Evaluation of Smoking and Money Advice training delivered by NHS Greater Glasgow & Clyde, evaluated by ASH Scotland (2014)

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1 Evaluation of Smoking and Money Advice training delivered by NHS Greater Glasgow & Clyde, evaluated by ASH Scotland (214) About this report ASH Scotland, the independent Scottish charity taking action to reduce the harm caused by tobacco, has a stated aim of working in partnership with others to help tackle tobacco-related inequalities. Part of this work includes supporting NHS boards to increase capacity for specific pieces of work. Under this rationale, we agreed to provide the monitoring and evaluation components of a two-year pilot project with NHS Greater Glasgow & Clyde (NHS GGC); this project aims to train a proportion of money advisors (and associated staff) from financial inclusion settings in how to raise the issue of smoking and tobacco use with their clients, with an intended outcome being that some clients choose to be referred on to (and engage with) local NHS stop-smoking services. The ultimate objective of the two-year project is that referral rates into stop-smoking services increase as a result of these activities (from a starting level of zero until now, there have been no referrals), which in turn may help reduce health inequalities in areas of deprivation across the NHS GGC region. Further information about the full rationale and scope of the pilot project is available upon request from Karen Gray at NHS GGC. All eight CH(C)P areas across the NHS GGC region were invited to be part of the smoking and money advice project; five are doing so, but three Inverclyde, East Dunbartonshire and West Dunbartonshire are unable to participate at this point. The remaining areas involved are: NE Glasgow NW Glasgow South Glasgow Renfrewshire East Renfrewshire. This report presents data gathered from on-the-day evaluations and follow-up surveys completed by attendees at five training events held between January and July 214, all of which were delivered by an NHS GGC trainer. A total of 51 people attended the training (although not all completed the evaluations); most were money advisors or financial inclusion workers, but some were support workers or administrators and are therefore not necessarily directly involved with delivery of advice to clients. NHS GGC money advice training report (ASH Scotland) November 214 1

2 Training Sessions NHS GGC s standard Health Behaviour Change (HBC) training module was used as the basis for every session, with a bolt-on topic of smoking and tobacco. Each course lasted half a day and aimed to deliver the following six learning outcomes: By the end of the course, participants will be able to: 1. Identify concepts of individual health behaviour change in common use within the wider context of health inequalities; 2. Describe tobacco related issues in relation to risks/effects of smoking, barriers/benefits to stopping and what can make it difficult to stop smoking; 3. Introduce brief negotiation skills including, open questioning, reflecting, giving feedback and summarising; 4. Identify opportunities and explore barriers in their own practice to incorporate brief negotiation techniques; 5. Describe evidence-based stop-smoking treatments and services and understand how to signpost to these services; 6. Explain the data collection requirements for the money management and tobacco pilot. Each of the five training sessions were delivered to money advice workers from a specific geographical area, with those from the South sector of Glasgow having more attendees than other regions: region NW NE South East Ren Ren totals Session 1 (28 Jan 14) 9 9 Session 2 (19 Mar) Session 3 (4 April) Session 4 (18 June) 7 7 Session 5 (22 July) totals The places of employment/volunteering also ranged across the five sessions: Money Matters Advice Centre ( an independent financial inclusion service for the south side of Glasgow (18) GEMAP Scotland ( a financial inclusion and money advice service which operates mainly in the north-east of Glasgow (13); East Renfrewshire Council s Customer First service, which offers advice across a range of areas (welfare, benefits, housing etc.) (8); Renfrewshire Council s Families First service, which provides support and advice to families with under-5 s (5); Citizens Advice Bureaux in Drumchapel and Maryhill & Possilpark (4); Drumchapel Money Advice Centre (1); NHS Money Advice (1); Home Start (in partnership with Families First) (1). NHS GGC money advice training report (ASH Scotland) November 214 2

3 The (self-described) roles of attendees were varied: Financial Inclusion Officer 12 Money Advisor 1 General Advisor 3 Admin Assistant 2 Energy Advisor 2 Family Keyworker 2 Team Leader 2 Welfare Rights Officer 2 Administrator 1 Asst. Chief Executive 1 Benefits Manager 1 Clerical Officer 1 Community Info Worker 1 Family Wellbeing Worker 1 Financial Capability Worker 1 Income Advisor 1 NHS Income Maximiser 1 Project Co-ordinator 1 Receptionist 1 Support Worker 1 Volunteer 1 (Unknown/undescribed 3) This range of roles demonstrates that knowledge of issues relating to financial inclusion, debt and welfare should not be limited to front-line staff, and that helping raise awareness of the links between smoking and its associated costs (plus the health and financial benefits of quitting) can be open to a broad range of professionals. NHS GGC money advice training report (ASH Scotland) November 214 3

