Claude's answer, unedited
Why some MECC Train the Trainer attenders cascaded the training and others didn't
Evidence base: 13 interviews with people who attended the session (AP1–AP13, corpus/). In corpus/index.csv, 7 are flagged as having cascaded (AP3, AP5, AP7, AP9, AP11, AP12, AP13) and 6 as not (AP1, AP2, AP4, AP6, AP8, AP10). Five of the people who cascaded are also MECC leads or coordinators (AP3, AP5, AP7, AP11, AP13). They describe the many other trainees in their organisations, and most of those trainees never delivered. So the evidence covers more than the 13 people interviewed.
Short answer
Few of the people who didn't cascade lacked interest in MECC or belief in it. Most finished the session motivated. What usually stopped them was something in their job or their organisation: delivering training wasn't part of their role, nobody protected time for it, managers didn't expect it or follow it up, there was no ready audience or slot to deliver in, or someone higher up blocked it. On top of that came confidence and content problems. Many trainees had never delivered training. Many found the slides heavy on statistics, policy and theory. Some didn't realise when they signed up that they would be expected to train others. Some felt they would be "teaching" colleagues what those colleagues already do. Others were put off by a confusing online platform and by having no one following up after the session. Small personal setbacks (illness, a bereavement, staff shortages) were then enough to stop the cascade altogether.
The people who did cascade almost all had delivery built into their job: a public health or MECC lead role, a commissioned contract, or a team that already ran regular training. They also had a ready-made audience or slot, backing from managers, and usually someone to co-deliver with or lean on. Experience of training or public health helped, and so did adapting the slides to their own audience. Personal drive mattered too ("I'm chatty. I'm gobby", AP11). But on its own it wasn't enough: AP6 is highly motivated and still avoided core MECC delivery.
Barriers: what stopped people cascading
1. Delivering isn't part of the job, and there's no time
This was the barrier mentioned most often, both by the people who didn't cascade and by the leads describing their trainees.
- AP5 (trust MECC lead) on why they succeeded where others didn't: "ultimately, it's part of my job … I have time set aside to do that, whereas people who … [attended] Train the Trainer … weren't necessarily in that kind of role." When AP5 chased trainees, they replied: "I just haven't got the capacity to deliver this at the moment or … it's not my role."
- AP8 (cardiac rehab nurse, no): "It's the word extra … that extra sometimes is just the extra bit you haven't got time for." At AP8's session, AP8 could "feel the stress in the room … oh my God, this is another thing I've got to do."
- AP4 (no): "It's not in my job plan in any way. It's my choice." Sick leave was followed by a backlog of "more pressing things", so their two booked sessions slipped.
- AP12 (yes) says the same about colleagues: "It's not we haven't got the attitude, it's the time."
- AP1 (no, still planning) found that organising the cascade "has added a massive amount to workload". That was despite the training's message that MECC isn't extra work.
2. Managers don't expect it, release staff for it or follow it up
- AP6 (no): "Management don't have time … They do not like it." Ward staff "don't even have time to do" their mandatory training. In their old role a manager said: "what's that going to do for my service?"
- AP8 (no): AP8's manager had put them forward to "tick a box". At AP8's appraisal the manager agreed they didn't need to deliver: "part of us felt relieved that I had kind of been given the get-out-of-jail-free card."
- AP10 (no) is the clearest case of a block from above. AP10 was confident and ready to deliver "the next week". But their manager and a partner organisation decided to make bespoke slides first, and those slides were still unfinished about 10 months later, when AP10 left: "so much focus on making it perfect rather than just getting out and doing it … if you've got like a blockage above you, you can't move through."
- AP13 (lead) summarises feedback from their trainees: "either the manager's not supportive of the extra time … or we didn't actually realise what we were signing up to … or … I don't feel confident." Of their cohort, "we're lucky to have maybe 10% … delivering core MECC routinely."
3. Not knowing they'd be expected to train others
- AP6 (no): trainees "were told the expectation was they needed to deliver … four sessions in a year and nobody had a clue about it." AP6 thought the role would be "like an ambassador not to deliver training". AP6 also calls the name "Train the Trainer" unclear and suggests "Become a MECC Trainer" instead.
- AP4 (no): found the course by chance in a newsletter and wasn't clear what commitment it involved. "Some people that have signed up … have gone to do the MECC training rather than the Train the Trainer."
- AP5 (lead) is more sceptical: "possibly having a Train the Trainer course on your CV looks very good … nobody is going to really ask you whether you actually delivered." AP3 suspects some students attended "to get a qualification" rather than to deliver.
4. Low confidence as a trainer and in the subject
- AP9 (yes) on fellow trainees: "they weren't trainers … what if I can't answer the questions." AP11 (yes) also says people "are worried about what they're going to be asked" and say "I'm not from a health background."
- AP7 (lead): "I think confidence is a lot of the problem … if they're thinking well, I've got to deliver that just how [the principal trainer] delivered it."
- AP8: "within the first couple of minutes … you think oh, I can do this … but then as time goes on your confidence does fade."
- Even some people who did cascade felt this. AP3 has delivered once and prefers a co-host. AP5 was "quite nervous". AP12 found the first session "a bit nerve wracking".
5. The content felt heavy and too generic, and the course had little practice
- AP6 (no) found the slides "top heavy with stats" and "way beyond my pay grade". When asked to deliver core MECC to HR, AP6 "froze … I don't understand them", and it caused them stress, so they avoided it.
- AP1, AP11 and AP13 all say the policy, health-inequalities and behaviour-change-model sections come too early or are too many. AP4 and AP9 found some of the models hard to explain to others.
- Several people wanted more practice at actually delivering the training rather than talk about trainer qualities: AP1, AP3, AP8, AP10 and AP13.
