Health Expectations - 2013 - Roussy - Enhancing Health Care Workers Understanding and Thinking About People Living With

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doi: 10.1111/hex.12146
Enhancing health-care workers’ understanding and

thinking about people living with co-occurring
mental health and substance use issues through
consumer-led training
ronique Roussy BSc (Hons) MSc,* Nikos Thomacos BA (Hons) BBus PhD GCHE,† Annette
Ve
Rudd BSocWk (Hons) BA‡ and Belinda Crockett BAppSc (Hons) BA PhD GCHE§¶
*Senior Project Officer – Health Promotion and Service Development, Knox Community Health Service, Ferntree Gully, VIC,
†Senior Lecturer, Department of Occupational Therapy, School of Primary Health Care, Monash University, Frankston, VIC,
‡Health Promotion Manager, Knox Community Health Service, Ferntree Gully, VIC, §Population Health Leader, Eastern
Melbourne Medicare Local, Croydon, VIC and ¶Adjunct Senior Lecturer, School of Public Health and Preventive Medicine,
Monash University, VIC, Australia
Abstract
Correspondence Background Stigma and judgemental assumptions by health work-
Nikos Thomacos PhD, BA (Hons),
BBus GCHE
ers have been identified as key barriers to accessing health care for
Senior Lecturer people living with co-occurring mental health and substance use
Department of Occupational Therapy issues (dual diagnosis).
School of Primary Health Care
Room G4.28, Monash University – Objective To evaluate the effectiveness of consumer-led training by
Peninsula Campus
people with dual diagnosis in improving the knowledge, under-
McMahons Road
Frankston standing and role adequacy of community health staff to work
VIC 3199 with this consumer group.
Australia
E-mail: nikos.thomacos@monash.edu Methods A controlled before-and-after study design with four
Accepted for publication waves of quantitative data collection was used. Qualitative data
30 August 2013 were collected to explore participants’ views about training. Partici-
Keywords: alcohol and drug, pants were staff from two community health services from Victoria,
community health, consumer-led, Australia. Recruitment occurred across various work areas: recep-
consumers, dual diagnosis, health
tion, oral health, allied health, counselling and health promotion.
communication, mental health,
primary health care, stigma, At baseline, all participants attended a 4-h clinician-led training
substance use, training, workforce session. The intervention consisted of a 3-h consumer-led training
development session, developed and delivered by seven individuals living with
dual diagnosis. Outcome measures included understanding of dual
diagnosis, participants’ feelings of role adequacy and role legiti-
macy, personal views, and training outcomes and relevance.
Results Consumer-led training was associated with a significant
increase in understanding. The combination of clinician-led and
consumer-led training was associated with a positive change in role
adequacy.
Conclusions Consumer-led training is a promising approach to
enhance primary health-care workers’ understanding of the issues
faced by dual-diagnosis consumers, with such positive effects
© 2013 John Wiley & Sons Ltd. 1567

Health Expectations, 18, pp.1567–1581
13697625, 2015, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.12146 by Lovisenberg Diaconal University College, Wiley Online Library on [22/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1568 Effectiveness of consumer-led training, V Roussy et al.
persisting over time. Used alongside other organizational capacity

building strategies, consumer-led training has the potential to help
address stigma and judgemental attitudes by health workers and
improve access to services for this consumer group.
providers.10,13 Examples of such barriers

