Making every contact count with seldom‐heard groups? A qualitative evaluation of voluntary and community sector (VCS) implementation of a public health behaviour change programme in England

Abstract Making Every Contact Count (MECC) is a national, long‐term public health strategy in England. It supports public‐facing workers to use opportunities during routine contacts to enable healthy lifestyle changes. This paper reports the findings from an external evaluation of voluntary and community sector (VCS) delivery of MECC in the North East of England, which focused on engaging under‐represented client groups. The study aimed to (a) Establish if (and how) MECC had impacted the workforce, including changes to staff knowledge, confidence and behaviour; (b) Identify benefits, challenges and unintended consequences; and (c) Explore outcomes for service users. A multi‐stage qualitative design focused on understanding both process and outcomes. The study utilised three data collection methods, including a journey mapping workshop (n = 20), semi‐structured interviews with delivery leads, VCS workers and volunteers who had accessed MECC training (n = 11), and focus group discussions with clients (n = 22). The findings illustrated positive early outcomes, including improvements in self‐reported staff knowledge and confidence as well as emerging examples of organisational culture shift and individual behaviour change. Alongside this, the data provided a rich picture of barriers and challenges which are examined at different levels—national programme, local programme, VCS sector, partner organisation, worker and client. The research highlights clear successes of the VCS delivery model. However, it is presented as a ‘double‐edged sword,’ in light of associated challenges such as sector‐level funding uncertainty and accessibility of MECC resources to diverse client groups. The discussion considers issues related to the measurement and attribution of behaviour change outcomes for brief interventions, as well as fidelity, legacy and long‐term sustainability challenges. The recommendations call for system‐level analysis and comparison of different MECC implementation models, to improve our understanding of challenges, opportunities and programme reach for behaviour change intervention programmes—particularly in relation to seldom‐heard client groups.


| Policy context
Individual and collective behaviour change has emerged as a key priority in tackling chronic illness and improving population health across Europe (WHO, 2012). In 2014 it was estimated that health factors such as smoking, alcohol, physical inactivity and being overweight cost the NHS over £12.6 billion per year (NICE, 2014).
Detrimental health behaviours also impact local economies through reduced productivity, sickness absence and increased demand for social care (Beard et al., 2019).
Research shows that opportunistic behaviour change interventions delivered by health and social care practitioners during routine contacts with clients are cost-effective and can reduce local health inequalities (PHE, 2019a,b). Such interventions are becoming part of the remit of an increasing spectrum of workers across health, social care and wider public services (Byrne-Davis et al., 2018).
Making Every Contact Count (MECC) is a long-term public health strategy, rolled out in NHS Trusts and local authorities across England since 2010. It supports public-facing workers to, 'use opportunities during routine contacts to support, encourage and enable people to consider healthy behaviour changes' (PHE, 2016:5). MECC targets a range of health factors including smoking, diet, physical activity, alcohol use, mental health and wellbeing (HEE, 2021). It involves frontline workers initiating brief, health-related conversations as part of routine appointments and-where appropriate-signposting to local services and information: 'The ultimate aim is to make health-related behaviour change interventions commonplace in a wide range of settings within and beyond the NHS.' (Nelson et al., 2012:655) A key focus of MECC is on developing staff competencies and organisational processes, through the provision of training and materials, to enable effective interventions to take place (HEE, 2021).

| Existing literature
Despite its prominence as a national public health strategy, there has been limited academic research published on the implementation and impact of MECC. Evidence is predominantly drawn from small-scale studies in clinical or other healthcare contexts, with a central focus on process evaluation rather than impact. Difficulties assessing outcomes have been highlighted as particularly problematic, with researchers often relying on indirect staff feedback or compiled case studies to draw conclusions about client outcomes (Nelson et al., 2012;Patten & Crutchfield, 2016). Evaluation of MECC in local government contexts has focused on internal staff groups such as housing officers or social workers, rather than wider community organisations (Dewhirst & Speller, 2015).
Despite its limited scope, the existing literature illustrates positive early experiences of MECC implementation. Nelson et al's. (2012) interview-based study of NHS and public health practitioners in two English regions identified strengths including MECC's simplicity, flexibility and low cost. Reported organisational benefits include a positive impact on perceived organisational culture and increased team-bonding opportunities (Dewhirst & Speller, 2015), alongside changes to operational systems and practice (Patten & behaviour change intervention programmes-particularly in relation to seldom-heard client groups.

