suggestions, and concerns had indeed been considered and used to shape future training sessions and resources. “It wasn’t a polished product when we got it. So our feedback was useful in relation to what was actually going to happen with the pack.” – Emma “I know some changes have been made in some of the slides, and you know the way some of the modules are delivered. I think that’s really good so obviously feedback has been taken in, and it’s been developed.” – Sean Opportunities to collaborate on and make suggestions to change ENGAGE resources was of particular importance to some Trainers who described previous disappointments with other trainings, and specifically the trend of recycling loosely relevant material. In contrast, ENGAGE audio–visual resources and interactive exercises that were based on local knowledge and contexts, and created specifically for the ENGAGE training programme contributed to the credibility of the content. “ENGAGE was pretty much developed by ourselves from our own research, from our own experience of working with groups and working with men … there’s such an Irish flavour to it.” – Jack Similarly, the ENGAGE team noted that the training programme was consistently evolving. Although they set out with specific intentions from the start, the programme and resources changed based on the feedback they received as well as their own observations. Consistent planning meetings, keeping in regular contact with Trainers, and ‘trial and error’ emerged as key mechanisms that allowed the ENGAGE team to both collect and translate feedback into practice. “There was a lot of painstaking time spent going through different iterations of the drafts and I think it’s important […] We were having a stab at something, trying something out and it was a bit scary. Weren’t sure where it would go and yet that has evolved and developed into something much more structured, and coherent, and systematic, and embedded now.” – Richard Professional and personal practice The training impacted all participants in terms of personal and professional development. Reflections commonly centred on notions of confidence and personal growth. The training both validated participants’ interest in or passion for men’s health, and contributed to their confidence in working in the field as well as engaging with men in their personal lives. “On a personal level I’m a daughter, I’m a wife, I’m a mother. So just from that alone I suppose ensuring that with my own socialisation and upbringing that I am aware of how I engage with my own, the men in my own life and that really, it brings it home.” – Rachel Trainers and the ENGAGE team also noted how this personal growth simultaneously impacted their practice. The content of the training challenged many Trainers to reflect critically on their own prejudices. Specifically, some noted that despite being aware of men’s health issues in the past, the training provided them with an outlet or opportunity to critique their understanding of men, and confront misinformation, stereotypes, and gender norms. “Yeah, to be honest, I thought it was great because like I was aware of men’s health and I was aware of my own prejudice a little bit. ‘Oh sure they’ll never come’ and you know some of those kind of random comments.” – Emma “They’ve been challenged at a personal level […] to reflect on how they relate to men and women.” – Richard Trainers also explained that group discussions and interactive activities created an environment where they could bring their practice into the room during training, and then gave them the confidence to bring lessons learned into their practice after the training ended. “I have learned a lot of techniques which I didn’t have. I had mostly or mainly theory and I learned practical applications I guess to, to bring the information across in an interactive way so that is very useful” – Aisling “It’s just helping me, and I think it’s making me better as a tutor, […] and it’s empowering me to empower the health care workers – Ciara The supplemental resources made it easier for Trainers to reference back to key information, and incorporate this learning into their practice. For active Trainers, being able to put their own unique touches on the material further instilled confidence in the ENGAGE content, and their ability to deliver the training. “Just to know that the material is so strong, that the material is so good, that you’re not going to be knocked on the material. […] It’s great to have the confidence in the material.” – Jack Simultaneously, participants indicated that the resources were, at times, too extensive and that the biggest challenge they faced was trying to get through everything while balancing normal work practices. “There's nothing wrong with the pack at all. It’s more that there's so much in the pack, […] and I’m nearly daunted even by the thoughts of looking at it. […] It’s like I had so much going on here that how am I going to get the time to go through all of this stuff.” – Sarah Reflections from the focus group mirrored these experiences. ENGAGE team members identified the intentional use of an experiential learning approach as a particular strength of the programme. In line with this strategy, Facilitators drew on the experiences in the room to shape discussions, and subsequent learning. By using this method, Facilitators intended to start the process of reflective practice in the room on training days by encouraging participants to link their practice into the topics covered with the hope that participants would continue to make connections and think critically about their work independently. “We can get people to embody the learning from the time they come in. If we can ‘conversationalise’ it, operationally you’re saying this can also be done like this elsewhere” – Luke “The first time they ever had to practice was in the safety of residential training. Where they were really supported to give this a go and put a toe in the water. So we weren’t sending people out day one, having never attempted to do a workshop on men’s health.” – Matilda Yet, making the training experiential and impactful took more effort and energy than the ENGAGE team could measure or articulate in the focus groups. The ENGAGE team discussed the importance of this approach, but that others in future should be aware of the ‘hand on’ and emotional commitment of experiential learning, and providing support and mentorship after training ends. „[I] would’ve felt very hands on. Very hearts on. “– Luke “Giving the Trainers an experiential learning experience is more effective, embodied learning. And [Trainers] require a lot of mentoring to deliver the training, and also an awful lot of support afterwards, both in terms of co-facilitation but I also think in terms of vision.” – Matilda Many of the ENGAGE team members discussed their involvement as a labour of love. As one participants described, meaningful mentorship and sustained support was not just about being hands on, but “hearts on” as well. Despite the commitment of the ENGAGE team to support Trainers, inactive Trainers, often described feeling awkward or uncomfortable with the amount of support available and their inability to follow through with training obligations. For many Trainers, professional or personal responsibilities were already too much to juggle in addition to training. Some were embarrassed or uncomfortable when discussing their inability to deliver training, and noted that they often felt guilty when receiving communication or updates from ENGAGE staff. “I was feeling a bit guilty because I hadn’t had a chance, but it kept it on my radar, getting regular communication from the ENGAGE team.” – Emma All Trainers came to similar conclusions that it was harder to find the momentum and confidence to deliver the training the longer it was put off. Thus, delivering training straight away was determined to be confidence-building, and a lesson learned that most participants agreed on. “I think the danger is that if you don’t deliver it very shortly after being trained as a Trainer you would, that initial confidence will be gone […] I know people who have trained in it and they still haven’t delivered it and the longer they leave it the more daunting it is for them, you know.” – Jack Peer-based support All participants reflected on the significance of social, and peer-based aspects of the ENGAGE training programme. Many participants described working in men's health as isolating, and noted that the opportunity to work with like-minded professionals was a primary motivating factor for participating in ENGAGE. All participants commented that an emphasis on group work, opportunities for discussion, a residential component to the training, and emphasis on mentorship, “bonding”, and “buddying up” played a crucial role in building a strong network during the training sessions. “You had two days, you were eating with people, you were in classrooms with people. There