Introduction
include the stigma associated with living with
People with alcohol and other drug (AOD) use co-occurring illicit drug use and mental health
issues also commonly experience co-occurring problems; challenges associated with respond-
mental health issues.1,2 The co-occurrence of ing to complex and concurrent vulnerabilities;
drug and mental health concerns (dual diagno- a lack of holistic or comprehensive services; a
sis) has been consistently confirmed. Recent lack of appropriate services; poor service user
Australian data suggest that, overall, recent knowledge of available services; inadequate
users of illicit drugs (past 12 months) were referral processes and pathways; overly restric-
more likely to have been diagnosed or treated tive intake requirements; and service providers’
for a mental illness than those who had not judgemental assumptions regarding people liv-
used during the last 12 months. This associa- ing with dual diagnosis.9,10,14–16
tion was evident for a range of individual sub- Consumers, health practitioners and policy-
stances: cannabis, ecstasy, meth/amphetamines makers all stress the need for further education
and cocaine.3 Recent data from the Illicit Drug of primary health-care workers (including
Reporting System (IDRS), Australia’s national reception staff) regarding dual diagnosis, to
illicit drug monitoring system, found that 63% increase understanding and reduce stigma,
of Victorian participants who self-reported illi- judgemental attitudes and assumptions associ-
cit drug use also self-reported mental health ated with dual diagnosis.9,10,12,15–17 Indeed,
problems. Furthermore, of those with self-iden- improving the way people with dual diagnosis
tified co-occurring illicit drug use and mental are perceived by health-care workers is seen as
health problems, 90% reported having sought necessary to enhance service responses in
assistance from mental health services.4 This favour of this consumer group, as well as this
high prevalence of dual diagnosis is a concern consumer groups’ experiences of such services.
and highlights the importance of having a com- Consumer involvement in training and educa-
petent workforce that is aware of the complex tion is therefore viewed as instrumental in
issues faced by individuals with dual diagnosis. achieving these outcomes.13,15
Dual diagnosis is typically associated with a Consumers have been increasingly involved
range of poorer health and well-being out- in the training of students, primary health-care
comes. Compared to those with a single disor- workers and their organizations in fields such
der (e.g. depression), people living with dual as mental health and nursing.18–23 Consumers
diagnosis are more likely to experience physical may take on a variety of roles, including as
health problems, suicidal thoughts or behav- ‘consultants’ in the development of materials
iour, social isolation, homelessness and high and as trainers or teachers.21,22,24 However,
volumes of service utilization.5–8 Not surpris- there is a paucity of published examples of
ingly, concerns that people living with dual consumers having a high level of autonomy
diagnosis are regularly falling through the and ownership over the development and deliv-
‘cracks’ have been regularly raised by mental, ery of training packages. In 1995, Cook et al.25
AOD and other health service providers over demonstrated that the post-training attitudes of
the past decade.9–12 A range of barriers to American mental health professionals were sig-
access treatment and follow-up have been nificantly more positive when trained by a con-
identified by both consumers and service sumer than by a non-consumer. Again in the
© 2013 John Wiley & Sons Ltd

Effectiveness of consumer-led training, V Roussy et al. 1569
USA, a consumer-led intervention was shown The aim of the current study was therefore
to effectively improve mental health provider to evaluate whether consumer-led training
competencies in domains such as delivery of would be effective in improving the knowledge,
care, teamwork and in the delivery of holistic understanding and confidence of community
responses to mental health problems.26 In the health staff to work with people living with co-
Australian context, Meehan and Glover27 dem- occurring mental health and substance use
onstrated that consumer-led training enhanced issues, a dual diagnosis. Additionally, how the
mental health providers’ knowledge of con- outcomes of consumer-led training differ from
sumer-focussed, recovery-based ‘good’ practice. those of more traditional training, that is,
To our knowledge, no study to date has training delivered by ‘expert’ dual-diagnosis cli-
examined the outcomes of consumer-led train- nicians, was also investigated.
ing specifically for dual diagnosis or when
delivered to a diverse audience of primary
Method
health-care professionals and administrative
staff. In addition to providing allied health,
Study design
counselling, oral health and health promotion
services, many Victorian community health ser- A controlled before-and-after study design was
vices also offer AOD treatment services.13 As used, with two sites and four waves of data
such, they are currently targeted by National collection. The approach taken is summarized
and State initiatives to enhance their dual-diag- in Fig. 1.
nosis capability and linkages with mental Two independent community health services
health services.13 Enhancing the health-care from the Metropolitan Region of Melbourne,
workforce’s understanding of, and capacity to Victoria, Australia, were involved. One acted
respond to, the needs of people living with dual as the intervention site and the other as the
diagnosis is of concern for both practice and control site. Both organizations are similar in
policy. size, with 125 staff members at the interven-
INTERVENTION
Clinician-led
Consumer-led training
training
intervention
Intervention
group
Control
group
Data measurement 1 Data measurement 2 Data measurement 4

Data measurement 3
Pre dual diagnosis training; Post dual diagnosis training; 5 months Post
Post intervention
Pre intervention Pre intervention intervention
Figure 1 The study used a controlled before-and-after design with two sites and four waves of quantitative data collection.