4 average score On-the day evaluations On-the-day evaluations were adapted from the standard paper-based versions used by NHS GGC for all their HBC training and were distributed at the start of the session, then re-issued at the end, to gauge if there had been any change/increase/improvement (in a range from 1-5, with 1=low, 5=high) in selfreported knowledge, awareness or skills relating to various components of the training. The standard on-the-day evaluation sheet is attached at Appendix 1. 5 pre-/post- training scores: average for all sessions (n=51) before after area of competency It is clear from the pre-/post-training evaluations that there were improvements to knowledge, skills and awareness in all five areas of competency within the HBC model. This suggests that similar training in other money advice settings may be effective in helping to raise the issue of smoking and its impact on finances, with the potential for a subsequent increase in the number of referrals into stop-smoking services. NHS GGC money advice training report (ASH Scotland) November 214 4

5 Participants at each training session were also asked to identify what aspects of the course they liked, disliked, will use and wanted to know more about; they were also invited to leave any additional comments about the training course as a whole. Comments have been grouped into common themes: I liked How the training was delivered/presented/structured (2) The content of the training (9) Learning about the different ways of raising the issue/encouraging people to stop smoking (7) Learning about [stop-smoking] services available in the community (6) The interactive elements (6) Learning about the effects of smoking/using tobacco (4) Learning about the referral process (3) The clarity of the information (3) Group discussions (2) Guest speakers (2) Learning about how much money could be saved/financial aspects of smoking (2) Learning about the smoking and money advice project (2) The informal setting (2) The pace of the training (2) Using case studies helped make it real (2) Creating different scenarios with characters (1) How informative the tutor was (1) Learning about [stop-smoking] products (1) Smoking facts/quiz (1) The length of the training appropriate for material/subject matter (1). I ll use The knowledge I ve gained/information I ve been given (15) Interview techniques (including motivational interviewing)/methods of raising the issue (1) The referral system (9) Information about stop-smoking services (7) Information about money saved/financial benefits of quitting (3) The ideas to help those who want to quit (1) The money tin (1). I didn t like The training could have been shorter (2) Some of the exercises were too simple (1). NHS GGC money advice training report (ASH Scotland) November 214 5

6 I want to know more about The effect of smoking on the body (3) What chemicals are in cigarettes (1) Success stories how it is working (1) The success rates for clients in deprived areas (1) What happens at the service (1) Prescriptions / medicines available (1) People in certain group i.e. disabilities etc. and what is available (1) Statistics figures i.e. death rates and look more at legislation (1) School visits and what you would do to encourage young people to stop smoking (1) E-cigs, if and when research is complete, if they are harmful (1) Posters for display (1) Who to refer to (1). I d also like to say The training and content were good/helpful/informative (14) The trainer was knowledgeable/content was well-delivered (7) The training was enjoyable (5) I m now going to make a quit attempt myself (1) I feel more confident about discussion with client re. smoking cessation services (1) A free app and training for the referrals would be great (1) Good to participate as a group (1). It is clear from this feedback that the training sessions have, overall, been well received and have provided knowledge and resources for attendees to use on an ongoing basis. It is also apparent, from the I want to know more about section, that the training has stimulated an interest in wider issues relating to smoking and tobacco use; this is encouraging and suggests that follow-up information sessions (or refresher training) may be welcomed by this cohort. NHS GGC money advice training report (ASH Scotland) November 214 6

7 no. of responses Three-month follow-up evaluations Three-month follow-up evaluations were developed by ASH Scotland and approved by NHS GGC; they were completed online (via SurveyMonkey) and distributed by to attendees. A total of 34 people responded to (or at least started) the three-month follow up survey which equates to 67% of those who attended the training. After a preamble to establish where and for whom a respondent worked/volunteered, the questions were designed to ascertain if there had been any changes to the frequency with which attendees now raise the issue of smoking and tobacco use, as well as recording any changes to their knowledge, confidence and/or skills around the subject. The aggregated responses to the survey questions are presented below. Q1: Compared with before the training, do you now raise the issue of smoking and tobacco use (within a money advice context), more often, about the same or less often? 3 Q1: frequency of raising the issue (n=32) more often about the same less often frequency Most respondents to the survey (24 of 32 = 75%) stated that they now raise the issue of smoking and tobacco use more often than they used to, within a money advice context which fulfils at least one aim of the pilot project. None stated that they raise the issue less often. It is worth noting, however, that this represents less than half (24 of 51 = 47%) of the whole cohort that attended training, so cannot be assumed to be true for all. One additional comment was left at this question: o [I raise the issue of smoking/tobacco use] often with family members who are smokers. NHS GGC money advice training report (ASH Scotland) November 214 7