was always time for discussion and I think that’s important that, you know, when we’re as professionals we should be checking in with others.” – Sean “[It’s] around the isolation that people can feel, working in men’s health. So you know, we chose residential training for a reason, a very particular reason. To bring people together, to support them to network and to have time outside of the group.” – Matilda The emphasis on peer dynamics extended beyond participation in training, and entered into Trainers’ discussions of delivering training. Trainers discussed that training alongside a co-facilitator—and often an experienced mentor —enriched their experience. “Buddying up” took pressure off of them to be the only expert in the room, and created a greater pool of knowledge and expertise to draw upon in the training sessions. “Of all the training I’ve done in the past this one I particularly prefer to do it with somebody else. I think there’s great merit in it, in doing that because when you have another man or even if you had another woman with you it’s just different skills in the room.” – Sophie Some Trainers and ENGAGE team members commented that specifically pairing a male trainer with a female trainer allowed for more balanced gendered perspectives and dynamic training sessions. “I think that women can do the training but I think there’s certain elements that […] kind of solidifies it more when a man is saying it. And I hate to say that as a woman, but when you have a group of men looking in the group, I would just feel more comfortable co-training with another man. I think women can do the training, but I just think it’s a much nicer approach to have a mix of genders there.” – Sophie “The other thing about the experience that I thought was important, was it was about men and women together. And it wasn’t siloed, it was about, you know, men and women both reflecting on how they are with each other in the world. Both as Trainers and individuals and people and for me, that was a really strong part of the experience.” – John Co-facilitation, however, was challenging for many participants. Trainers identified incompatible schedules, working in different regions, and a hesitancy to reach out to other Trainers as barriers. Yet, many Trainers recognised that if they failed to reach out to their peers to plan a training, they would not just be limiting their own opportunities to train; rather, they’d be limiting opportunities for others to deliver training as well. “The frustrating part is getting another co-facilitator to be able to have the same day and then when you’re dealing with a group of fifteen or eighteen we are dealing with professionals and they also have to take a day from work to do the training […] it’s like walking a tight rope to get it to fit.” –Sean Trainers articulated that their peers were not only their greatest allies, but also their greatest resource. Trainers took great pride in learning from one another during the training, working together in delivering training, and feeling connected through emails and consistent communication. The ENGAGE team further noted that encouraging Trainers to work together and stay in contact would ultimately create a wider net of support, whereby peers would be less reliant on the Facilitators for help. Despite the camaraderie in the group during training sessions, many were reluctant to make use of peers as a resource outside of ENGAGE settings. “We’re all creatures of go away and get on with it and I think it was clear that we weren’t making use of some of the resources there which is actually getting on the phone and you know talking. […] Sometimes we fall back into the trap of we’re gone back into isolation again” – Sean DISCUSSION This study used principles of a process and theory-based evaluation (Birkmayer and Weiss, 2000) to identify the mediators of diffusion in a ToT model of men’s health training, and to explore the impact of the underlying theories that were used to shape the ENGAGE programme. Data suggest that the structural components of the programme—recruitment, content and approach, environment, and training delivery—were key elements that were used to foster buy-in at individual and organisational levels. Tangential mechanisms of support—regular communication, opportunities for feedback, “buddying-up”, mentors, refresher days, supplemental resources and availability of Facilitators—similarly impacted the degree to which Trainers had positive experiences of the programme and ultimately felt capable of continuing their relationships with peers, delivering training, and influencing their organizational culture. From the point of view of the ENGAGE team, each aspect of the training programme was designed to carve out pathways from individual learning to organizational change. The team’s key assumption was that if individuals are given the tools, confidence, and support to engage with men, then Trainers can not only improve their own practice, but also influence norms of practice at organisational levels (institutionalisation). The extent to which these underpinning goals were realized is the topic of an outcome-oriented investigation and therefore beyond the scope of this paper. However, data from elsewhere suggest that service providers can benefit from such training (McCullagh, 2011). However, unravelling how theoretical principles used in the planning stages, subsequently underpin decisions made at implementation, is an important approach for generating more generalizable strategies for future promising practices (Birkmayer and Weiss, 2000). As we discuss generalizable strategies and implications for future training programmes, it is also important to discuss the sustainability and replicability of such strategies. The programme content and approach to training garnered buy-in from Trainers at the individual level approach. Specifically, a focus on both academic and practical information, local contexts, and holistic accounts of wellbeing and gender made ENGAGE trustworthy to Trainers. These strategies have been cited in health education research, and are well documented as being useful in tailoring complex information to a wide range of audiences and fostering ownership (Kreuter, 2000). Data suggest that the experiential learning approach was a catalyst in the transition between generating trust in the content and facilitating buy-in and ownership over the proposed techniques for engaging men. This approach created opportunities for Trainers to internalise practices by engaging in deep personal reflection and simultaneously develop the confidence and capacity to deliver the training afterwards by tailoring the content to their own interpretations and experiences. This finding is echoed in experiential learning theory, whereby, through a series of experiences, learners both comprehend and apprehend new material; a process of parallel abstract and tangible learning that allows for multiple levels of understanding (Baker et al., 2002). By aligning feelings, personal experiences and skill development, learning became embedded and memorable (Baker et al., 2002); as many Trainers noted, they did not remember what exactly was said in the sessions, but the remember how they felt, and what they changed in their practices afterwards. Learning—especially for adults—is more impactful when people are able to foster deeper connections with material, apply learning to personal experiences, and make sense of what they are learning in relation to how they might use or apply new information (Baker et al., 2002; Miller et al., 2008). This approach allows for adaptability over time as learning is tailored to the ever-changing experiences and knowledge of individuals. Thus, as ENGAGE demonstrates, there is room for pre-determined content to be adapted iteratively each time training is conducted—allowing for changes over time or changes in audience. How a programme or set of practices can maintain relevance over time by adapting to changing circumstances, continuously eliciting individual ownership over content, and influencing beliefs and practices are key determinants of sustainability (Shediac-Rizkallah and Bone, 1998; Scheirer, 2005). While it is clear that the specific content used in this training will not remain relevant indefinitely, the approach used to develop and deliver holistic, evidence-informed, tailored, and interactive material can be useful over time. The process of using feedback to reflect on and change content as the programme evolved was used by the ENGAGE team, further promoted sustainability; by building in mechanisms of adaptability, ENGAGE maintained relevance across different years, and cycles of Trainers. The importance of feedback as a sustainability-promoting process is not to be underestimated (Shediac-Rizkallah and Bone, 1998; Scheirer, 2005). Seeing their suggestions reflected in subsequent versions of the training further encouraged individual buy-in as