tion site and 115 at the control site. Both The intervention consisted of a 3-h, con-
deliver a range of oral health, allied health, sumer-led training session, entirely developed
counselling, family and children services, and and delivered by a group of individuals living
health promotion projects and programmes. with co-occurring mental health and substance
However, key differences between sites are use issues. Over a 2-month period, eight peo-
noteworthy. Firstly, the intervention site offers ple living with dual diagnosis worked together
AOD counselling services, while the control with two facilitators from the Association of
site does not. The latter, however, coordinates Participating Service Users, a consumer-based
the regional Needle and Syringe Program. organization dedicated to increasing the par-
Consequently, we can reasonably assume that ticipation of people currently or previously
consumers at each organization would differ, using illicit drugs in health systems and policy,
as would their expectations and experiences at to develop their own training package. A total
each site. Secondly, at the commencement of of seven consumers living with dual diagnosis
the project, the intervention site had already were involved in delivering the session. Their
benefited from 3 years of funding to build the session involved the provision of evidence-
capacity of its AOD team to work with based information on substance use, addiction
consumers with dual diagnosis. To optimize and its impact on brain function, denial,
comparability between sites and also minimize relapse and compliance rates. They used role
the effect of service mix and service user make play and personal stories to illustrate barriers
up and experiences on the study results, a to health care and ways in which services can
clinician-led training session regarding dual be improved, and provided an opportunity for
diagnosis was provided to both study sites session attendees to ask questions. The
prior to the consumer-led training at the consumer-led training was delivered to the
intervention site. intervention site only, 2 months after the
At each site, staff were recruited to partici- clinician-led training.
pate in the study prior to commencing the cli-
nician-led training session. Recruitment
Measures
involved raising awareness of the training via
email to all staff; with those unable to attend The Work Practice Questionnaire (WPQ) has
the clinician-led training being excluded from been shown to be a reliable tool for assessing
participating. Staff members from all areas of the impact of AOD-related training and devel-
both organizations were encouraged to attend. opment.28 In the current study, the WPQ was
refined so it could be used to assess the impact
of dual-diagnosis-focussed training. As in the
Training and intervention
original form of the WPQ, the questionnaire
A 3.5-h, clinician-led training session was deliv- applied in the current study contained eight
ered by a senior dual-diagnosis clinician at domains. Together, the domains encompassed
both the intervention and control sites. Topics a total of 22 subthemes. Each subtheme repre-
covered in this session included defining dual sented a total of three to nine statements,
diagnosis; prevalence of dual diagnosis in which participants rated their level of agree-
health-care settings and the general population; ment or disagreement to using a seven-point
barriers to treatment; the local health-care ser- Likert scale. Higher scores represented higher
vice system; relevant dual-diagnosis policy; levels of agreement. The six subthemes consid-
dual diagnosis and marginalization; and atti- ered in this paper as study variables are under-
tudes and values regarding dual diagnosis that standing, role adequacy, role legitimacy,
influence practice. The session was delivered personal views, training outcomes and training
using a mix of content delivery, case scenarios relevance (Table 1). Examples of subthemes
and individual reflection. excluded here for future analysis include

opportunity for input, team cohesion, system control site. Questions focused on staff expe-
influence and monitoring and review. rience of the training delivered, knowledge
Data were collected on four occasions: gained, usefulness of the training, and
at baseline (before any training), after the changes in confidence and work practices.
clinician-led training, after the consumer-led
training and 5 months following the con-
Data analysis
sumer-led training. Four 1-h focus groups
were also conducted to further explore par- Data were screened for accuracy of entry and
ticipants’ perspectives on the training ses- missing values from cases (i.e. participants).
sions delivered. Three focus groups were Mean substitution was applied to address the
held at the intervention site (including one issue of missing values. Data were analysed
exclusively with management) and one at the using Statistical Package for Social Sciences
Table 1 Subthemes from the modified Work Practice Questionnaire utilized for data collection, which were used as variables
for this study
Domain* Subthemes Example of underlying statements
Dual diagnosis Understanding of dual diagnosis, mental health How would you rate your understanding of dual-
and alcohol and other drug (AOD) diagnosis? Mental health? AOD?
Individual Role adequacy I am confident in my ability to respond to dual-
diagnosis-related issues
I have the necessary knowledge to work with
people with dual-diagnosis-related issues
Role legitimacy I have a legitimate role to play in responding to
alcohol- and other drug-related issues
I am clear about my responsibilities in responding
to alcohol- and other drug-related issues
Personal views and understanding I think it would be difficult to live with dual
diagnosis
I generally think people living with dual diagnosis
bring their difficulties on themselves
Training Training outcomes This training programme has enabled me to
respond to dual-diagnosis-related issues with
greater confidence
I gained skills and knowledge from this training
programme that enabled me to work more
effectively with people with dual-diagnosis-
related issues
Training relevance I changed the way I worked as a result of this
training and development
I changed the way I thought about people living
with dual-diagnosis-, mental-health- and AOD-
related issues as a result of this training and
development
Personal and Age, gender, current position, length of work in
organizational organization, length of work in sector, principal
demographics areas of work, time spent responding to dual-
Education and Education completed, previous training and
previous development in dual diagnosis, mental health
training and/or AOD
*Domains excluded from data analysis were team, workplace and organizational.