- AP1: running core MECC and Train the Trainer back to back left people who were new to MECC "confused and bamboozled".
- AP7: the course is "too left to the individual" to adapt afterwards. It is quite healthcare-focused and generic, while trainees need help tailoring it to their own setting and building local signposting.
6. "My colleagues already do this"
- AP8: delivering to experienced clinicians felt like "teaching your granny how to suck eggs", and AP8's confidence "dropped off quite quickly". AP5 had the same worry. AP6 thinks established teams need short "MECC awareness" sessions, not full training.
7. No structured follow-up, and resources that are hard to find
- AP2 (volunteer, no): "the course is finished, goodbye". There was "no positive communication to go on from", no one checked in, and AP2 hadn't found the slides or the online platform. "There should be a clear … structure … to get you from … done the course, to actually doing some sessions."
- The FutureNHS platform was described as "really clunky" (AP4), "way too confusing" (AP6) and "daunting" (AP5). People wanted a step-by-step "how to deliver your first session" guide and a physical starter pack (AP4, AP5, AP6). The registration app/website and the evaluation logistics added friction (AP1, AP3, AP13).
- The peer forums were poorly attended and seen as long or "showcasey" (AP1, AP11, AP13). Several people never had time to attend (AP9, AP12).
8. Practical and personal disruptions
Shift-working, part-time and casual staff spread over five sites (AP1); scarce training venues (AP4, AP5); old buildings with poor wi-fi (AP10); illness and bereavement right after the course (AP4, AP8); COVID wiping out a whole cohort of 80 trainers (AP5); staff turnover. These were mainly decisive where nothing in the role or the organisation pushed the cascade back onto the agenda.
9. No reward for lower-banded staff
AP6 (Band 4): "I'm teaching people that are higher paid than me … and I get nothing for it." AP6 suggests paying per session delivered.
Enablers: what helped the people who did cascade
| Enabler | Who | Evidence |
|---|---|---|
| Delivery is part of the role or a contract | AP5, AP7, AP9, AP11, AP13 (and AP3 as lead) | AP7: "It was part of my job description." AP9's organisation won a council contract for 8–12 sessions a year. AP13: the trainees who delivered routinely had "opportunities within their job already to deliver education" (public health fellows, a public health midwife, clinical educators, health coaches). |
| A ready-made slot and audience | AP12, AP5, AP13, AP3 | AP12: "had we not had that slot already kind of pencilled in [the weekly CPD hour] and had [the trust MECC lead] not … given me the support she was, it would have been a lot more difficult." AP5 and AP13 embedded MECC in inductions, preceptorship and the care certificate. AP6 also delivers MECC content at care certificate level. |
| Manager and organisational backing | AP7, AP9, AP12, AP13, AP3 | AP7: family hubs cascaded because "they had management who already had had experience of MECC … steered at a very kind of leadership kind of level." AP13: one keen team had "a manager who is very interested and passionate". AP3: the director of public health was "on board" and it's in the public health plan. |
| A co-trainer, buddy or mentor | AP12, AP9, AP3, AP5 | AP9: "if you do it as a pair it's always easier." AP12 was coached by the trust lead. AP5 co-delivers with a trainee who asked to "have a go without feeling like I'm thrown into the deep end." |
| Admin support | AP9, AP13, AP5 | AP9: a colleague "does the recruitment" and bookings. AP13 dropped the app and lets trainers take paper registers. AP5 offered to "set up the bookings, … do the admin". |
| Prior training or public health experience | AP5, AP9, AP11, AP12, AP7 | AP11: "my background really made it super easy." AP9: "I had a little bit of the background." |
| Freedom to adapt the slides | AP1, AP5, AP7, AP9, AP11, AP12, AP13 | People cut the policy and theory, moved "what MECC is and isn't" or the 3As earlier, added local data and signposting, and added skills practice. AP10's case shows the opposite: when they couldn't make the slides "their own", delivery stalled. |
| Ready-made slides, resources and a responsive regional team | AP1, AP3, AP7, AP9, AP12 | AP1: "a massive relief … I don't have to go away and do all of this myself." The regional coordinator was described as quick to respond (AP1, AP3, AP9). The MECC Gateway gave people confidence that they "don't need to know the answers" (AP11, AP12). |
| Personal drive, plus "selling" MECC to services | AP11, AP12, AP9 | AP11 offers to train a service only on condition that it sends staff to Train the Trainer. AP12: "if I want to do something I'll kind of find a way." AP9: "Give it a go." |
What the comparison suggests
Splitting the group by outcome, motivation after the course was high on both sides. What separates them is whether there was a structural pull: a role, contract, slot, manager or deadline that made delivery happen. Where there wasn't, delivery depended entirely on spare time and self-confidence, and any setback (illness, workload, a stalled approval) stopped it. AP13's organisation reached the same conclusion. It stopped open, trust-wide Train the Trainer sessions and now trains only teams that have committed to cascading, because with those teams "we've got a bit more leverage".
Participants suggested:
- make the delivery expectation explicit before people sign up, with line-manager agreement and a delivery plan (AP5, AP6)
- separate "learn MECC" from "become a trainer" (AP4, AP6)
- include delivery practice and an action plan for each trainee's own setting (AP1, AP7, AP8, AP13)
- trim the theory and statistics (AP1, AP6, AP11, AP13)
- provide a step-by-step first-session guide and a physical pack (AP4, AP5, AP6)
- set up buddying and co-delivery (AP4, AP5, AP9)
- follow up with each trainee personally (AP2)
- offer refreshers and local, practical peer support (most participants)
Caveats
- This is a small, self-selected sample from one region (the North East). Interviews were in 2023.