Trainers could explicitly see the inclusions of their opinions, preferences and expertise. Yet, the numerous drafts of the content and resources, hours spent in planning meetings, and tedious time spent reviewing evaluation and feedback forms, were referred to as a ‘labour of love’ and also a daunting part of the programme for the ENGAGE team. The team was uncertain if they would have the same time and energy to commit to this level of reflective practice in the future. Nevertheless, the significance of this reflective practice and attention to detail in gauging the overall impact of the training cannot be underestimated. Mechanisms of support were deemed critical to not only sustain participation and interest in ENGAGE, but also, to facilitate movement from individual ownership to community and organisational ownership. While top-down support through regular communication and mentorship were deemed to be important, enabling Trainers to support each other was seen by all as optimal. Again in line with the experiential learning model, building team capacity through meaningful shared experiences, group learning, and camaraderie were also deemed to be important. Moreover, addressing the common experience of professional isolation through opportunities for networking and bonding made the training more meaningful and memorable to Trainers. Findings suggest that as Trainers became confident in the group and their ability to rely on one another for support, they began to demonstrate a sense of community ownership over their network. The ENGAGE team envisioned that as confidence in and comfort with the peer network grew, support could transition to a bottom-up approach and become self-sustaining. While some Trainers indeed took advantage of this peer network, some were still too shy or hesitant to fully engage with each other and abstained from or felt uncomfortable with contacting each other to co-facilitate training sessions or maintain professional relationships. In combining an experiential learning approach and mechanisms of peer support and mentorship, Trainers were able to begin the process of reflective practice during their initial training sessions. Specifically, Trainers were able to bring their personal experiences and understandings into the training, and use elements of the training to question or challenge their own practice and organizational culture. Echoed in our own findings, the process of influencing organizational norms is indeed a critical element of achieving lasting relevance and changes in practice (Shediac-Rizkallah and Bone, 1998; Scheirer, 2005). To achieve organizational ownership, our data suggest the importance of ongoing support. Data indicate that reflective practice began during sessions and among the safety of a peer space; Trainers were encouraged to think critically about their work, practice new techniques with peers, and adapt information to fit their own needs as practitioners. Creating a space to practice techniques with peers is indeed a crucial step before sending practitioners out on their own (Miller et al., 2008). While data on the extent to which organizational culture has changed are forthcoming, our data suggest that building in processes of reflective practice into practice and providing ongoing support may be important as changing organizational culture and fostering buy-in for men’s health initiatives can be a long, isolating and challenging process. Similarly, while delivering training to other organizations also created more opportunities for Trainers to institutionalize practices beyond their own backyard, navigating the culture and boundaries of other organizations was difficult. Inherent within this process of encouraging reflective practice was an emphasis on safe space and shared learning; the residential component of the training was of particular note for most participants. Notwithstanding the consistently positive reactions to the residential component, the feasibility of replicating this model is a predominant issue. Having the funding to pay for food and accommodation over 4 days for a group may not be possible for others considering a ToT model. In replicating this model, others may need to consider how they can achieve a high-level of team bonding in shorter time-frames or through other team-building exercises. CONCLUSION This study set out to identify the mediators of diffusion of a ToT programme that contribute to the institutionalisation of new practices. Focusing on the ENGAGE training programme, we explored the process (planning, implementation and maintenance) of using a ToT model of training to affect change at a practice level in health and social settings. Our findings indicate that an experiential learning approach in combination with mechanisms for feedback and fostering peer-based support are key strategies that foster individual, community and organizational-level ownership. Moreover, by adapting in response to feedback, ENGAGE was able to remain relevant over a number of years (2012–2014) and is still ongoing. As such, core strategies used by ENGAGE could be used to inform new models of health training for years to come. FUNDING This study was supported by the Health Promotion and Improvement section within the Health and Well-being Division of the Health Service Executive. ACKNOWLEDGEMENTS We applied the ‘first last author emphasis’ approach for the sequence of authors. We are grateful for the stimulating discussions and comments by Aoife Osborne and Martin Doheny. REFERENCES Baker A., Jensen P., Kolb D. A. ( 2002). Conversational Learning: An Experiential Approach to Knowledge Creation . Quorum Books, Westport. Barton A. ( 2000) Men's health: a cause for concern. Nursing Standards , 15, 47– 52. Google Scholar CrossRef Search ADS   Birkmayer J. D., Weiss C. H. ( 2000). Theory-based evaluation in practice: what do we learn? Evaluation Review , 24, 407– 431. Google Scholar CrossRef Search ADS PubMed  Caperchione C. M., Vandelanotte C., Kolt G. S., Duncan M., Ellison M., George E. et al.   ( 2012) What a man wants: understanding the challenges and motivations to physical activity participation and healthy eating in middle-aged Australian men. American Journal of Men’s Health , 6, 453– 461. Google Scholar CrossRef Search ADS PubMed  Department of Health and Ageing ( 2010) National Male Health Policy. Building on the Strengths of Australian Males. Department of Health and Children (DOHC) ( 2008) National Men’s Health Policy 2008–2013. Working with Men in Ireland to Achieve Optimum Health and Wellbeing . Department of Health and Children, Dublin. European Communities, Directorate General for Health and Consumers ( 2011). The State of Men’s Health in Europe. Hobbs A. ( 1995) Shattering the myths of masculinity. Healthlines , 51, 14– 16. Kreuter M. W. ( 2000) Tailoring: what’s in a name? Health Education Research , 15, 1– 4. Google Scholar CrossRef Search ADS PubMed  McCullagh J. ( 2011). The invisible man—development of a national men’s health training programme for public health practitioners: challenges and successes. Public Health , 125, 401– 406. Google Scholar CrossRef Search ADS PubMed  Miller K. K., Riley W., Davis S., Hansen H. ( 2008) In situ simulation: a method of experiential learning to promote safety and team behavior. Journal of Perinatal & Neonatal Nursing , 22, 105– 113. Google Scholar CrossRef Search ADS   Robertson S., White A., Gough B., Robinson M., Seims A., Raine G., et al.   ( 2015) Promoting Mental Health and Well Being with Men and Boys: What Works ? Centre for Men’s Health, Leeds Beckett University, Leeds. Robertson S., Witty K., Zwolinsky S., Day R. ( 2013). Men’s health promotion interventions: what have we learned from previous programmes? Community Practitioner , 86, 38– 41. Google Scholar PubMed  Rogers E. M. (ed.) ( 2003) Diffusion of Innovations , 5th edition. Free Press, New York. Scheirer M. A. ( 2005) Is sustainability possible? A review of commentary on empirical studies of program sustainability. American Journal of Evaluation , 26, 320– 347. Google Scholar CrossRef Search ADS   Shediac-Rizkallah M. C., Bone L. R. ( 1998) Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice and policy. Health Education Research , 13, 87– 108. Google Scholar CrossRef Search ADS PubMed  Spencer J., Jordan R. ( 1999) Learner centred approaches in medical education. British Medical Journal , 318, 1280– 1283. Google Scholar CrossRef Search ADS PubMed  White A., de Sousa B., De Visser R., Madsen S.A., Makara P., Richardson N. et al.   ( 2013) Europe’s ‘missing men’; the impact of life expectancy improvements on men’s premature mortality. Journal of Epidemiology & Community Health , 10, 1– 7. White A., McKee M., Richardson N., De Visser R., Madsen S. A., de Sousa B., et al.   ( 2011) Europe’s men need their own health strategy. British Medical Journal , 343, d7397– d7411. Google Scholar CrossRef Search ADS PubMed  Wilkins D., Savoye E. (eds) ( 2009) Men’s Health Around the World: A Review of Policy and Progress Across 11 Countries . European Men’s Health Forum, Belgium. © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Health Promotion International Oxford University Press