(SPSS) 18 for Windows (SPSS Inc., Chicago, IL, Table 2 Participation in data collection and percentage of
attrition for each site, per quantity of surveys completed
USA). Bonferroni adjustments were made to
the alpha (a) levels in all relevant analyses per- Participation in data collection
formed to control for Type 1 error.
Completed Completed 3 Completed 4
Due to insufficient numbers, surveys com-
initial surveys (% surveys (%
pleted at the control site at the 5-month survey attrition) attrition)
follow-up (time four) were excluded from data
Intervention 38 27 (28.9) 23* (39.5)
analysis. Consequently, four waves of data
site
were analysed for the intervention site, whereas Control site 33 18* (45.5) 8 (75.8)
only three waves were analysed for the control Total 71 45 (36.6) 31 (56.3)
site. Only data from participants who com-
*Participants used in data analysis.
pleted four waves of data collection at the
intervention site and three waves of data col-
lection at the control site were retained for site and 18 at the control site. Due to partic-
analyses. ipant fatigue, only 31 participants completed
An overall score was computed for each the fourth wave of data collection at the 5-
study variable (understanding, role adequacy, month follow-up: 23 at the intervention site
role legitimacy, personal views, training out- and 8 at the control site (Table 2). Attrition
comes and training relevance) by adding up the at time four was therefore much greater at
ratings given to all statements under a particu- the control site (75.8%) than at the interven-
lar subtheme. One-way repeated measures tion site (45.5%). A total of 23 staff mem-
ANOVA was conducted to compare mean scores bers participated in the focus groups: 8 from
of understanding, role adequacy, role legiti- the control site and 15 from the intervention
macy and personal views over time at each site.
study site. Mean scores of training outcomes Characteristics of survey participants are
and training relevance, as measured after the detailed in Table 3. At both sites, the majority
clinician-led training and the consumer-led of participants were female and aged between
training, were compared within each study site 35 and 54 years. Nearly three-quarters of
using paired samples t-tests. Independent sam- respondents classified themselves as ‘team
ples t-tests were conducted to compare the members’. At both sites, the highest level of
mean scores of all six study variable between educational attainment for approximately half
the two sites. Pearson’s product-moment corre- of respondents was a bachelor’s degree or a
lation coefficients (r) were calculated to explore graduate certificate/diploma.
the association among study variables.
Focus groups were audio-recorded and sub-
Comparability of study sites
sequently transcribed. Thematic analysis was
undertaken using the transcripts to gain an in- Analyses were carried out to examine the
depth understanding of staff’s perceptions and comparability of participants across sites.
experiences of the training.29 For the purposes Attributes such as age distribution, highest
of this article, quotes have been used to further level of educational attainment, position type
illustrate and explore the quantitative findings. (management vs. non-management) and type
of work (care vs. non-care) did not differ sig-
nificantly between sites. At the intervention
Results
site, more participants had previously
attended AOD, mental health- or dual-
Study participants
diagnosis-related training and development
In total, 41 participants completed at least (47.8%, compared to 22.2% at the control
three waves of survey: 27 at the intervention site) and reported spending more of their

Table 3 Characteristics of staff who completed three waves

of data collection at the control site and four waves at the Correlations among demographic and study
intervention site (N = 41) variables
Intervention Control No significant correlations were found among
(n = 23) (n = 18) demographic and study variables (under-
Characteristics n % n % standing, role adequacy, role legitimacy and
personal views) at baseline. Regardless of study
Age in years
site, age and position type were not found to
≤34 3 13.0 2 11.1
35–54 18 78.3 13 72.2 be correlated to any of the study variables. The
≥55 2 8.7 3 16.7 proportion of time spent responding to dual-
Gender diagnosis issues was significantly positively
Male 0 0 2 11.1 associated with understanding (r = 0.59, P <
Female 23 100 16 88.9
0.001), role adequacy (r = 0.74, P < 0.001),
Current position
in organization
role legitimacy (r = 0.68, P < 0.001) and per-
Manager or 6 26.1 6 33.3 sonal views (r = 0.31, P < 0.05) at baseline.
team leader Having attended previous training and devel-
Team member 17 73.9 12 66.7 opment regarding dual diagnosis was also sig-
or staff member nificantly positively associated with
Approximate percentage of time spent responding to dual-
understanding (r = 0.58, P < 0.001), role ade-
0% 6 26.1 5 27.8 quacy (r = 0.71, P < 0.001), role legitimacy
1–20% 11 47.8 12 66.7 (r = 0.66, P < 0.001) and personal views
21% or more 6 26.1 1 5.6 (r = 0.50, P < 0.001) at baseline. Being in a
Principal areas role involving direct contact with people living
of work*
with dual diagnosis was significantly positively
Non-care (no contact 12 53.2 5 27.8
with clients)
associated with greater scores of understanding
Care (direct contact 11 47.8 13 72.2 (r = 0.36, P < 0.05), role adequacy (r = 0.52,
with clients) P < 0.001) and role legitimacy (r = 0.37, P <
Highest level of education completed 0.05) at baseline, but not with personal views
Basic (secondary 7 30.4 3 16.7 (r = 0.29, P = 0.07). Educational attainment
to diploma)
was only significantly positively correlated with
Standard (bachelor 12 52.2 9 50.0
and graduate role legitimacy (r = 0.36, P < 0.05) and per-
certificate/diploma) sonal views (r = 0.38, P < 0.05) at baseline.
Postgraduate (master’s 4 17.4 5 27.8
and doctorate)
Previously completed training/development with a primary Correlations among study variables
focus on dual diagnosis, mental health or alcohol/drugs
Yes 11 47.8 4 22.2
Using data from both sites, understanding was
No 12 52.2 14 77.8 significantly positively correlated with role ade-
quacy (r = 0.76, P < 0.001), role legitimacy
*Where staff members endorsed both areas of work, they were only
assigned to the ‘care’ category (9 at intervention site, 8 at control (r = 0.52, P < 0.001), training outcomes
site). (r = 0.49, P < 0.001) and training relevance
(r = 0.46, P < 0.001). Role adequacy was sig-
nificantly positively correlated with role legiti-
work time responding to dual diagnosis macy (r = 0.66, P < 0.001), training outcomes
(26.1%, compared to 5.6%). Although t-tests (r = 0.54, P < 0.001) and training relevance
did not find between-site differences for these (r = 0.58, P < 0.001). Role legitimacy was sig-
two variables, we believe them to be a mean- nificantly positively correlated with personal
ingful reflection of the differences between views (r = 0.41, P < 0.001) and training rele-
each organization. vance (r = 0.43, P < 0.001). Personal views