8 no. of responses no. of responses Q2: Since your training, how confident do you now feel about raising the issue of smoking and tobacco use within a money management or advice setting? Q2: confidence in raising the issue (n=32) very confident quite confident not very confident not at all confident level of confidence All respondents stated that they are now either very or quite confident about raising the issue of smoking and tobacco use within a money advice context; this is an encouraging sign that they may be more likely to initiate conversations with clients in what has often been seen as a sensitive topic. Q3. Since your training, how confident do you now feel about making appropriate referrals on to NHS stop-smoking services, based on your client's needs? Q3: confidence about making appropriate referrals (n=31) very confident quite confident not very confident not at all confident level of confidence All respondents stated that they are now either very or quite confident about making appropriate referrals on to local stop-smoking services as a result of the training which increases the likelihood of more people being signposted into local NHS stop-smoking support. NHS GGC money advice training report (ASH Scotland) November 214 8

9 no. of respondents Q4: Since your training, do you now know what NHS services are available in your local area to help clients stop smoking or using tobacco (and who to contact)? Q4: knowledge of where and to whom to refer clients (n=31) know services AND contact name know services but NOT contact name level of knowledge 1 1 don't know services don t know services BUT know who to OR who to contact contact Most respondents (21 of 31 = 68%) stated that they now know both what NHS stop-smoking services are available locally, and whom to refer clients on to. Just over a quarter, however (8 of 31 = 26%), didn t know who to contact. This suggests that more could be done to cement the links between stop-smoking services and money advice settings in the respective locales, to encourage referrals and enquiries between organisations. NHS GGC money advice training report (ASH Scotland) November 214 9

10 no. of responses no. of responses Q5: Since your training, we'd like to find out how knowledgeable you now feel about money issues relating to smoking and tobacco (e.g. the approximate cost of buying 2 cigarettes/5g of tobacco, how much money could be saved over a week, month or year if individuals quit etc.): Q5: knowledge of money issues (n=31) very knowledgeable quite knowledgeable not at all knowledgeable level of knowledge All respondents stated that they are now either very or quite knowledgeable about money issues relating to smoking and tobacco use, which in turn should help cement confidence about raising the issue within a money advice setting. Q6: Since your training, we'd like to find out how knowledgeable you now feel about health issues around smoking and tobacco use. Q6: knowledge of health issues (n=31) very knowledgeable quite knowledgeable level of knowledge not very knowledgeable not at all knowledgeable All respondents stated that they are now either very or quite knowledgeable about health issues relating to smoking and tobacco use again, this should help maintain confidence in starting conversations with clients in a money advice context on the topic of smoking. NHS GGC money advice training report (ASH Scotland) November 214 1

11 Respondents were finally asked if they had any additional comments, questions or feedback about the training they had attended; six responses were left: o Easier to gauge interest of clients wanting to quit smoking, but if they definitely don't want to stop I do not push further. Training has allowed me to realise what is appropriate or when it is appropriate to discuss about stop smoking o Training was great & I felt we benefited as an organisation by having this. I have mentioned your services to a few of our service users & advised them I could make a referral when they feel the time is right to quit o I've raised it a few times, but never done a referral. I tend to find the smokers are already aware of the pitfalls, health-wise and budget-wise, but are put off because they think it would be too difficult. Perhaps I am not persuasive enough! o I mention smoking more now with people I meet in the community, more from the health perspective than the financial perspective, because my job doesn't involve directly giving financial advice. I find that the people who are willing to chat about it and take away information are those who were already thinking of quitting or had some awareness of the health implications and costs associated with smoking o Most of my work is focused on welfare rights, and so it may be that I have less cause/opportunity to raise the issue of tobacco use than an advisor concentrating on debt advice or financial capability. However, although I found the training interesting, enjoyable and informative and I think that smoking cessation work is enormously important, I still feel, as I did prior to the training, that a money advice appointment is rarely the place to be making these interventions. In general I feel that welfare rights or debt advice should be focused first and foremost on increasing an individual's or family's income and should not encompass budgeting advice unless the client specifically requests it. All that being said, the model provided during the training of a person's cycle of motivation to quit was very helpful - also the suggestions of ways to raise the issue - and I will certainly feel more confident now to bring up smoking where it DOES feel appropriate - probably in a situation where budgeting advice has already been suggested, or else where there is a good level of trust established between me and the client o Enjoyed the training was very informative and taught me a lot that I wasn't aware of. Now more confident when approaching the client regarding this subject. NHS GGC money advice training report (ASH Scotland) November