- Several "cascaders" are MECC leads whose job is delivery, so the yes/no split partly reflects role rather than the training itself.
- The index flags are rough. AP3 is coded "Yes" but personally delivered one finance-module session; a commissioned charity delivers core MECC. AP6 is coded "No" but delivers MECC content within care certificate training. AP1 is coded "No" but had five sessions scheduled for December. AP12 had delivered once.
- Much of the evidence about non-cascaders is second-hand, from the leads, and some of it is speculation (for example the "CV" motive).
The blind review of the answer
The reviewer's own text, unedited. It knew the answer as finding.md, the question as question.txt and the transcripts as documents/, the names in its blind copy. Its first line names the reader it wrote for: Steve Powell of Causal Map, for whom the test was run.
Blind review: why MECC Train the Trainer attenders did or didn't cascade
Reader: Steve. Finding reviewed: the whole of finding.md, which answers question.txt. Documents: the 13 transcripts in documents/ (AP1–AP13) and documents/index.csv. The finding draws on all 13, so all 13 were read in full. Each claim was then checked against the passages around it. There is no published report to compare with. Nothing outside this folder was read.
Overall
The finding holds up well. Almost every quotation is word for word, and almost every attribution is to the right speaker. Every index flag in the evidence base and the caveats matches index.csv. The main barriers are each well grounded in the transcripts: role and time, managers, unclear expectations, confidence, heavy content, "colleagues already do this", no follow-up, a confusing platform, and pay. The faults are in a few places:
- one invented detail (a bereavement);
- an enablers table that counts AP5's offers of help to others as things that helped cascaders, although AP5 says those offers did not work;
- AP6 used as the test case for "drive isn't enough" without saying that AP6 had the role and the manager's request too;
- some quotations and attributions that turn a speaker's guess into a fact.
Root errors
| # | What is wrong at the root | What the documents show | Kind | Where | Substantive | Sentences it makes wrong |
|---|---|---|---|---|---|---|
| 1 | AP8's setback is called a bereavement, and the finding says AP8's illness came "right after the course". | The event is redacted throughout: "the next day (circumstances) so I literally did the training and then boom was hit with a (circumstances)" (AP8). Nothing in the transcript says what it was. AP8's illness was at the course, not after it: "I had a viral illness, and I had no voice at all … so I went". | invented detail | writing | Yes | (a) Short answer: "Small personal setbacks (illness, a bereavement, staff shortages) were then enough…"; (b) Barrier 8: "illness and bereavement right after the course (AP4, AP8)". |
| 2 | AP5 is listed under the enablers "A co-trainer, buddy or mentor" and "Admin support", as if these helped AP5 cascade. The evidence given is AP5's offers to other trainees. | AP5 delivers alone: "I don't do that for MECC. I just deliver MECC by myself" and "it definitely would have, I think helped to have a buddy". Offering co-delivery and admin did not get the trainees delivering: "I've offered the support … I'll set up the bookings, I'll do the admin … 34 staff since September last year and I don't think any of them … other than these three, have delivered one session." The co-delivery with a trainee is planned, not happening yet ("I'd scheduled a session for her team … So, we're doing that"), but the finding writes "co-delivers". | lost context | writing | Yes | (a) Table row "co-trainer…: AP5 co-delivers with a trainee…"; (b) Table row "Admin support…: AP5 offered to 'set up the bookings, … do the admin'". |
| 3 | AP6 is the one case given for "personal drive … on its own … wasn't enough", which implies AP6 had drive but no structural pull. | AP6 had both the role and the manager's request, and avoided core MECC because of the content: "in this role absolutely because it's part of my role"; "my boss did ask me to deliver one to HR and the proper MECC, core MECC. I froze because I looked at the slides … I don't understand them." Where AP6 does have a slot (the care certificate), AP6 delivers MECC content. So AP6 shows that structure was not enough when the content was too hard. That cuts against "What separates them is whether there was a structural pull". | lost context | writing | Yes | (a) "But on its own it wasn't enough: AP6 is highly motivated and still avoided core MECC delivery."; (b) What the comparison suggests: "What separates them is whether there was a structural pull …" (stated without the AP6 exception). |
| 4 | Small setbacks are said to have stopped the cascade altogether. | AP4's sessions are delayed, not stopped: "I have got two courses booked but they haven't been delivered yet … my plan would be to do one online and one face to face. Probably three times a year each." AP1 is also still going ahead (five sessions in December). The claim holds for AP8, and in a different way for AP10. | overgeneralisation | writing | No | (a) Short answer: "…were then enough to stop the cascade altogether."; (b) Comparison: "any setback (illness, workload, a stalled approval) stopped it." |
| 5 | "AP8's manager had put them forward to 'tick a box'" is stated as fact. | This is AP8's guess at what happened: "I think she got pressure from above … so obviously last September, October she gets an email or whatever from management … so she quickly sends out an email, (AP8) will you do this, we need to tick a box". | lost context (guess presented as fact) | writing | No | Barrier 2: "AP8's manager had put them forward to 'tick a box'." |
| 6 | "one keen team had 'a manager who is very interested and passionate'" is given as evidence of manager backing. | AP13 is speculating: "I don't know whether that's because they had, or they have a manager who is very interested and passionate about it, or whether, I don't know…". | lost context (guess presented as fact) | writing | No | Table row "Manager and organisational backing": "AP13: one keen team had…". |