Table 4 Person product-moment correlations (r) among study variables, both sites combined (N = 41)
Role Role Personal Training Training

Understanding adequacy legitimacy views outcomes relevance
Understanding – 0.76* 0.52* 0.35* 0.49* 0.46*

Role adequacy – – 0.66* 0.38*† 0.54* 0.58*‡
Role legitimacy – – – 0.41*† 0.27 0.43*
Personal views – – – – 0.15 0.14
Training – – – – – 0.77*
outcomes
Training – – – – – –
relevance
*Correlation significant at P ≤ 0.01.

†Correlation significant at the intervention site only (n = 23).
‡Correlation significant at the control site only (n = 18).
were not associated with training outcomes

Understanding
(r = 0.15, P = 0.18) nor with training relevance
(r = 0.14, P = 0.23). Finally, training outcomes Mean understanding scores were compared
and training relevance were significantly posi- over time (Fig. 2). As expected given the dif-
tively correlated (r = 0.77, P < 0.001). Table 4 ference in service mix between the two sites,
contains a summary of these findings. along with the previous capacity building
Interestingly, understanding and personal activity undertaken at the intervention site, a
views were significantly positively correlated significant difference was observed in under-
(r = 0.35, P < 0.001), as were role adequacy standing levels between the intervention and
and personal views (r = 0.37, P < 0.001). But, the control sites at baseline (P < 0.05). Follow-
when correlations were calculated for each site, ing the clinician-led training, an increase in
these associations only remained significant at understanding was observed at the control site.
the intervention site. Subsequent to this change, the mean difference
12.50
Intervention site (n = 23)
12.00
Control site (n = 18) 12.00 12.00
11.50
(SD: 2.30) (SD: 2.05)
Understanding score
11.00
10.50
10.48 10.52
10.00
(SD: 3.25) (SD: 2.66)
9.50 9.56
9.44 (SD: 2.15)
9.00
(SD: 2.31)
8.50
8.28
8.00
(SD: 2.35)
7.50
Baseline Clinician-led Consumer-led 5-month follow-up
training training
Timing of data collection
Figure 2 Based on one-way repeated measures ANOVA, the variation in mean understanding score was significant (P < 0.01)
between clinician-led training and consumer-led training at the intervention site. There was a non-significant trend (P = 0.07)
towards increased understanding at the control site following the clinician-led training.

in understanding scores between study sites sumer-led) was associated with significantly
became non-significant (P = 0.18). Following higher role adequacy scores after the con-
the consumer-led training, understanding sumer-led training, compared to baseline
scores increased by 15% at the intervention (P < 0.05).
site (P < 0.01), thus resulting in a significant
difference between sites (P < 0.01). Under-
Role legitimacy
standing remained at an increased level at the
intervention site, even 5 months following the Most probably reflective of the presence of a
consumer-led training. relatively large AOD team at the intervention
site, role legitimacy levels were higher
(P < 0.05) at baseline [mean (M) = 24.26, stan-
Role adequacy
dard deviation (SD) = 6.98] compared to the
Similar to understanding, the mean scores for control site (M = 19.39, SD = 5.73) and
role adequacy were significantly different remained so after the clinician-led training (M
between sites at baseline (P < 0.05). This differ- intervention = 25.09, SD = 5.30; M con-
ence across sites remained significant following trol = 21.44, SD = 5.23; P < 0.05) and after the
both types of training. At the control site, no consumer-led training (M intervention = 24.78,
difference in role adequacy was found across SD = 6.15; M control = 20.39, SD = 5.15;
the three data collection points (Fig. 3). The P < 0.05). No significant changes were observed
slight but non-significant increase at time three in role legitimacy over time, at either site.
might be attributable to organizational activity
after the clinician-led training, such as the
Personal views
recruitment of a new Needle and Syringe Pro-
gram coordinator (personal communication Mean personal views scores were similar across
from the collaborating general manager of the the two sites at baseline (M interven-
control site). At the intervention site, both tion = 15.78, SD = 2.78; M control = 16.22,
training sessions were associated with a non- SD = 2.21; P = 0.59), as well as after the clini-
significant, incremental rise in role adequacy. cian-led training (M intervention = 16.74,
However, the cumulative effect of the two SD = 2.28; M control = 16.33, SD = 1.97;
training sessions (i.e. clinician-led and con- P = 0.55) and the consumer-led training (M
26
25.35 24.87
Control site (n = 18) (SD: 6.75) (SD: 6.75)
24
23.83
Role adequacy score
(SD: 6.83)
22
21.70
(SD: 7.08)
20
19.39
(SD: 5.41)
18
17.56 17.28
(SD: 5.32) (SD: 5.32)
16
Baseline Clinician-led Consumer-led 5-month follow-up
training training
Timing of data collection
Figure 3 Based on one-way repeated measures ANOVA, only the cumulative effect of both clinician-led and consumer-led
training was associated with a significant change in role adequacy at the intervention site.