A process evaluation of a Training of Trainers (TOT) model of men’s health training

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Abstract

Abstract This study set out to identify the mediators of diffusion of a Training of Trainers (ToT) programme; focusing on ENGAGE, Ireland’s national men’s health training programme, we explored the process (planning, implementation and maintenance) of using a ToT model of training to affect change in gender sensitive health and social service provision for men. Our findings indicate that an experiential learning approach in combination with mechanisms for feedback and fostering peer-based support during training and beyond are key strategies that foster individual (Trainer), community (of Trainers) and organizational (Trainer workplaces) level ownership. Moreover, by adapting in response to feedback, ENGAGE was able to remain relevant over a number years and to different cohorts of Trainers. As such, core strategies used by ENGAGE could be used to inform new models of health training elsewhere. Training of Trainers, institutionalisation, sustainability, men’s health INTRODUCTION Background In recent years, the spotlight focused on men’s health has highlighted the excess burden of ill-health, mortality and premature death experienced by many men, and poorer men in particular (European Communities, 2011; White et al., 2013). Since 2008 national men’s health policies have been published in Ireland, Brazil and Australia prompting calls for an increased policy focus on men’s health more generally (White et al., 2011). Central to this increased focus on men’s health have been calls for a greater provision of gender sensitized health-related services for men (Department of Health and Children, 2008; Department of Health and Ageing, 2010; European Communities, 2011). Engaging men in health-related services, however, poses unique challenges to service providers who often see men as ‘hard to reach’ (Wilkins and Savoye, 2009; Caperchione et al., 2012). Many service providers struggle to identify men’s health needs, how to effectively reach men and the type of services to which men might respond (Hobbs, 1995; Barton, 2000). The importance of appropriate training (initial and ongoing) for those involved in men’s health work has been previously identified in research as key to successful health interventions for men (Robertson et al., 2013, 2015). In recognition of the need for services providers need to be supported to adopt gender sensitive work practices, Ireland’s national men’s health policy recommended the development of men’s health training targeted at front line service providers. ‘ENGAGE’, Ireland’s National Men’s Health Training programme, was developed by a partnership of statutory, academic and community sectors, to meet that recommendation. ENGAGE is a comprehensive 1-day training that aims to increase participants’ understanding of best practices in engaging men with health and social services and aims to address what many would regard as the current deficit in gender sensitive service provision for men. The Diffusion of Innovations Theory (Rogers, 2003) informed the approach used to implement the ENGAGE training programme. ‘Diffusion’, in this case, describes the process by which an ‘idea’ (i.e. gender sensitivity in service provision) spreads to a specific population (i.e. service providers), with the intended end result being that service providers adopt a new behaviour (i.e. gender sensitive work practices). A ‘Training of Trainers’ (ToT) cascade model of delivery was adopted; individuals from key organizations were recruited to the ToT training to become Trainers of the ENGAGE 1-day training programme for service providers. Trainers committed to deliver three ENGAGE training programmes. With respect to diffusion, a total of 57 Trainers were trained in three cohorts from 2012 to 2014. At the end of September 2015, 62 training events had taken place that were attended by 810 front line service providers. The purpose of this study is to investigate the process by which the ToT model was developed and implemented in order to effect maximum diffusion. Specifically, this study aims to understand both the mediators of diffusion, and the underlying theoretical assumptions (as articulated by Birkmayer and Weiss, 2000) that were used in the planning and implementation stages of the ENGAGE programme so that generalisable strategies can be identified that may inform how models of training may be implemented in the future. An overview of the development and implementation of ENGAGE The process of developing, delivering, and maintaining the ENGAGE training is detailed in Figure 1. The ENGAGE training [both the TOT and the 1-day training for service providers] was overseen by the ‘ENGAGE team’ [n = 7]. Four organizations partnered to create the ENGAGE training; a Facilitator from each organization developed the training and was responsible for its delivery and maintenance. An editor was responsible for creating the online discussion forum. The Coordinator fulfilled an administrative role and was responsible for communicating with the group of Trainers. A researcher led an outcomes evaluation that will be reported elsewhere [see corresponding author]. In addition to these human resource costs, core funding of €35 000 was secured to implement the ENGAGE programme. Fig. 1: View largeDownload slide ‘ Engage’, National Men’s Health Training Programme: development, delivery and maintenance process methods adopted. Fig. 1: View largeDownload slide ‘ Engage’, National Men’s Health Training Programme: development, delivery and maintenance process methods adopted. A plan for sustaining the diffusion of ENGAGE underpinned the implementation process and was based upon an adaptation of Shediac-Rizkallah and Bone’s (Shediac-Rizkallah and Bone, 1998) conceptual framework that includes: Project design and implementation factors ENGAGE was piloted over a 24-month period to a variety of service providers (see Figure 1). Based on feedback from the pilot phase and personal reflections from Facilitators, the ENGAGE training content and methodology was adapted and refined before delivery to Trainers. The five ENGAGE Units include: an overview of men’s health, gender and social determinants of health; strategies for practitioner support; guiding brief interventions with men; strategies for engaging with men; and mechanisms for men’s development groups and sustained engagement. Using experiential and interactive methodologies, opportunities were created for Trainers to connect with the subject matter on a personal level to promote a deeper integration of their learning. Upon completion of the training, Trainers were resourced with an ENGAGE training folder that consisted of session plans, handouts, audio-visual aids and a promotional flyer. Mentoring and technical assistance was offered to Trainers post training in the form of opportunities for co-facilitation, regular email and phone communication, two refresher meetings and an online resource repository that was continually updated. Factors within the organisational setting Following a wide marketing strategy, Trainers were selected based on four specific criteria: the strategic relevance of their representative organization to men’s health; having a remit to deliver training; having facilitation experience; and having knowledge of men’s health. It was endeavoured to achieve a wide geographical spread and, over time, to recruit two or more participants from the same organization. Factors within the broader community environment (i.e. community of Trainers) All Trainers underwent two 2-day residential training blocks delivered 1 month apart. Experiential methodologies prompted the sharing of experiences and knowledge between Trainers. Consistent with adult learning theory, Trainers were also given the opportunity to practice using the skills and information that they had received by co-facilitating a workshop to their peers (Spencer and Jordan, 1999). At the end of training, Trainers were formally certified as ‘ENGAGE Trainers’ and networking amongst the community of Trainers was encouraged via an online discussion forum and offline via the sharing of contact details. METHODOLOGY Informed, written consent was given by all participants in this research, which was approved by Waterford Institute of Technology’s Research Ethics Committee (Ref: 14/HSES/05). All data represented in this study have been de-identified and made anonymous. The ENGAGE team and ENGAGE Trainers comprised the study population. All Trainers consented to be contacted for this evaluation via email at recruitment. This study overlapped with the training of the 2014 cohort, and only one 2014 Trainer