| 7 | The AP4 quotation drops the speaker's hedge. | "I do think that perhaps some people that have signed up to it have gone to do the MECC training rather than the Train the Trainer training." The quotation starts after "perhaps", which makes AP4 sound more certain. It is also cut at "Train the Trainer" without an ellipsis. | quotation altered | writing | No | Barrier 3: AP4 quotation "Some people that have signed up … rather than the Train the Trainer." |
| 8 | The AP6 quotation changes a word. | "…I'm teaching people that are higher paid than me, I'm delivering an impacted thing … but I get nothing for it." The finding prints "… and I get nothing for it." | quotation altered | writing | No | Barrier 9: AP6 quotation. |
| 9 | The AP11 quotation silently drops a repeated phrase. | "I'm chatty. I'm chatty. I'm gobby…". The finding prints "I'm chatty. I'm gobby" with no ellipsis. The sense is unchanged. | quotation altered | writing | No | Short answer: "('I'm chatty. I'm gobby', AP11)". |
| 10 | "don't need to know the answers" is put in quotation marks for both AP11 and AP12, and credited to the MECC Gateway. | AP11 said it ("you don't need to know the answers, that's why the MECC Gateway's there"). AP12 did not use the words. AP12 credits the training with giving "permission to say right … I'll find out about it and get it back to you". | misattribution | writing | No | Table row "Ready-made slides…": "The MECC Gateway gave people confidence that they 'don't need to know the answers' (AP11, AP12)." |
| 11 | AP4 is said to have found some of the models "hard to explain to others". | AP4 knows the models well and says other people may find them hard to understand: "I'm familiar with both of them … I think that could be a bit scary to some people … you're actually asking people to understand a quite tricky concept and then apply it." (AP9 does fit the claim: "I found that hard to explain.") | misattribution | writing | No | Barrier 5: "AP4 and AP9 found some of the models hard to explain to others." |
| 12 | AP1 appears in the table headed "what helped the people who did cascade". | AP1 is a non-cascader in the index and the finding's own text ("AP1 (no, still planning)"). AP1 had not delivered at interview: "We haven't." | other (wrong group) | writing | No | Table rows "Freedom to adapt the slides" and "Ready-made slides…", in the "Who" column (2). |
| 13 | AP5 is cited for "scarce training venues". | AP5's point is that no venue could hold 200 preceptees, which online delivery solves: "Obviously, we'd never have a venue that was available to deliver to 200 people". AP5's face-to-face problem was attendance ("they were terribly attended"), not finding a venue. AP4 does fit the claim. | lost context | writing | No | Barrier 8: "scarce training venues (AP4, AP5)". |
| 14 | The five leads are said to describe trainees of whom "most … never delivered". | This holds for AP5, AP7, AP11 and AP13. AP3 does not say it. AP3 reports two finance colleagues "delivering that like pretty much every month since" and a charity delivering core MECC, and AP3 is unsure about the rest. | overgeneralisation | writing | No | Evidence base: "They describe the many other trainees in their organisations, and most of those trainees never delivered." |
| 15 | The regional coordinator is said to be "quick to respond", citing AP9 among others. | AP1 ("on hand quite quickly") and AP3 ("pretty quick … normally within the day") support this. AP9 says only that the coordinator was helpful ("always been very helpful when I ask loads of questions") and says nothing about speed. | overgeneralisation | writing | No | Table row "Ready-made slides…": "quick to respond (AP1, AP3, AP9)". |
Checked and supported
These claims were tested and hold, so they are listed here only so the denominator is visible.
- Index and evidence base: every index flag (cascaded yes/no). The five leads or coordinators (AP3, AP5, AP7, AP11, AP13).
- Quotations from transcripts: the AP5 "part of my job" and "capacity … not my role" quotations; AP8 "the word extra", "stress in the room", "get-out-of-jail-free card", "confidence does fade", "granny … suck eggs"; AP4 "not in my job plan"; AP12 "it's the time" and the CPD-slot quotation; AP1 "massive amount to workload", "confused and bamboozled", "a massive relief"; AP6 on management, ESR, "what's that going to do for my service?", "four sessions", ambassador, "Become a MECC Trainer", "top heavy with stats", "way beyond my pay grade", "froze", the £50 per session suggestion; AP10 "the next week", the bespoke slides and the roughly 10-month delay (Nov 2022 to about Sept 2023), "blockage above you"; AP13 trainee feedback and "10%"; AP5 "CV"; AP3 "qualification"; AP9 "what if I can't answer", "as a pair", "does the recruitment", "Give it a go", the 8–12 sessions contract; AP7 "confidence is a lot of the problem", "too left to the individual", "part of my job description", family hubs; AP11 "worried about what they're going to be asked", "super easy"; AP2 "the course is finished, goodbye", "no positive communication", "clear … structure".
- Platform and practical barriers: "clunky" (AP4), "way too confusing" (AP6), "daunting" (AP5); the five sites and shift staff (AP1); the 80-trainer COVID cohort (AP5); poor wi-fi (AP10).
- Suggestions and caveats: the participant suggestions and who made them; the caveats about AP3, AP6, AP1 and AP12.
Not checkable here
- "one region (the North East)". The place names are redacted. Only AP9's passing "you look at the North East" bears on it, so the documents cannot confirm the sample's region.
No other claim rests on evidence outside these documents.
Most serious root errors
- #1 (invented bereavement): AP8's redacted "(circumstances)" becomes "a bereavement" in two places, and AP8's illness is moved to "after the course".
- #2 (AP5 as a co-trainer and admin enabler): AP5's offers to other trainees are counted as things that helped cascaders, although AP5 delivers alone and says the offers didn't get trainees delivering.
- #3 (AP6 used one-sidedly): AP6 is the evidence that drive isn't enough, but AP6 also had the role and the manager's request. That weakens the claim that structural pull is what separates the two groups.
Summary: sentences tested ≈120; root errors 15, of which substantive 3; sentences wrong in all 20.