intervention = 17.09, SD = 1.86; M con-

Discussion
trol = 16.00, SD = 2.11; P = 0.09). Personal
views, however, were higher at the intervention Our study demonstrates that consumer-led
site following the consumer-led training training by people with dual diagnosis has a
(P < 0.05) and at the 5-month follow-up positive impact on community health staff’s
(P < 0.01) compared with baseline. At the understanding and feelings of role adequacy in
control site, no such difference was found over working with and responding to the needs of
time. people living with dual diagnosis. Furthermore,
it appears that the change in understanding cre-
ated has the potential to be sustained over time
Training outcomes
for each participant involved. This was reflected
As illustrated in Fig. 4, intervention site partic- in comments made by focus group participants:
ipants rated the training outcomes of the clini-
I felt the consumer-led training stuck in my
cian-led training significantly higher than memory a lot more than the first training. (fg1)
participants at the control site did (P < 0.05).
In respect to the difference of training out- Even if you asked us in three or four months
comes at the intervention site between the clini- what the consumers talked about, we would be
cian-led and consumer-led training, outcomes able to recall it. (fg2)
were higher for the latter, although not signifi-
The maintained levels of understanding
cant (P = 0.067).
which we observed 5 months post-intervention
support previous findings regarding the
Training relevance involvement of consumers on student learn-
ing.21 Studies from Klein et al.30 and Wood
No difference in training relevance was found
and Wilson-Barnett31 have both demonstrated
between sites following the clinician-led train-
that medical and nursing students who were
ing (Fig. 5). A paired samples t-test revealed
exposed to consumers showed more empathy
that participants at the intervention site rated
and concern about the impact of illness and
training relevance significantly higher for the
symptoms upon the patients’ lives. In the case
consumer-led training than for the clinician-led
of Klein’s study, the medical students who had
training (P < 0.05).
30
Control site (n = 18) 23.87
(SD: 4.09)
25 22.17
(SD: 3.40) 19.33
Training outcome score
(SD: 4.85)
20
15
10
0
Clinician-led training Consumer-led training
Figure 4 Based on an independent samples t-test, the scores of training outcomes were significantly greater at the
intervention site than at the control site, for the clinician-led training.

25
Control site (n = 18) 20.43
(SD: 4.18)
18.52
20 (SD: 2.02)
16.89
Training relevance score

(SD: 3.64)
15
10
0
Clinician-led training Consumer-led training
Figure 5 Training relevance scores were not different across sites, for the clinician-led training. The relevance score of the
consumer-led training was significantly higher than that of the clinician-led training, at the intervention site.
been in contact with patients had maintained also observed at the intervention site. In light
their more positive attitude at the 2-year of this, it appears that when clinician-led train-
follow-up.30 Similarly, O’Reilly et al.32 demon- ing is presented in workplaces that already
strated the maintenance over 12 months of have a history of dual diagnosis (or similar)
decreased stigma and improved attitudes training and development, this does not result
towards the provision of pharmaceutical ser- in substantial change – be that in understand-
vices to consumers with a mental illness, for ing, role adequacy or role legitimacy. In con-
pharmacy students who had been exposed to a trast, at the control site where staff had not
consumer-led teaching intervention. enjoyed such training and development, a sig-
That being said, participants’ enhanced nificant shift in their understanding of dual
understanding and feelings of role adequacy diagnosis was observed. Acknowledging the
will not remain high by themselves. We could intervention site as a ‘primed’ environment is
reasonably anticipate that the effects of time, an important factor in interpreting the signifi-
changing roles and staff turnover will slowly cant increase in understanding following the
lessen the gains observed following the con- consumer-led training. According to interven-
sumer-led training, unless additional individual tion site focus group participants, the personal
and/or organizational training and develop- stories shared by consumers living with a dual
mental strategies are put into place. Our study, diagnosis were the main reason for the impact
however, did not seek to evaluate these. of this form of training:
As expected, participants who worked in
Personal story, it touches you in places that text
care-giving roles, those who spend more of book stuff can’t. (fg2)
their time responding to dual-diagnosis issues
and/or who had participated in previous dual Furthermore, commenting on the salience of
diagnosis, AOD or mental health-related train- the consumer-led training, an experienced
ing had higher baseline understanding, role AOD counsellor commented:
adequacy and role legitimacy scores. Consistent It enlivened me in a way that I haven’t had train-
with the presence of an AOD team and previ- ing do that in a long time, because of its real
ous dual-diagnosis-focussed capacity building, quality, and like, real people talking about their
higher baseline understanding, role adequacy, real experience and articulating it so well. Yeah,
role legitimacy and personal view scores were I was inspired. (fg2)