12 Summary This survey was intended to gauge the views of those who had attended NHS Greater Glasgow & Clyde s Smoking and Money Advice training, delivered in support of their pilot project of the same name. Five training sessions were delivered between January and July 214, with 51 attendees in total from five of the eight CH(C)P regions across the Health Board area. Attendees came from a range of occupations within money, financial and/or welfare advice settings to clients at specific centres. Because not all of those who attended training are involved with the direct delivery of advice some, for example, are administrative workers it cannot be assumed that all attendees are in a position to make direct referrals into stop-smoking services. This in turn may have a knock-on effect on the expected number of referrals made to those services. It is also worth noting that only a proportion of staff - not all - in money advice settings have been trained in how to raise the issue of smoking and tobacco use within a financial context, so referrals into stop-smoking services will come from a small number of people. If this two-year pilot project is successful, it is intended that more staff from money advice settings will be trained in raising the issue of smoking and tobacco use. The on-the-day evaluations indicate that there were self-reported improvements to knowledge, skills and awareness in all five areas of competency within the HBC model three of the five areas saw a doubling in self-assessment levels (knowledge/awareness of HBC theories; knowledge/awareness of health improvement guidelines; knowledge/awareness of stop-smoking services), with the other two areas (skills around motivational interviewing; knowledge/awareness of smoking and tobacco) also showing significant improvement. The qualitative element of on-the-day evaluations also yielded positive feedback - the content, structure and delivery of the course was appreciated by many, with the knowledge gained being seen as helpful for future work. One person suggested that a free app [for mobile phones] relating to the topic would be helpful, although they didn t elaborate on what the content of such a product might be. There does appear to be a good level of interest in topics related to the training, elucidated in the I want to know more about feedback section of the on-the-day evaluations. This indicates that followup training and/or information sessions (on topics such as the health effects of smoking) may be of subsequent interest to this group. Approximately two-thirds of attendees went on to complete the three-month follow-up evaluation; whilst this is a healthy proportion, the results cannot be assumed to represent the views or attitudes of all those who attended training but it is a helpful indicator. Respondents to the survey stated that they now raise the issue of smoking and tobacco use more frequently within their work setting than they did before they attended training. Whilst this statistic is to be welcomed, there is a caveat that this is true only for 24 of the 51 people in the group as a whole, since one-third didn t respond to the three-month survey. It is, however, a promising start. NHS GGC money advice training report (ASH Scotland) November

13 The same cautious approach should be used when analysing results for subsequent questions in the three-month follow-up survey. There were improvements across all indicators used for evaluation confidence in raising the issue of smoking; confidence in making appropriate referrals; knowledge of where and to whom to refer clients; knowledge of money issues relating to smoking; knowledge of health issues relating to smoking but these can only be claimed for those who completed the survey. It is to be hoped, however, that these increases to confidence and knowledge will translate into closer relationships between money advice settings and stop-smoking services, if financial advisors do indeed start to refer their clients on for help with quitting smoking and tobacco use. The final comments of those who completed the three-month survey help illuminate the reality of working in the money advice/financial inclusion/welfare and benefits sector that it is a complex and sensitive area, with some workers reluctant to address the financial side of smoking unless directly requested to do so. Others, however, can see what their role might be in helping raise the issue of smoking and finances within their workplace. Whilst we know that not all smokers want to quit, there is established evidence to suggest that almost three-quarters of smokers do want to quit which means that money advice settings (with their higher proportion of clients from areas of disadvantage, which in turn have higher smoking rates) are highly likely to have clients who may be open to help with stopping smoking. If they can be assisted towards that support, their health both physical and financial may be improved in the long term. Linda Bates Development Officer, ASH Scotland November 214 Action on Smoking & Health (Scotland) (ASH Scotland) is a registered Scottish charity (SC 1412) and a company limited by guarantee (Scottish company no ). NHS GGC money advice training report (ASH Scotland) November

14 Appendix 1 Smoking and Money Advice Training - Session Evaluation Self-Assessment of knowledge and skills Listed below are some knowledge and skills specific to supporting health behaviour change. Please read them and then using the rating below please insert the number that best represents your level of knowledge and skills before the session today and at the end of the session today. 1 = low 5 = high Knowledge/Skills Pre-course Post-course Knowledge/Awareness of behaviour change theories Skills around motivational interviewing (e.g. reflecting, summarising) Knowledge/Awareness of health improvement recommendations/guidelines Knowledge/Awareness of health improvement services Knowledge/Awareness of smoking/tobacco Please complete the following statements in whatever way is most appropriate for you. I liked I ll use I didn t like NHS GGC money advice training report (ASH Scotland) November

15 I want to know more about I d also like to say NHS GGC money advice training report (ASH Scotland) November