The comparison with the published paper
Claude's answer beside the paper's Results section
We are grateful to Beth Nichol and her colleagues at Northumbria University, who did what few researchers do: they deposited their interview transcripts openly alongside their published study. That is excellent practice, and without it neither this example nor any check of it would be possible. We have every reason to think they designed and carried out their study with care and skill. The comparison below is not a verdict on it: an AI model read the paper's results against only the 13 attender transcripts, while the authors drew on 21 interviews and 373 survey responses and wrote for a journal's readers rather than for our one question.
The paper on these interviews is Nichol et al. (2026), "Exploring the ‘train the trainer’ model for delivering Making Every Contact Count (MECC) training at scale: A qualitative study", British Journal of Health Psychology, doi:10.1111/bjhp.70076, published under CC BY 4.0. Its Results section was put through the same blind review as Claude's answer, by a separate Claude Opus 5.5 session told nothing about where the text came from, and two judges compared the two texts.
The paper drew on more evidence than the reviewer had: 21 interviews (the 13 attenders, 6 people who did not attend and 2 principal trainers) and 373 comments from post-training surveys. So the reviewer could not check its quotations from a principal trainer (PT1) or its claims from the surveys, and listed them as not checkable rather than as errors. The paper was written for a journal, not to answer this one question.
What the reviews found
Errors each blind reviewer found, out of the sentences it tested. A root error is one wrong statement or misreading, counted once however many sentences repeat it; the reviewer marked each as substantive or not.
| Text | Sentences tested | Root errors | Of which substantive |
|---|---|---|---|
| Claude's answer | about 120 | 15 | 3 |
| The paper's Results section | 44, plus 32 codes in its Table 1 | 5 | 4 |
What the judges preferred
Judgements won by each text, out of 4: two judges, OpenAI's gpt-6-sol and Google's gemini-3.1-pro-preview, each shown the pair in both orders, so that a preference for whichever text came first would show. They did not know which text was which.
| Text | Overall | Writing | Parsimony | Coverage | Evidence | Calibration |
|---|---|---|---|---|---|---|
| Claude's answer | 4 | 4 | 4 | 4 | 4 | 4 |
| The paper's Results section | 0 | 0 | 0 | 0 | 0 | 0 |
- Overall: which text better serves the evaluator's whole intent, judged against a rubric written from the question alone.
- Writing: states its conclusions clearly, as a narrative a professional reader can follow, with the evidence close to each.
- Parsimony: says what the question needs and no more.
- Coverage: how many of the distinct parts of the question, and of the conclusions a careful reader would expect, it settles.
- Evidence: each conclusion carries its specific evidence close by.
- Calibration: says how far each conclusion can be trusted and where the evidence is thin or divided.
The paper's Results section, as the reviewer read it
The authors' text, taken verbatim from the published article and shown as the reviewer received it: the Results section alone, without the paper's introduction, methods or discussion. The paper labels the attenders AT rather than AP; the reviewer found that each AT quotation matches the AP transcript of the same number.
RESULTS
Themes and sub‐themes guided by the TDF
Specific barriers and facilitators according to TDF domains are described in the mixed methods paper (Nichol et al., 2026). The main sub‐themes within each TDF domain and corresponding example codes are provided in Table 1, and the full coding framework (including example quotes) is provided in Data S3. Participants placed value on individuals who were interested in MECC self‐selecting themselves to become MECC trainers as opposed to mandatory training with disinterested attendees (Intentions). However, top‐down drivers were perceived to be much more valuable. For example, a reported difficulty in identifying an audience was most often attributable to a limited staff capacity to attend MECC training (a top‐down influence) rather than a lack of interest in MECC (a bottom‐up influence). Thus, the paucity of incentives to deliver MECC training meant that benefits for MECC trainers to delivering MECC training without top‐down support was low (Reinforcement). Also, some participants suggested that ‘TtT’ is not clear on what it requires from attendees (Environmental Context and Resources), demonstrable by the finding that many attendees were unaware that they were attending a TtT programme (Knowledge) and instead wanted to learn more about MECC rather than deliver MECC training (Goals).
The reviewer read this table flattened into lines of text, its cells separated by vertical bars.
| TDF domain | Sub‐theme | Example codes |
|---|---|---|
| Behavioural regulation | Monitoring and improving |
|
| Beliefs about capabilities | Confidence to deliver MECC training |
|
| Perceived need and ability |
| |
| Beliefs about consequences | Beliefs around the impact of MECC |
|
| Emotion | Passion towards MECC |
|
| Emotions around training delivery |
| |
| Environmental context and resources | Top‐down drivers to support cascade |
|
| Bottom‐up drivers to support cascade |
| |
| Engaging and mobilizing the right individuals in the right way |
| |
| Infrastructure to support cascade at organization |
| |
| Limited time |
| |
| Balancing utility with feasibility |
| |
| Accessibility considerations |
| |
| Goals | Goals that facilitate cascade of MECC training |
|
| Goals (or lack of) to attend TtT and deliver MECC training |
| |
| Intentions | Motivation and interest in cascading MECC training |
|
| Knowledge | Knowledge of the training content needed |
|
| Memory, attention and decision processes | Learning process during TtT training |
|
| Retaining memory after TtT training |
| |
| Reinforcement | Intrinsic or extrinsic consequents for the individual |
|
| Extrinsic consequents for the organization |
| |
| Skills | How to be a MECC trainer |
|
| Interactive TtT training needed |
| |
| Social influences | Peer support as essential to facilitating cascade |
|
| Social/professional role and identity | Ownership of MECC training delivery as part of role |
|
On attending the MECC TtT programme, a high level of knowledge was required to deliver the MECC training content around public health statistics, health inequalities and theory (Knowledge), thus participants commonly felt a lack of confidence to deliver the content (Beliefs about Capabilities). Participants were unclear on how much of the complex information related to MECC delivery, so found it difficult to consolidate it (Memory, Attention and Decision‐Making Processes), especially if they had no experience in training delivery, which created stress or discomfort around delivering MECC training (Emotions). Face‐to‐face training encouraged facilitators, such as shared learning and interaction, but the logistical challenges of face‐to‐face training were acknowledged by participants (Environmental Context and Resources). Refresher training was thought to update knowledge, aid memory of content, revive motivation to deliver training and encourage social support (Environmental Context and Resources).