K E Y W O R D S
behaviour change, health policy, health promotion, health services research, public health, qualitative research, voluntary and community sector What is known about this topic • Interventions focused on health behaviours such as diet, physical activity, smoking and alcohol are considered central to improving health.
• MECC supports health and social care practitioners to deliver brief interventions, through training and resources.
• There is limited understanding of outcomes and challenges for practitioners, organisations and clients-particularly in non-clinical contexts and with under-represented client groups.

What this paper adds
• MECC led to positive outcomes including improved staff knowledge and confidence, organisational culture shift and individual behaviour change.
• Advantages of VCS delivery included the breadth of client groups accessing interventions, while challenges included funding uncertainty and accessibility of MECC resources.
• Wider discussion includes long-term sustainability challenges, support requirements and barriers to measuring outcomes.
Crutchfield, 2016). For frontline workers, findings demonstrate improved skills, knowledge and confidence measured using pre-and post-training evaluation questionnaires-for both MECC and similar behaviour change programmes (Bull & Dale, 2020;Dewhirst & Speller, 2015;Patten & Crutchfield, 2016). However, the sustainability of specific techniques included in MECC training, such as open discovery questions and goal-setting, seems to be more varied (Frost et al., 2018;Lawrence et al., 2016).
Existing studies illustrate variable uptake of MECC, which is explained by a range of practical, attitudinal and cultural barriers (Keyworth et al., 2018). Examples include resistance from medical practitioners, unease about the potential to offend clients and staff concerns over workload increases related to recording, referral and monitoring requirements (Keyworth et al., 2018;Nelson et al., 2012;Patten & Crutchfield, 2016). Dewhirst and Speller (2015) highlighted that, while staff knowledge and confidence increased as a result of MECC, there was little change to the wider factors that make discussing healthy lifestyles easier or more difficult-such as time available, client attitudes and service organisation. Greater exploration of factors affecting the use of behaviour change interventions post-training, including workplace barriers and the availability of support, is needed (Bull & Dale, 2020).

| The role of the VCS in health and social care delivery
The last few decades have seen a significant increase in the delivery of public services by the voluntary and community sector (VCS) in the UK and internationally (Dacombe & Morrow, 2016;Newbigging et al., 2017). Research shows that VCS agencies are well-placed to cross institutional boundaries in health and social care and increase capacity related to health promotion, yet they experience challenges related to training needs, resources and lack of systematic approaches to outcomes evaluation (Boyle et al., 2007;Croft & Currie, 2020). Findings also highlight the challenges of partnership working between VCS and statutory functions such as general practice, including differences in operational systems, governance and professional boundaries (Southby & Gamsu, 2017).
A unique and distinctive feature of the VCS role in public service delivery has been the ability to gain the trust of under-represented groups, enabling engagement with-and playing an important role in the provision of services for-those considered 'seldom-heard', 'marginalised' or 'hard-to-reach' (Flanagan & Hancock, 2010;Healthwatch, 2020;Powell et al., 2017). Such phrases are used to describe groups who have traditionally been excluded from, or inadequately represented in, services or decision-making. Examples include ethnic minority groups, carers, the LGBTQ + community, people with mental or physical disabilities, refugees and asylum seekers, people experiencing homelessness and young people (Flanagan & Hancock, 2010;Healthwatch, 2020).
Barriers to accessing services for this cohort are well-documented.
Findings highlight a need for flexible service boundaries, increased partnership working and time to establish trust in order to improve service experience and engagement (Flanagan & Hancock, 2010). It is argued that the greater flexibility and ability to establish trust by the VCS has led to its relative success in engaging under-represented groups, when compared to more mainstream approaches (Flanagan & Hancock, 2010;Goopy & Kassan, 2019;Powell et al., 2017).
The challenges of realising the policy goal of greater VCS involvement in health and social care delivery has led to initiatives such as financial incentives and the creation of new workforce roles and network structures to support VCS engagement (Croft & Currie, 2020;Isaacs & Jellink, 2007;Jennings, 2015). A recent study of voluntary sector involvement in integrated care provision by Croft and Currie (2020) illustrated the value of dedicated workforce roles in facilitating joint working and supporting VCS agencies to navigate the complex system barriers between health and social care. The findings highlighted the importance of regulation and 'normative control' exerted by commissioners, to maximise engagement from healthcare professionals and reduce the risk of exploitation of VSC provider flexibility to 'patch' provision by overstretched service providers. b. Identify any benefits, challenges and unintended consequences.