delivered training within the study timeframe (end of December 2014; 42 training days delivered to 571 service providers). Therefore, a total of 39 Trainers were invited by the authors directly to participate in this study. Three Trainers were no longer active in their organizations, and could not be reached, thereby reducing the study population to 36 Trainers. Using data from the parallel outcome evaluation, Trainers were categorized as very active (≥3 trainings delivered), active (1–2 trainings delivered) and inactive (0 trainings delivered); the activity level of Trainers who participated in this study is representative of the activity levels of all ENGAGE Trainers (see Table 1). Table 1: Activity of trainers as of the end December 2014 Year  Trainers (number)  Very active trainers (≥3 trainings delivered)   Active trainers (n = 1–2)   Inactive trainers (n = 0)   n  %  n  %  n  %  2012  18  5  28  8  44  5  28  2013  20  1  5  12  60  7  35  Total  38  6  16  20  53  12  31  2014  19      1  5  18  95  Total  57        Year  Trainers (number)  Very active trainers (≥3 trainings delivered)   Active trainers (n = 1–2)   Inactive trainers (n = 0)   n  %  n  %  n  %  2012  18  5  28  8  44  5  28  2013  20  1  5  12  60  7  35  Total  38  6  16  20  53  12  31  2014  19      1  5  18  95  Total  57        Multiple data collection tools were adopted in order to fit the needs and preferences of participants; a semi-structured, qualitative interview guide was used with participants in telephone and in-person interviews and was then modified into an online survey. Some 16 Trainers self-selected to do the online survey (n = 5) or an interview (n = 8 telephone and n = 3 person-to-person). Participation was a challenge for this study because Trainers work full time and many were on vacation during the data collection period. While the participation rate was lower than desired, the sample of Trainers was representative of the diverse activity level of Trainers and participants provided adequate insight into their experience of ENGAGE. Five members of the ENGAGE team (focus group) participated in the study. The first author conducted, transcribed verbatim and coded the data, using qualitative thematic content analysis, from all in-person and telephone interviews. Codes were created based on both unique language and from previously identified points of interest (e.g. mechanisms of support). Once transcripts were coded, thematic memos were created from both the interviews and online survey data to illustrate how key excerpts were categorized into major and sub themes. Themes from both data sources were consistent. The fifth author (ENGAGE team member) then reviewed the coded transcripts and the theme memos in order to ensure consistency in the analysis. Themes and codes were discussed openly and used to guide a final reading of the transcripts and development of a comprehensive list of themes. The authors then worked collaboratively to write the final manuscript. RESULTS All participants reflected broadly on their experience of the ENGAGE training programme and specifically the ToT model that was used in this health training. Responses were captured by several overarching themes, including: individual and organizational buy-in, collaborative approach, professional and personal practice and peer-based support. In particular, issues of trust, clarity, reliability and confidence emerged from interviews as key mechanisms that instilled this sense of buy-in and ownership among Trainers at each stage of the programme. Both Trainers and ENGAGE team members unanimously identified that mechanisms of support were the backbone of the training programme, and the catalysts for diffusion. This section will outline in detail the factors that contributed to the perceived strengths and challenges of the ToT model. Individual and organizational buy-in The notion of ‘buy-in’ was understood by participants as the degree to which the training aligned with values, “moral compasses”, or goals either on an individual or organizational level, and was salient in the responses of both Trainers and ENGAGE team members. Trainers discussed applying to the Engage training with some initial sense of buy-in based on a perceived synergy between the training objectives and their own personal or professional interests and values. These factors also facilitated the Trainers’ sustained involvement in ENGAGE over time and their motivation to deliver training. Trainers commonly noted the application of training material with their practice, and actively took it upon themselves to advocate on behalf of ENGAGE and share the lessons they learned from their experience. Commonly, buy-in was discussed in terms of participants’ own understanding of the importance of such training, and their enthusiasm to be involved. As one participant described, “My sense from working in the community is there's a real need for this, for this particular training. That would have been reflected within the amount of people when it was put out to all HSE [national health service] users, is the interest of people around it.” – Emma Similarly, members of the ENGAGE team discussed that congruence between organizations and prospective Trainers was an intentional strategy used in the recruitment phase and was paramount to the diffusion of ENGAGE. The ENGAGE team commented that all Trainers were deliberately recruited. Those just “looking to put something on their C.V.” were intentionally avoided. Prospective Trainers who intended to influence organizational practices related to the engagement of men in health services, were deemed a better fit for the training. The focus group unanimously concluded that this strategy was an important first step in ensuring that the incoming Trainers would have some degree of buy-in, and would therefore be in a realistic and strategic position to deliver training. Moreover, their existing experience and interests would align with the content and ethos of ENGAGE, making the training both enjoyable and beneficial. Organizational-level buy-in was discussed by participants as an important factor that either enabled or prevented Trainers from participating fully in the ENGAGE training, and upholding their commitment to training service providers. Initial organizational support enabled Trainers to take time off of work to participate in and deliver training, and attend refresher sessions. Some Trainers noted that their organizational affiliation further enhanced their ability to deliver training because the particular brand or reputation added extra credibility. “I was more privileged than most in that [Organisation] is my work, and I had been doing a lot of training and I had a lot of contact with different groups. So, I actually went back to some of the groups I already did training with and I said, ‘You know the training I did with you in the past, well now there’s a new training pack and it’s called ENGAGE’.” – Jack Yet, Trainers also expressed frustration with navigating managerial red tape or influencing internal organizational culture. Negotiating time off, getting support from upper management, and explaining the purpose of ENGAGE to “non-medical” or “pedantic” employers were frequently cited challenges. The ENGAGE team similarly noted that the frustration of going from a positive training experience to an unsupportive organization can smother momentum for delivering training or making any changes to practice. “I have to explain the value and why you would do this. I would have some really good people and […] I’ve other people going, ‘Well what does this have to do with caring for somebody?’ And […] they just were an admin person and they didn’t get it”. – Ciara “The biggest challenge is not getting lone individual visionaries […] The harder one is getting their organisational buy-in to do something with it afterwards […] The people who come away after four days training, who are buzzed to the nines, soon lose it when somebody’s saying, ‘no you can’t have time off to deliver that training’.” – John Participants also reflected on the unique challenge of facilitating organizational buy-in around the topic of men’s health. Many participants discussed the difficulty of demonstrating the importance of addressing men’s health, meaningfully engaging with men, and allocating funding to gender-based initiatives. Specifically, some participants commented that countering the relative invisibility of men’s health and persistent gender stereotypes at work threatened their ability to foster buy-in for the ENGAGE training, and influence organizational change more broadly. “When you say, ‘I’m doing the national men’s health training programme engaged with men’, I think that people don’t understand what you’re talking about initially because you know some people kind of say in a joking, ‘how to engage with men ha ha ha’.” – Sophie As Trainers were given the task of setting up their own ENGAGE training sessions and recruiting service providers as participants, they also found it challenging to generate external organizational buy-in in their role as Trainers. Promoting the training, selling the concept of meaningful engagement with men, and navigating training policies in other organizations were commonly cited obstacles that participants faced. For example, one participant found that influencing organizational culture related to sports, and specifically trying to facilitate buy-in around the value of promoting the wellbeing of male athletes, was difficult. “For training lads for football, they just weren’t grasping the concept that they had a role to play in helping that player’s health. […] They were there to train the player, and not to be wondering, ‘are they alright?’” – Rachel Ultimately, participants came to a similar conclusion that organizational buy-in—whether it was the Trainers’ own organizations or a prospective organizations to deliver training to—could make or break the ToT model. “The challenge starts then when you release [the Trainers]. If you release them and say, “Look off you go now you’re trained,” it’s doomed to failure really. So, you have to be realistic. […] We’ve learnt through experience, that you need to kind of mentor and support people once they completed the training. To get up and running and develop confidence, well through that, and delivery.” – Richard Collaborative approach All participants named the collaborative approach, both between ENGAGE team members and Trainers, as a significant component of the training that established trust, reliability and individual ‘buy in’ from Trainers. The initial collaboration between ENGAGE team members to integrate their diverse skills base to develop the content was commonly referenced as a success of the training. Many Trainers recognized the diverse skills and expertise of the Facilitators, and subsequently attributed the credibility of the training programme to the holistic (rather than biomedical) content and the well-researched and delivered information. “The fact that we were actually doing something around men’s training to try and engage men. […] Like what exactly is men’s health? What it comes down to, not just the physical aspects. It included looking holistically at the man.” – Rachel “You can see how the research […] it’s the backbone of what is actually being delivered. […] This isn’t just some willy-nilly thing that someone in a department thought of, this was you know a lot of research to show the need for this type of training. – Emma In addition to recognizing the strong collaboration between the ENGAGE team members, participants commented on the ongoing collaboration between team members and Trainers. All participants cited opportunities for feedback as a key aspect of the training. Trainers and service provider participants were invited to share oral and written feedback throughout their training sessions, consult privately with Facilitators, and comment specifically on initial versions of the resource pack as well as the training sessions. Trainers took pride in knowing that their suggestions, and concerns had indeed been considered and used to shape future training sessions and resources. “It wasn’t a polished product when we got it. So our feedback was useful in relation to what was actually going to happen with the pack.” – Emma “I know some changes have been made in some of the slides, and you know the way some of the modules are delivered. I think that’s really good so obviously feedback has been taken in, and it’s been developed.” – Sean Opportunities to collaborate on and make suggestions to change ENGAGE resources was of particular importance to some Trainers who described previous disappointments with other trainings, and specifically the trend of recycling loosely relevant material. In contrast, ENGAGE audio–visual resources and interactive exercises that were based on local knowledge and contexts, and created specifically for the ENGAGE training programme contributed to the credibility of the content. “ENGAGE was pretty much developed by ourselves from our own research, from our own experience of working with groups and working with men … there’s such an Irish flavour to it.” – Jack Similarly, the ENGAGE team noted that the training programme was consistently evolving. Although they set out with specific intentions from the start, the programme and resources changed based on the feedback they received as well as their own observations. Consistent planning meetings, keeping in regular contact with Trainers, and ‘trial and error’ emerged as key mechanisms that allowed the ENGAGE team to both collect and translate feedback into practice. “There was a lot of painstaking time spent going through different iterations of the drafts and I think it’s important […] We were having a stab at something, trying something out and it was a bit scary. Weren’t sure where it would go and yet that has evolved and developed into something much more structured, and coherent, and systematic, and embedded now.” – Richard Professional and personal practice The training impacted all participants in terms of personal and professional development. Reflections commonly centred on notions of confidence and personal growth. The training both validated participants’ interest in or passion for men’s health, and contributed to their confidence in working in the field as well as engaging with men in their personal lives. “On a personal level I’m a daughter, I’m a wife, I’m a mother. So just from that alone I suppose ensuring that with my own socialisation and upbringing that I am aware of how I engage with my own, the men in my own life and that really, it brings it home.” – Rachel Trainers and the ENGAGE team also noted how this personal growth simultaneously impacted their practice. The content of the training challenged many Trainers to reflect critically on their own prejudices. Specifically, some noted that despite being aware of men’s health issues in the past, the training provided them with an outlet or opportunity to critique their understanding of men, and confront misinformation, stereotypes, and gender norms. “Yeah, to be honest, I thought it was great because like I was aware of men’s health and I was aware of my own prejudice a little bit. ‘Oh sure they’ll never come’ and you know some of those kind of random comments.” – Emma “They’ve been challenged at a personal level […] to reflect on how they relate to men and women.” – Richard Trainers also explained that group discussions and interactive activities created an environment where they could bring their practice into the room during training, and then gave them the confidence to bring lessons learned into their practice after the training ended. “I have learned a lot of techniques which I didn’t have. I had mostly or mainly theory and I learned practical applications I guess to, to bring the information across in an interactive way so that is very useful” – Aisling “It’s just helping me, and I think it’s making me better as a tutor, […] and it’s empowering me to empower the health care workers – Ciara The supplemental resources made it easier for Trainers to reference back to key information, and incorporate this learning into their practice. For active Trainers, being able to put their own unique touches on the material further instilled confidence in the ENGAGE content, and their ability to deliver the training. “Just to know that the material is so strong, that the material is so good, that you’re not going to be knocked on the material. […] It’s great to have the confidence in the material.” – Jack Simultaneously, participants indicated that the resources were, at times, too extensive and that the biggest challenge they faced was trying to get through everything while balancing normal work practices. “There's nothing wrong with the pack at all. It’s more that there's so much in the pack, […] and I’m nearly daunted even by the thoughts of looking at it. […] It’s like I had so much going on here that how am I going to get the time to go through all of this stuff.” – Sarah Reflections from the focus group mirrored these experiences. ENGAGE team members identified the intentional use of an experiential learning approach as a particular strength of the programme. In line with this strategy, Facilitators drew on the experiences in the room to shape discussions, and subsequent learning. By using this method, Facilitators intended to start the process of reflective practice in the room on training days by encouraging participants to link their practice into the topics covered with the hope that participants would continue to make connections and think critically about their work independently. “We can get people to embody the learning from the time they come in. If we can ‘conversationalise’ it, operationally you’re saying this can also be done like this elsewhere” – Luke “The first time they ever had to practice