After receipt of MECC TtT training, some participants discussed their concern that staff in their organization were already competent in the skills required to deliver MECC and engaged in MECC conversations without the need for training (Beliefs about Capabilities). Subsequently, these participants expressed uncertainty of how to approach MECC training in order to acknowledge the existing competency of the audience. Also, a time delay between attending the MECC TtT programme and cascading MECC training made cascading less likely as momentum was lost (Environmental Context and Resources) and content was forgotten (Memory, Attention and Decision‐Making Processes).
Meta‐themes that transcend TDF domains
Four meta‐themes were identified (see Table 2 for example quotes). Each meta‐theme is discussed in turn.
The reviewer read this table flattened into lines of text, its cells separated by vertical bars.
| Meta‐theme | Quotes |
|---|---|
| The need for practical and psychological preparedness to deliver MECC training | AT7: ‘I think there's definitely something that's needed that then makes it actionable and I think maybes it is that kind of practical right so I've done that session on MECC what it could be within the same core session, but actually this is my little action plan that I'm going to kind of start with and then support after that’ AT6: ‘if you have somebody with a plan coming out and saying it's already been discussed, this is where we're going to go with it, and I want to deliver this, this and this and I've actually already emailed people. That's what I would have said is the best way. So, the strategy afterward, they have to be prepared to be ready to go’ |
| Successful cascade is influenced by the MECC training content | AT11: ‘I think if you're going to ask someone to then train that and they don't have that background, if you make it too overly complicated, they're going to go all right, yeah I'll do the train the trainer and then they go nah, I don't feel confident because I don't actually understand that part myself.’ AT6: ‘I froze because I looked at the slides and went, I don't understand them. I don't get them. And when I looked and I had that conversation with my boss and I said look, I don't get it and I'm struggling with it and it's causing me stress. And she, because she's from a higher level, she was like I don't understand why, this is what you work with all the time. I says yeah, but these are heavy stats. These are Band 6. There's this more experience talking about the stats, so if there's any questions you can answer them comfortably. So, I avoided doing that. I don't think I was very popular. But it was causing me stress. It was causing me a bit of wellbeing, mental wellbeing issues’ PT1: ‘And they'd just made it their own and it was just like well that's my job done. All it took for me was you're the experts, I'm not. I'll give you these slides, but it doesn't mean anything unless you've got ownership’ |
| Limited accessibility of the pedagogical approach to both MECC TtT and MECC training | AT11: ‘the trainers are NHS background, so by default I'm an NHS learner, sort of kind of we've all been, so regardless of your learning style, we're probably conditioned to learn in a certain way. Well, it is because NHS background's usually we'll train you, see one, do one, off you go kind of background. And I think that's what the training is like, whereas my colleague who did the training with me is then coming with me to do further, you know, to observe the training that I do, and I wonder if that's because she's not that kind of see one, do on, off you go kind of learner’ AT7: ‘Maybes it's kind of having that conversation with the team to bring them on board, help them to understand where MECC fits, but then right, well how do we do this together as a team. So, maybes it's more around rather than cascading training, maybes it's around equipping people to having facilitated conversations’ AT13: ‘some of it might have to happen in trust induction or on a pre‐existing training programme, like we've got preceptorship and care certificate, health and wellbeing champions is another one that we've got and we weave MECC into those. So they're quite good because we've got a bit of a captive audience and quite high numbers’ AT1: ‘I think what didn't work on that day for some of the team was the Train the Trainer directly following, like immediately following the core training. I don't think that really worked because as I say there were a number of people in that core MECC training who had no experience with MECC, never heard of MECC, didn't know what it was, who went through the core training and came out the other side a little bit sort of confused and bamboozled and then within 30 min later they're then going into Train the Trainer. And I just think that was too much for them on that day’ |
| A need to shift the focus from quantity to quality of MECC training cascade | AT11: ‘I think that the blanket approach is quite often a ticky box approach of well all of our staff are trained in MECC. Lovely but have you moved that forward? Have you embedded that into policy, into working practices, into everyday activities. And I think train the trainer should be that person who's going well hang on, you know, can we do things differently… and then that can disseminate and be the voice for actually we need to do this, or we need to change this. You do need that because if you're trained in it and then there's no champion there going well can we do this, can we do that, I sometimes think it just gets well right we've done that and it's in a folder with everyone's name on and nothing happens’ PT1: ‘And they gave a total different spin on it to what I would do from a public health and they were very human and funny and you could just see how they made it their own’ |
The need for practical and psychological preparedness to deliver MECC training
From the post‐survey comments, it was apparent that many participants showed no intention of utilizing the MECC TtT programme to deliver training, with some noting their surprise at the TtT training. Many TtT attendees were not prepared to become a MECC trainer. Yet as the MECC TtT training was readily available, individuals were nonetheless encouraged to complete it. Individuals felt more ready to deliver MECC training if it helped to fulfil their role and achieve strategic goals that were set by leadership and management. Active involvement in the planning and goal setting for MECC training delivery created more motivation and preparedness to deliver MECC training than if goals were imposed onto them.