| The current study
c. Explore the extent to which MECC had influenced outcomes for end users.

| Research context
The evaluated programme was funded from June 2017 to September 2019 by a local authority in the North East of England. It involved the delivery of training in MECC brief interventions to over 500 frontline staff, alongside a £300,000 grant fund made available to local VCS organisations to enable participation and embedding of the MECC approach. The programme design targeted VCS organisations who were working with seldom-heard groups such as asylum seekers, carers and people with learning difficulties, as well as those at heightened risk of wider health inequalities such as cancer survivors. A total of 19 local VCS partners were involved initially, forming the primary focus for the research. Later phases extended to wider council services and additional groups including the LGBTQ + community and armed forces service leavers.

| Study design
The research utilised a three-stage, qualitative design: 1. Journey mapping workshop with the MECC delivery team, VCS leads, workers and volunteers (n = 20).
The combination of methods allowed a range of perspectives to be sought and was considered important to maximise validity of the findings through triangulation (Patton, 2002). The study received ethical approval from Northumbria University (ref 15553). Written informed consent was obtained from participants at the start of the workshop, interviews and focus groups. Discussion prompts for each stage are provided in Table 1.

| Sampling
A purposive sampling approach was taken whereby prospective participants were approached due to their involvement in MECC as workers, volunteers or clients. All 19 VCS organisations were approached to take part via an opt-in invitation email, sent out by the MECC programme on behalf of the research team in order to uphold data protection requirements. Separate invitation emails were sent regarding each study element (including the mapping workshop, interviews, focus groups and a final dissemination event), approximately 6-8 weeks apart. Table 2 provides an overview of the organisational focus and core client group of participating VCS organisations, alongside an indication of their level of involvement in the study. 13 VCS partners took part in at least one element of primary data collection, alongside one internal council department. The focus of organisations for those who did not take part included homelessness, dementia, eating disorders, poverty and learning difficulties. Where reasons for non-participation were provided these included staffing and capacity challenges, particularly for smaller organisations. Table 3 provides an overview of key sample details and data generated at each research stage.

| Stage 1: Mapping workshop with MECC delivery team, VCS leads and frontline workers
An initial, face-to-face journey mapping workshop brought together VCS service managers, frontline workers and volunteers

| Stage 2: Semi-structured interviews with delivery team, VCS leads and frontline workers
Stage 2 explored the views of delivery leads, frontline workers and volunteers in more depth. One-to-one semi-structured interviews (n = 11) were undertaken with local authority MECC delivery leads (n = 3), VCS MECC leads and frontline workers (n = 6) and one internal council department (n = 2). The majority of interviews took place in a private meeting room at the participant's place of work, with one conducted via telephone and one on university premises according to participant preferences. Interviews were audio-recorded and lasted from 34 to 95 min.

| Stage 3: Focus groups with clients and service users
Three focus groups took place during June-July 2019, involving 22 clients plus 3 supporting frontline workers. All 19 organisations were invited to take part, of which 3 opted in during the study timeframe.
Each focus group was facilitated by two researchers and took place on the VCS organisation's premises, as part of a regular group meeting. Study information was sent ahead to group facilitators, alongside an offer to discuss any specific requirements or attend an earlier meeting to introduce the research team in advance. Materials were adapted where required, for example through the development of large-print study information sheets and shortened discussion questions. Focus groups lasted between 49 and 79 min, with two of the three being audio-recorded. In the remaining group, detailed notes were taken.
Focus group participants represented a range of seldom-heard groups including those with learning disabilities and difficulties, young people, older people and mental health service users.
Participant status as a member of an under-represented group was inferred from the person's group membership (for example being a member of a learning difficulties group), rather than the collection of detailed demographic or needs-related information from individual participants. Related ethical considerations and limitations are considered in the discussion section.