was in the safety of residential training. Where they were really supported to give this a go and put a toe in the water. So we weren’t sending people out day one, having never attempted to do a workshop on men’s health.” – Matilda Yet, making the training experiential and impactful took more effort and energy than the ENGAGE team could measure or articulate in the focus groups. The ENGAGE team discussed the importance of this approach, but that others in future should be aware of the ‘hand on’ and emotional commitment of experiential learning, and providing support and mentorship after training ends. „[I] would’ve felt very hands on. Very hearts on. “– Luke “Giving the Trainers an experiential learning experience is more effective, embodied learning. And [Trainers] require a lot of mentoring to deliver the training, and also an awful lot of support afterwards, both in terms of co-facilitation but I also think in terms of vision.” – Matilda Many of the ENGAGE team members discussed their involvement as a labour of love. As one participants described, meaningful mentorship and sustained support was not just about being hands on, but “hearts on” as well. Despite the commitment of the ENGAGE team to support Trainers, inactive Trainers, often described feeling awkward or uncomfortable with the amount of support available and their inability to follow through with training obligations. For many Trainers, professional or personal responsibilities were already too much to juggle in addition to training. Some were embarrassed or uncomfortable when discussing their inability to deliver training, and noted that they often felt guilty when receiving communication or updates from ENGAGE staff. “I was feeling a bit guilty because I hadn’t had a chance, but it kept it on my radar, getting regular communication from the ENGAGE team.” – Emma All Trainers came to similar conclusions that it was harder to find the momentum and confidence to deliver the training the longer it was put off. Thus, delivering training straight away was determined to be confidence-building, and a lesson learned that most participants agreed on. “I think the danger is that if you don’t deliver it very shortly after being trained as a Trainer you would, that initial confidence will be gone […] I know people who have trained in it and they still haven’t delivered it and the longer they leave it the more daunting it is for them, you know.” – Jack Peer-based support All participants reflected on the significance of social, and peer-based aspects of the ENGAGE training programme. Many participants described working in men's health as isolating, and noted that the opportunity to work with like-minded professionals was a primary motivating factor for participating in ENGAGE. All participants commented that an emphasis on group work, opportunities for discussion, a residential component to the training, and emphasis on mentorship, “bonding”, and “buddying up” played a crucial role in building a strong network during the training sessions. “You had two days, you were eating with people, you were in classrooms with people. There was always time for discussion and I think that’s important that, you know, when we’re as professionals we should be checking in with others.” – Sean “[It’s] around the isolation that people can feel, working in men’s health. So you know, we chose residential training for a reason, a very particular reason. To bring people together, to support them to network and to have time outside of the group.” – Matilda The emphasis on peer dynamics extended beyond participation in training, and entered into Trainers’ discussions of delivering training. Trainers discussed that training alongside a co-facilitator—and often an experienced mentor —enriched their experience. “Buddying up” took pressure off of them to be the only expert in the room, and created a greater pool of knowledge and expertise to draw upon in the training sessions. “Of all the training I’ve done in the past this one I particularly prefer to do it with somebody else. I think there’s great merit in it, in doing that because when you have another man or even if you had another woman with you it’s just different skills in the room.” – Sophie Some Trainers and ENGAGE team members commented that specifically pairing a male trainer with a female trainer allowed for more balanced gendered perspectives and dynamic training sessions. “I think that women can do the training but I think there’s certain elements that […] kind of solidifies it more when a man is saying it. And I hate to say that as a woman, but when you have a group of men looking in the group, I would just feel more comfortable co-training with another man. I think women can do the training, but I just think it’s a much nicer approach to have a mix of genders there.” – Sophie “The other thing about the experience that I thought was important, was it was about men and women together. And it wasn’t siloed, it was about, you know, men and women both reflecting on how they are with each other in the world. Both as Trainers and individuals and people and for me, that was a really strong part of the experience.” – John Co-facilitation, however, was challenging for many participants. Trainers identified incompatible schedules, working in different regions, and a hesitancy to reach out to other Trainers as barriers. Yet, many Trainers recognised that if they failed to reach out to their peers to plan a training, they would not just be limiting their own opportunities to train; rather, they’d be limiting opportunities for others to deliver training as well. “The frustrating part is getting another co-facilitator to be able to have the same day and then when you’re dealing with a group of fifteen or eighteen we are dealing with professionals and they also have to take a day from work to do the training […] it’s like walking a tight rope to get it to fit.” –Sean Trainers articulated that their peers were not only their greatest allies, but also their greatest resource. Trainers took great pride in learning from one another during the training, working together in delivering training, and feeling connected through emails and consistent communication. The ENGAGE team further noted that encouraging Trainers to work together and stay in contact would ultimately create a wider net of support, whereby peers would be less reliant on the Facilitators for help. Despite the camaraderie in the group during training sessions, many were reluctant to make use of peers as a resource outside of ENGAGE settings. “We’re all creatures of go away and get on with it and I think it was clear that we weren’t making use of some of the resources there which is actually getting on the phone and you know talking. […] Sometimes we fall back into the trap of we’re gone back into isolation again” – Sean DISCUSSION This study used principles of a process and theory-based evaluation (Birkmayer and Weiss, 2000) to identify the mediators of diffusion in a ToT model of men’s health training, and to explore the impact of the underlying theories that were used to shape the ENGAGE programme. Data suggest that the structural components of the programme—recruitment, content and approach, environment, and training delivery—were key elements that were used to foster buy-in at individual and organisational levels. Tangential mechanisms of support—regular communication, opportunities for feedback, “buddying-up”, mentors, refresher days, supplemental resources and availability of Facilitators—similarly impacted the degree to which Trainers had positive experiences of the programme and ultimately felt capable of continuing their relationships with peers, delivering training, and influencing their organizational culture. From the point of view of the ENGAGE team, each aspect of the training programme was designed to carve out pathways from individual learning to organizational change. The team’s key assumption was that if individuals are given the tools, confidence, and support to engage with men, then Trainers can not only improve their own practice, but also influence norms of practice at organisational levels (institutionalisation). The extent to which these underpinning goals were realized is the topic of an outcome-oriented investigation and therefore beyond the scope of this paper. However, data from elsewhere suggest that service providers can benefit from such training (McCullagh, 2011). However, unravelling how theoretical principles used in the planning stages, subsequently underpin decisions made at implementation, is an important approach for generating more generalizable strategies for future promising practices (Birkmayer and Weiss, 2000). As we discuss generalizable strategies and implications for future training programmes, it is also important to discuss the sustainability and replicability of such strategies. The programme content and approach to training garnered buy-in from Trainers at the