The current findings are consistent with not impact on role legitimacy. Indeed, Skinner
other studies looking at reducing stigma and et al.38 noted that organizational initiatives and
promoting understanding of marginalized and approaches are needed alongside workforce
discriminated populations. Findings over the development interventions to enhance workers’
last decade, for example, suggest that contact sense of role legitimacy. Simply put, organiza-
between the public and members of a minority tional-level change and support are needed for
group (i.e. mental illness, transgender/transsex- workers to feel confident in the scope of their
ual) is a more effective strategy to diminish roles: training on its own is not adequate.
stigma than education alone.33–36 Furthermore, That said, understanding, role adequacy and
a meta-analysis from Pettigrew and Tropp37 role legitimacy were all positively and signifi-
suggests that anxiety is reduced and empathy cantly associated. As such, workers with a
increased following contact with a minority good understanding of dual diagnosis were
population and that both these changes medi- more likely to feel adequate when working with
ate the reduction in prejudice. Our observation people living with dual diagnosis and that they
of enhanced staff understanding and role ade- have a legitimate role to play in supporting
quacy following contact with people living with these consumers. Additionally, understanding,
dual diagnosis through consumer-led training role adequacy and role legitimacy were all posi-
is consistent with these previous findings and tively correlated with training outcomes and
adds to the current body of evidence. training relevance. Emphasizing the promi-
With regard to role adequacy, neither type nence of consumer-led training in particular,
of training resulted in significant change when one focus group participant commented:
considered in isolation at either study site. The
I barely remember exactly the content of the first
findings suggest that it was the combination of training but the second one I think about almost
both clinician-led and consumer-led training every couple of days as I’m seeing clients, I
that resulted in an enhanced sense of confi- think. You remember what that client said
dence and role adequacy. This suggests that because it impacts on your work. (fg1)
both types of training were valued, with one Personal views, on the other hand, were not
complementing the other. An explanation of linked to either training outcomes or training
why this might be the case can again be found relevance. This suggests that seeking to merely
from the intervention site focus groups: dispel misconceptions and assumptions might
She [expert trainer] actually set the scene for the not be enough to create a change in staff’s
other stuff [consumer-led training]. (fg1) approach to consumers. Rather, to be effec-
tive, training should seek to enhance empathy
I mean, if I had to choose one [training session] for a particular consumer group,21,37 under-
it would be consumer, but the two together I standing of the complex issues they face in
thought worked really well. (fg2)
everyday life and how best to respond to their
As both training sessions primarily sought to needs within a professional environment.15
change participants’ perceptions of people liv- Personal views did change, but only following
ing with dual diagnosis and the complexity of the consumer-led training. The following focus
their lives, it is not surprising that, overall, no group quote from the intervention site illus-
significant increase in participants’ sense of role trates the increased empathy felt by a partici-
legitimacy was found. Increasing role legiti- pant after they had attended the consumer-led
macy is dependent on the organizational con- training:
text and limitations of the work performed. So I recall seeing this young couple in my local
Given the range of participant roles in our pro- supermarket and clearly they were substance
ject, from administration to clinical services, it affected with their toddler in the chair and –
is to be expected that the training alone may whereas before I might have been judgemental