| Analysis
The data was analysed thematically using an approach based on Ritchie and Spencer's (1994) thematic framework analysis. This involves a series of processes including familiarisation, indexing, framework development, mapping and interpretation. Facilitated using the QSR analysis software NVivo, an 'open coding' process was used to iteratively generate a thematic framework from the data. Mapping, interview and focus group data were initially coded separately; however, emerging themes were later merged into one shared framework due to a high level of correspondence between themes identified across the different data sources. An overview of themes and sub-themes generated through the analysis is provided in Table 4.
Emerging findings and research team interpretations were shared with the local authority programme team (n = 5) for discussion and interrogation at a face-to-face session in June 2019. Following this they were shared with VCS partners, clients and wider stakeholders TA B L E 2 Overview of organisational focus, client group and level of involvement in the study for participating VCS organisations for feedback and discussion, as part of a MECC celebration event in autumn 2019 (n = 69).

| Finding s
The findings reported here focus on VCS implementation and delivery of MECC. We examine key features and advantages of VCS delivery, before exploring outcomes for organisations, workers and clients. The final section outlines barriers and challenges to implementation, including those unique to the VCS context. The analysis highlighted a wide range of client groups accessed through the VCS delivery model. These included people with learning disabilities and difficulties, refugees and asylum seekers, the

| MECC implementation and VCS delivery with seldom-heard groups
LGBTQ + community, young carers, older people and those experiencing dementia, young mothers and women experiencing mental health problems. The potential for networking and collaboration across this landscape was an important part of MECC's perceived value to VCS partners: 'We wanted to be part of a consortium delivering the same ideology.' (R14, VCS Lead-workshop) TA B L E 3 Sample details and data generated for the three data collection phases

| Positive organisational outcomes
The findings articulated a range of positive outcomes for MECC partner organisations. MECC was commonly referred to as having reinforced or validated existing practice, providing a framework to underpin work that organisations were already doing or enabling them to go further in their approach to supporting behaviour change for clients: 'It provides the authenticity to do something we've

| Challenges and barriers to VCS implementation
Balanced against the identified benefits of VCS delivery, the data provided a rich picture of barriers and challenges to successful MECC implementation at different levels including national programme, local programme, VCS sector, partner, frontline worker and client. These are summarised in Table 5.
Key challenges at national programme-level included the accessibility and suitability of MECC training and resources for specific seldom-heard groups, such as those with English as a secondary language or those with learning difficulties. Flexibility was a crucial factor in successful implementation, as it enabled the development of bespoke, tailored programmes in response to locally identified need, interest and constraints.
Local programme-level challenges were also illustrated, including planning requirements and financial resources allocated to MECC. VCS sector and local partner-level barriers included variations in organisational commitment, capacity and workload pressures, staff turnover and the fluctuating VCS volunteer base. Many such challenges were linked to the wider context of sector-level financial uncertainty, which in turn led to concerns around MECC legacy, long-term sustainability and transfer of knowledge across the VCS workforce. Substantial barriers were also reported in relation to measuring MECC outcomes, with some partners feeling unable to provide sufficient capacity to fulfil MECC reporting requirements.
At frontline worker-level, while perceptions of the overall value of MECC were generally high for those involved in the evaluation, there were some notable individual differences. Where participants did not identify positive outcomes, a range of explanatory factors were identified. These included perceived relevance, background and existing knowledge, role and service focus (including nature and frequency of client contact), workload/capacity, and perceptions of client relationships-including the potential for MECC to negatively impact on these.
The data also illustrated several client-level challenges. These included individual differences in motivation, interest and attitude towards change, alongside complexity of existing health and wellbeing issues, wider personal circumstances (including financial situation), language barriers and cultural differences. Some of these issues