individual level approach. Specifically, a focus on both academic and practical information, local contexts, and holistic accounts of wellbeing and gender made ENGAGE trustworthy to Trainers. These strategies have been cited in health education research, and are well documented as being useful in tailoring complex information to a wide range of audiences and fostering ownership (Kreuter, 2000). Data suggest that the experiential learning approach was a catalyst in the transition between generating trust in the content and facilitating buy-in and ownership over the proposed techniques for engaging men. This approach created opportunities for Trainers to internalise practices by engaging in deep personal reflection and simultaneously develop the confidence and capacity to deliver the training afterwards by tailoring the content to their own interpretations and experiences. This finding is echoed in experiential learning theory, whereby, through a series of experiences, learners both comprehend and apprehend new material; a process of parallel abstract and tangible learning that allows for multiple levels of understanding (Baker et al., 2002). By aligning feelings, personal experiences and skill development, learning became embedded and memorable (Baker et al., 2002); as many Trainers noted, they did not remember what exactly was said in the sessions, but the remember how they felt, and what they changed in their practices afterwards. Learning—especially for adults—is more impactful when people are able to foster deeper connections with material, apply learning to personal experiences, and make sense of what they are learning in relation to how they might use or apply new information (Baker et al., 2002; Miller et al., 2008). This approach allows for adaptability over time as learning is tailored to the ever-changing experiences and knowledge of individuals. Thus, as ENGAGE demonstrates, there is room for pre-determined content to be adapted iteratively each time training is conducted—allowing for changes over time or changes in audience. How a programme or set of practices can maintain relevance over time by adapting to changing circumstances, continuously eliciting individual ownership over content, and influencing beliefs and practices are key determinants of sustainability (Shediac-Rizkallah and Bone, 1998; Scheirer, 2005). While it is clear that the specific content used in this training will not remain relevant indefinitely, the approach used to develop and deliver holistic, evidence-informed, tailored, and interactive material can be useful over time. The process of using feedback to reflect on and change content as the programme evolved was used by the ENGAGE team, further promoted sustainability; by building in mechanisms of adaptability, ENGAGE maintained relevance across different years, and cycles of Trainers. The importance of feedback as a sustainability-promoting process is not to be underestimated (Shediac-Rizkallah and Bone, 1998; Scheirer, 2005). Seeing their suggestions reflected in subsequent versions of the training further encouraged individual buy-in as Trainers could explicitly see the inclusions of their opinions, preferences and expertise. Yet, the numerous drafts of the content and resources, hours spent in planning meetings, and tedious time spent reviewing evaluation and feedback forms, were referred to as a ‘labour of love’ and also a daunting part of the programme for the ENGAGE team. The team was uncertain if they would have the same time and energy to commit to this level of reflective practice in the future. Nevertheless, the significance of this reflective practice and attention to detail in gauging the overall impact of the training cannot be underestimated. Mechanisms of support were deemed critical to not only sustain participation and interest in ENGAGE, but also, to facilitate movement from individual ownership to community and organisational ownership. While top-down support through regular communication and mentorship were deemed to be important, enabling Trainers to support each other was seen by all as optimal. Again in line with the experiential learning model, building team capacity through meaningful shared experiences, group learning, and camaraderie were also deemed to be important. Moreover, addressing the common experience of professional isolation through opportunities for networking and bonding made the training more meaningful and memorable to Trainers. Findings suggest that as Trainers became confident in the group and their ability to rely on one another for support, they began to demonstrate a sense of community ownership over their network. The ENGAGE team envisioned that as confidence in and comfort with the peer network grew, support could transition to a bottom-up approach and become self-sustaining. While some Trainers indeed took advantage of this peer network, some were still too shy or hesitant to fully engage with each other and abstained from or felt uncomfortable with contacting each other to co-facilitate training sessions or maintain professional relationships. In combining an experiential learning approach and mechanisms of peer support and mentorship, Trainers were able to begin the process of reflective practice during their initial training sessions. Specifically, Trainers were able to bring their personal experiences and understandings into the training, and use elements of the training to question or challenge their own practice and organizational culture. Echoed in our own findings, the process of influencing organizational norms is indeed a critical element of achieving lasting relevance and changes in practice (Shediac-Rizkallah and Bone, 1998; Scheirer, 2005). To achieve organizational ownership, our data suggest the importance of ongoing support. Data indicate that reflective practice began during sessions and among the safety of a peer space; Trainers were encouraged to think critically about their work, practice new techniques with peers, and adapt information to fit their own needs as practitioners. Creating a space to practice techniques with peers is indeed a crucial step before sending practitioners out on their own (Miller et al., 2008). While data on the extent to which organizational culture has changed are forthcoming, our data suggest that building in processes of reflective practice into practice and providing ongoing support may be important as changing organizational culture and fostering buy-in for men’s health initiatives can be a long, isolating and challenging process. Similarly, while delivering training to other organizations also created more opportunities for Trainers to institutionalize practices beyond their own backyard, navigating the culture and boundaries of other organizations was difficult. Inherent within this process of encouraging reflective practice was an emphasis on safe space and shared learning; the residential component of the training was of particular note for most participants. Notwithstanding the consistently positive reactions to the residential component, the feasibility of replicating this model is a predominant issue. Having the funding to pay for food and accommodation over 4 days for a group may not be possible for others considering a ToT model. In replicating this model, others may need to consider how they can achieve a high-level of team bonding in shorter time-frames or through other team-building exercises. CONCLUSION This study set out to identify the mediators of diffusion of a ToT programme that contribute to the institutionalisation of new practices. Focusing on the ENGAGE training programme, we explored the process (planning, implementation and maintenance) of using a ToT model of training to affect change at a practice level in health and social settings. Our findings indicate that an experiential learning approach in combination with mechanisms for feedback and fostering peer-based support are key strategies that foster individual, community and organizational-level ownership. Moreover, by adapting in response to feedback, ENGAGE was able to remain relevant over a number of years (2012–2014) and is still ongoing. As such, core strategies used by ENGAGE could be used to inform new models of health training for years to come. FUNDING This study was supported by the Health Promotion and Improvement section within the Health and Well-being Division of the Health Service Executive. ACKNOWLEDGEMENTS We applied the ‘first last author emphasis’ approach for the sequence of authors. We are grateful for the stimulating discussions and comments by Aoife Osborne and Martin Doheny. REFERENCES Baker A., Jensen P., Kolb D. A. ( 2002). Conversational Learning: An Experiential Approach to Knowledge Creation . Quorum Books, Westport. Barton A. 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Health Promotion InternationalOxford University Press

Published: Feb 1, 2018

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