Successful cascade is influenced by the MECC training content
Relatedly, active involvement in tailoring the MECC training content encouraged personal ownership over the content, which facilitated personal responsibility to cascade, which was particularly helpful for trainers whose delivery of MECC training was not part of their role. Furthermore, ownership over the course content encouraged training cascade.
MECC training content could also in itself be a barrier to cascade. The high informational load of the course content meant that participants reported feelings of overwhelm and required a lot of time to familiarize themselves with it after the MECC TtT programme. Specifically, those who were newly exposed to the statistics and theory content proposed that it was overcomplicating what they were being asked to do. Also, some participants felt limited by their abilities to amend the content accordingly for worries of compromising on training quality and consistency.
Limited accessibility of the pedagogical approach to both MECC TtT and MECC training
Despite participants reporting that a range of learning styles were catered to within the training, a didactic training approach meant that some participants reported feelings of overwhelm at immediately learning how to deliver MECC training after receiving it themselves. Whilst participants from health care settings struggled acutely with time and capacity issues, participants within these settings tended to be familiar with the didactic training style and TtT model of training delivery, particularly those with nursing backgrounds. Thus, combined with possessing higher relevant knowledge relating to MECC and feeling MECC to be part of their role, participants within health care settings were more confident with the pedagogical approach of the MECC TtT programme, whilst participants from other settings required more support.
Considering the learning approach of the MECC training, a minority of participants discussed alternative approaches to dissemination of MECC principles. For example, informal training delivery through conversations with other staff during existing meetings was considered to be more feasible and to encourage a culture change. Others shortened MECC training to make it more accessible or delivered it as part of other training programmes in order to frame MECC. Such seemingly beneficial adaptations suggested a need to consider the definition of ‘successful’ cascade of MECC training.
A need to shift the focus from quantity to quality of MECC training cascade
Monitoring was mainly discussed in relation to achieving organizational level targets concerning MECC delivery, through numbers of individuals who had received TtT training, number of MECC training sessions delivered and number of individuals delivered to. Whilst easily estimating the success of the TtT model through the number of individuals trained could be motivating, it could also encourage undue focus on numbers rather than the quality of TtT training and the value of the subsequent cascaded MECC training. Combined with a wide availability of the MECC TtT training, top‐down support often encouraged attendance at the MECC TtT training but did not extend further than attendance, including the preparation, planning, and time and audience needed to cascade MECC training. Thus, there was an overall focus on individuals completing the MECC TtT training, although this was insufficient to encourage cascade.
Despite this, participants recognized that there was a unique value to the TtT model in that it encouraged trainers with knowledge of the organizations and individuals they were delivering training to, thus increasing the quality of MECC training that was delivered.
The blind review of the paper's Results section
The reviewer's own text, unedited, under the same names for its blind copy as the review above.
Blind review: finding.md (MECC Train the Trainer cascade)
Reader: Steve. Reviewed under brief.md, reading only this folder.
Question (question.txt): What stopped attenders of the MECC Train the Trainer session from going on to deliver (cascade) the training in their own organisations, and what helped the ones who did?
Finding: the whole of finding.md: a results section with the TDF themes, Table 1 (sub-themes and example codes), Table 2 (quotes) and four meta-themes.
Documents: all 13 transcripts (AP1–AP13), each read in full. Per index.csv, AP3, AP5, AP7, AP9, AP11, AP12 and AP13 cascaded, and AP1, AP2, AP4, AP6, AP8 and AP10 did not.
Speaker labels: the finding labels quotes AT1, AT6, AT7, AT11 and AT13. Every AT quote matches the transcript with the same number (AT6 = AP6 and so on), so I took them as the same people. PT1 matches nobody in the documents (see "Not checkable here").
Root errors
| # | What is wrong at the root | What the documents show (speaker: verbatim) | Kind | Where | Substantive | Sentences it makes wrong |
|---|---|---|---|---|---|---|
| 1 | The finding says health care participants were familiar with the didactic TtT style, felt MECC was part of their role and were more confident with the TtT approach, while people from other settings needed more support. The main evidence for "health care participants are used to see one, do one" is AP11, who works in a local authority. The health care participants themselves show the opposite pattern. | AP11 (local authority, former school nurse): "by default I'm an NHS learner … see one, do one, off you go". AP6 (health care): "I think it's the biggest waste of time I've ever been at because I didn't actually understand what they were trying to deliver"; on the slides: "it's way beyond my pay grade". AP8 (health care): "I think I got much less confident"; her manager agreed she need not cascade. AP4 (health care): "It's not in my job plan in any way. It's my choice." AP12 (health care) had help: "Had I not had her, it would have been probably a different experience". In other settings: AP10 (public sector): "Oh, I was really confident. I would have done it the next week."; AP11 (local authority): "my background really made it super easy"; AP1 (local authority) felt able to deliver with no TtT. Four of the seven who cascaded are local authority or voluntary sector. | overgeneralisation (setting misattributed) | writing | Yes | (a) "Whilst participants from health care settings struggled acutely … particularly those with nursing backgrounds." (b) "Thus, combined with possessing higher relevant knowledge … participants within health care settings were more confident with the pedagogical approach …, whilst participants from other settings required more support." |