| Advantages and disadvantages of a VCS delivery model of MECC
The focus on the VCS as central delivery partner of a national health behaviour change programme provided a unique context within which to explore implementation and early impact from the perspective of partner organisations, frontline workers, volunteers and clients.
The findings highlighted clear successes of VCS implementation, including the diversity and extensive reach of the programme which engaged a range of seldom-heard groups. Close, trusted relationships and opportunities for regular client contact held by many partners created opportunities to develop creative, co-produced and relatively long-term interventions. Based on the current findings, we suggest that VCS-led implementation of brief interventions may hold the potential to reach a broader range of clients, and in more diverse ways, than more traditional forms of implementation by clinical practitioners. This supports existing literature which highlights the ability of VCS organisations to provide flexible, trusted services leading to improved engagement with those who are marginalised (Flanagan & Hancock, 2010;Goopy & Kassan, 2019;Powell et al., 2017).
There were however notable trade-offs associated with VCS delivery of MECC brief interventions. Conceptualised as a 'doubleedged sword', challenges included the need for substantial adaptation of resources and additional work-from both the MECC programme team and VCS partners-to improve accessibility to specific client groups. Additional administrative implications included the need for flexibility to respond to a fluctuating workforce and volunteer base, with a high prevalence of part-time working alongside limited organisational capacity to release workers for training.
The findings provide useful learning related to both the benefits and support requirements of increased VCS involvement in delivery of brief interventions, as well as other public sector initiatives such as social prescribing.
In the current study, much of MECC's reported success was attributed to the knowledge, enthusiasm and hard work of individual partners and delivery team members. While specific aspects of MECC were highly regarded-such as its flexibility and simplicity of the messages included in training sessions-the data also painted a rich picture of barriers and challenges to successful implementation. Many of the benefits and challenges identified here support findings reported in the wider literature (Bull & Dale, 2020;Nelson et al., 2012;Patten & Crutchfield, 2016). Table 5 however, additional layers of complexity were associated with the VCS delivery model, including sectorlevel funding uncertainty, high staff turnover and reliance on volunteers, and the specific needs and requirements of such a diverse client base. These required local programme leads to help address and navigate barriers faced by individual partners and the VCS sector more widely.

| Legacy and long-term sustainability
The evaluated MECC programme can be understood as a relatively short-term approach to behaviour change, having received timelimited funding over 2 years. Longer-term ambitions of continued, unfunded roll-out by its delivery partners raise questions regarding long-term sustainability and learning transfer. The need for highlevel, strategic commitment to ensure MECC's long-term success emerged as a key theme in this study, mirroring findings elsewhere in the literature (Dewhirst & Speller, 2015;Nelson et al., 2012).
The challenges of sustaining behaviour change for both practitioners and clients beyond an intervention's initial timeframe are well-documented Kwasnicka et al., 2016).
In the current study, the importance of long-term sustainability was visible from both the client and frontline worker perspective, in relation to maintaining individual behaviour change as well as the need to regularly update and reinforce key public health messages. The significant role of wider support networks was also highlighted, anchored in a conversation about cross-sector reduction in capacity to support health-related behaviour change in recent years. This raises important questions around who will be responsible for driving MECC forward in the longer term and the wider capacity required to support it locally.

| MECC as a universal public health solution
The findings reported here encourage wider discussion around MECC as a conceptual model, including its efficacy and inclusivity as a national model of health behaviour change. The research demonstrated that MECC in its original format may not be accessible for seldom-heard client groups or those with complex needs, with substantial tailoring required by those delivering interventions to enable meaningful participation. Whether this is a realistic expectation for those driving the initiative locally, or should instead be considered a crucial part of MECC's national remit, is open to debate. In addition, limited consideration of the impact of wider contextual factors such as income, family situation, stress and culture on health behaviour led to a perception of MECC as a westernised or 'privileged' approach to behaviour change. If MECC or other behaviour change interventions are intended to engage fully with seldom-heard groups, this work offers insight into areas for future development and investment. This is essential to ensuring that support for health behaviour change is accessible and embedded in the lives of those such interventions are seeking to improve.