about them and what they were doing. I remem- must implement complementary strategies such
ber thinking back to that session when I saw as mentoring and formal support, among
them and thinking about all this other stuff that
others.38,43,44 As such, the fact that consumer-
could be going on in their life. (fg3)
led training was delivered in parallel to other
Finally, training outcomes and training rele- dual-diagnosis capacity building activities at
vance were also significantly correlated. In the the intervention site might help to explain the
light of the significantly higher scores for train- current findings.
ing outcomes at the intervention site, we can
hypothesize again that primed environments
are more receptive to training. Conclusion
Consumer-led training appears to be a promis-
Limitations ing and effective approach in enhancing pri-
mary health-care workers’ understanding of the
Our study had a number of limitations. First issues faced by dual-diagnosis clients, with the
of all, participant fatigue resulted in substantial positive effects of such training persisting over
attrition at both sites. This meant that our final time. Used in conjunction with other organiza-
sample size constrained the range of statistical tional capacity building strategies, consumer-
tests that could be performed with confidence led training has the potential to help address
(e.g. within-group comparisons were not possi- one of the key barriers faced by this consumer
ble). Significant participant attrition is unfortu- group to access the services they need. Other
nately not unusual for studies conducted with sectors, such as mental health, could also bene-
health professionals using a repeated measures fit from a similar initiative, especially given the
design.39–42 Common challenges to the continu- current national and state reforms to improve
ity of sample size over time include staff turn- the health-care workforce’s dual-diagnosis
over and having minimal time and flexibility to capability.13
accommodate research activities among one’s
usual clinical duties.41,42 We also acknowledge
that a small sample size may have resulted in a Acknowledgements
biased data set, with only staff interested in
working with people living with dual-diagnosis Special thanks are extended to the passionate
participating. However, where applicable and consumers who made this project possible;
meaningful, appropriate adjustments were Regina Brindle, Miriam Clarke and Kelly
made to control for the risk of Type 1 error, Muldoon from the Association of Participat-
that is, Bonferroni corrections. Needless to say, ing Service Users; Bronwyn Williams from the
additional research conducted with larger Eastern Dual Diagnosis Service (Eastern
samples and better participant retention rates Health); Adina Heilbrunn for her support
is needed to confirm and extend the current with data collection; staff at Manningham
findings. Community Health Service who trialled our
Finally, our study did not seek to examine questionnaire; and to the staff and manage-
the impact of consumer-led training on practice ment who actively supported and participated
change or service users’ experiences. Rather, in the research at Knox Community Health
we sought to assess its impact on workers’ Service and Whitehorse Community Health
understanding and role adequacy. Training is Service.
only one of many strategies required to create
long-term practice change. For example, it has
Source of funding
been shown that for the effects of training to
persist and lead to tangible change in consum- Funding for this project was provided under
ers’ experience and outcomes, organizations the Evaluating Effectiveness of Participation

(EEP) initiative, from the Quality, Safety and 9 Todd FC, Sellman JD, Robertson PJ. Barriers to
Patient Experience Branch of the Victorian optimal care for patients with coexisting substance
use and mental health disorders. Australian and New
Government Department of Health (Mel-
Zealand Journal of Psychiatry, 2002; 36: 792–799.
bourne, Victoria, Australia). 10 Staiger PK, Thomas AC, Ricciardelli LA, McCabe
MP, Cross W, Young G. Improving servicers for
individuals with a dual diagnosis: a qualitative study
Ethical approval reporting on the views of service users. Addiction
This study was approved by Monash Univer- Research and Theory, 2011; 19: 47–55.
11 Donald M, Dower J, Kavanagh D. Integrated
sity’s Human Research Ethics Committee. versus non-integrated management and care for
clients with co-occurring mental health and
substance use disorders: a qualitative systematic
Conflict of interest review of randomised controlled trials. Social
The authors declare that they have no conflict Science & Medicine, 2005; 60: 1371–1383.
12 Kavanagh DJ, Greenaway L, Jenner L et al.
of interest.
Contrasting views and experiences of health
professionals on the management of comorbid
substance misuse and mental disorders. Australian
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13697625, 2015, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.12146 by Lovisenberg Diaconal University College, Wiley Online Library on [22/02/2023].

Enhancing health-care workers’ understanding and

© 2013 John Wiley & Sons Ltd. 1567

persisting over time. Used alongside other organizational capacity

providers.10,13 Examples of such barriers

© 2013 John Wiley & Sons Ltd

Data measurement 1 Data measurement 2 Data measurement 4

© 2013 John Wiley & Sons Ltd

© 2013 John Wiley & Sons Ltd

Domain* Subthemes Example of underlying statements

© 2013 John Wiley & Sons Ltd

© 2013 John Wiley & Sons Ltd

Table 3 Characteristics of staff who completed three waves

© 2013 John Wiley & Sons Ltd

Role Role Personal Training Training

Understanding – 0.76* 0.52* 0.35* 0.49* 0.46*

*Correlation significant at P ≤ 0.01.

were not associated with training outcomes

© 2013 John Wiley & Sons Ltd

© 2013 John Wiley & Sons Ltd

intervention = 17.09, SD = 1.86; M con-

© 2013 John Wiley & Sons Ltd

Training relevance score

© 2013 John Wiley & Sons Ltd

© 2013 John Wiley & Sons Ltd

© 2013 John Wiley & Sons Ltd

© 2013 John Wiley & Sons Ltd

© 2013 John Wiley & Sons Ltd

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