| Understanding and measuring brief intervention outcomes
Finally, while the research documented positive early outcomes of MECC, it also raised a series of issues related to programme implementation, monitoring and evaluation. The findings emphasise the need for simple, appropriate and realistic reporting requirements.
There was wide variation in motivation and commitment to monitoring outcomes among VCS partners, alongside practical issues related to the robustness of recording systems and their accessibility to external evaluation. Issues related to the visibility of MECC as a standalone programme with separate, attributable and measurable outcomes-as with many brief interventions and preventative approaches-presented further, substantial barriers: 'I think people don't really see it as a programme.
They just see it as a nice walk on a Friday afternoon … and that's the whole idea of it of course.' (R30, VCS frontline worker)

| Study limitations
While this research provides some promising early findings, it shares several limitations with earlier work on brief interventions and the role of VCS organisations in service delivery. Limitations include the focus on one specific programme in one geographical location at one time-point, which may or may not prove transferable to other contexts. In addition, a lack of accessible reporting systems or research team involvement in the programme's planning stages created an unavoidable reliance on qualitative methods and process evaluation. These points reflect challenges reported elsewhere and re-emphasise the call for long-term, strategic evaluation of MECC alongside investment in shared, accessible evaluation tools (Nelson et al., 2012;Patten & Crutchfield, 2016).
Regarding the focus on seldom-heard groups, it was beyond the scope of the evaluation to examine the extent to which VCS partners meaningfully engaged their target client base. Even with the heightened focus on under-represented groups within the studied MECC delivery model, we can assume that there will have been a significant cohort of people who fell outside the programme's reach. Focus group participant status as a member of a seldom-heard group was inferred from their membership of a particular VCS organisation, rather than being objectively measured. This decision was made based on ethical considerations and in light of the wider challenges of engaging 'hard-to-reach' groups in research (Rockcliffe et al., 2018;Waheed et al., 2015). Similarities shared by the VCS organisations who did not opt-in to the evaluation raise future research questions around the feasibility of delivering such interventions with client groups who may be facing an immediate crisis, or a complex or progressive diagnosis-for example those experiencing homelessness, eating disorders or dementia.

| Conclusion and Recommendations
This paper contributes to learning related to MECC and other brief intervention programmes, through the detailed analysis of a VCSled delivery model in practice. While this has been demonstrated to add value through diversity, reach and the close nature of client contact, it has simultaneously been illustrated to create a uniquely challenging environment for implementation. This highlights a need for system-level analysis and comparison of different brief intervention delivery models, to expand our understanding of barriers, facilitators and programme reach beyond traditional implementation contexts.
Building on the multi-layered identification of barriers and challenges to implementation, the findings led to several recommendations for local and national implementation of MECC and other brief intervention programmes. Recommendations include the development of diverse and accessible resources at a national level that are suitable for different backgrounds, cultures and levels of need-alongside increased opportunities for sharing learning among delivery partners. Furthermore, there is a need to develop robust, shared evaluation and monitoring tools which take into account wider pressures on delivery partners and are simple to use, realistic and accompanied by supporting guidance or training. Finally, this work challenges a critical assumption of MECC-and many other behaviour change programmes-that contact with those in need of support should be facilitated through standardised public health messages rather than tailored, individualised support co-produced with those whose lives it seeks to change.

ACK N OWLED G EM ENTS
The authors would like to thank the funder for commissioning this research. We are grateful to the workers, volunteers and clients of the participating VCS organisations for their valuable contributions to the study. We would also like to acknowledge the support of local authority colleagues who were integral to enabling the evaluation to take place, including the MECC Programme Lead and delivery team.
We would like to thank the reviewers for their helpful comments on earlier versions of this paper.

CO N FLI C T O F I NTE R E S T
The authors declare that there is no conflict of interests. The research was undertaken externally by the academic research team, independent from the funding organisation.

AUTH O R CO NTR I B UTI O N
All authors contributed to the conceptualisation and design of the study. Mapping workshop data was collected by DH, RW, KB and GC. Interviews were undertaken by DH, KB and GC. Focus group discussions were facilitated by DH, KB, HH and GC. DH and RW coded and analysed the data. All authors contributed to interpreting the data. The first draft of the manuscript was written by DH. All authors contributed to the development, reviewing and editing of the paper. All authors read and approved the final manuscript.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request. The data are not publicly available due to privacy or ethical restrictions.