| 2 | Experienced participants' accounts of other people's difficulty are written up as the participants' own experience, or as the view of the newly exposed. Most interviewees said they were confident with the content. The people who called it overcomplicated were mostly already familiar with it and spoke on behalf of novices. | AP11: "the statistics and all of that I already knew"; "if you make it too overly complicated, they're going to go … I don't feel confident" (about others). AP13: "I do think it can be hard for them" (porters, ward clerks). AP4: "I think that could be a bit scary to some people" (she knows COM-B already). AP1: "I could just tell by looking around at colleagues that they felt a bit lost" (he himself was fine). AP3: "might be a bit overwhelming for someone without a health background". AP9: "I really feel for those who hadn't trained before". Only AP6, and partly AP3, describe their own loss of confidence from the content. | misattribution | writing | Yes | (a) "… thus participants commonly felt a lack of confidence to deliver the content (Beliefs about Capabilities)." (b) "Specifically, those who were newly exposed to the statistics and theory content proposed that it was overcomplicating what they were being asked to do." |
| 3 | Suggestions are reported as an observed effect. Nobody reports having planned their own cascade beforehand and being more motivated as a result. AP6 and AP7 propose pre-planning as a remedy. One case runs against "imposed goals mean less motivation": AP7's team cascaded under an expectation they had no say in. Other participants ask for more manager-set expectation, not less. | AP6 is recommending, not reporting: "That's what I would have said is the best way". AP7 also wishes for it: "I think there's definitely something that's needed that then makes it actionable". AP7 on her own team: "There was that expectation that everybody was going to do that, so it wasn't really optional", and they did cascade. AP5 suggests "almost like line manager approval to attend … Almost like an informal contract". AP6 himself says: "you only get on if you're management understand that that is what an expectation is". | lost context (hypothetical as fact) | writing | Yes | "Active involvement in the planning and goal setting for MECC training delivery created more motivation and preparedness to deliver MECC training than if goals were imposed onto them." |
| 4 | "A minority of participants" discussed alternative ways to spread MECC. In fact 7 of the 13 did. | AP7: "maybes it's around equipping people to having facilitated conversations". AP6: "it would be calling it MECC awareness"; care certificate. AP13: "we weave MECC into those". AP3: core MECC "as a core health champion module". AP5 cut it to 1.5 hours and took it to preceptees. AP11: "MECC could be your hub and then you have your spokes"; delivered on a digital platform. AP10: "it would have been quite nice just to be able to pop the MECC in those two hours". | wrong count | writing | Yes | "Considering the learning approach of the MECC training, a minority of participants discussed alternative approaches to dissemination of MECC principles." |
| 5 | In three Table 2 quotes, words are dropped or merged without an ellipsis. None of the changes alters the sense. | AP11 l.74: "they go nah, you know, I don't feel confident". AP7 l.118: "Maybes it's kind of, you know, kind of having that conversation". AP13 l.6: "So they're, they're quite good". AT6's "plan" quote also joins two turns across an interviewer "Yeah. So." with no mark, though no words of AP6's are lost. | quotation altered | writing | No | The AT11 "if you're going to ask someone…" quote; the AT7 "Maybes it's kind of having that conversation…" quote; the AT13 "some of it might have to happen in trust induction…" quote. |
Weaknesses not counted as errors
- "However, top-down drivers were perceived to be much more valuable." The comparison is the authors' own. No participant weighs top-down drivers against self-selection. It leans on AP13's move to targeted teams ("we've got a bit more leverage"). Self-directed cascaders cut against it: AP4 ("I've not really felt that I particularly needed it") and AP11/AP12 ("I'm passionate about it", "determination").
- "A didactic training approach meant that some participants reported feelings of overwhelm at immediately learning how to deliver…" The only account of this is AP1, describing colleagues, not himself. Most participants described the TtT as interactive (AP1, AP2, AP4, AP5, AP8, AP12). AP3 says the reverse about timing: "I do think it helps like being quite close together." This is borderline on root error 2.
- Ownership through tailoring "was particularly helpful for trainers whose delivery of MECC training was not part of their role." Apart from the PT1 quotes (not checkable), the support is AP10, talking about his team's other training ("it felt like it was their training"), and AP12's own preparation. No participant makes the comparison with trainers for whom delivery was part of the role.
Checked and supported
All 32 example codes in Table 1 have support in the documents. The following claims also hold:
- TtT unclear about what it requires: AP6, AP4, AP13, AP3.
- Attendees thinking they had come for MECC training rather than TtT: AP6's account of his cohort, AP13's cohort feedback, AP4.
- Lack of incentives: AP6, with AP4's leaderboard idea.
- Audience problems mostly about staff capacity rather than interest: AP1, AP5, AP6, AP10, AP11, AP12, AP13. Lack of interest also appears, in AP6 and AP11.
- Logistics of face-to-face training: AP1, AP5, AP7, AP8.
- Purposes of refresher training: AP3, AP4, AP6, AP7, AP10, AP12.
- "Staff already do MECC": AP5, AP6, AP8, AP11, AP13. AP8's uncertainty about how to approach a team that already does it.
- Delay leads to forgetting and lost momentum: AP5, AP6, AP8, AP10.
- Role and strategic fit: AP3, AP5, AP7, AP9.
- Worries about quality and consistency when amending content: AP7, AP8, AP10, AP13.
- Monitoring by numbers: AP1, AP5, AP6, AP13.
- Support stopping at attendance: AP6, AP8, AP13.
- Value of local trainers who know their organisation: AP7, AP10, AP11, AP12.
Apart from root error 5, the Table 2 quotes match word for word: AT7 (l.170), AT6 "plan", AT6 "froze", AT11 pedagogy and AT11 "ticky box" (whose ellipsis is marked), and AT1 ("30 min" for "30 minutes").
Not checkable here (not counted)
- The mixed methods paper (Nichol et al., 2026), Data S1/S3, and the remark in the Table 1 caption on the optimism domain.
- "From the post-survey comments, it was apparent that many participants showed no intention … with some noting their surprise". This comes from survey data, not the interviews.
- Both PT1 quotes in Table 2 ("And they'd just made it their own…", "And they gave a total different spin on it…"). No PT speaker is in the documents, and a search for the quoted words finds nothing. Much of the "ownership" paragraph rests on PT1.
Other notes
- The Table 1 caption cites "Data S1" while the text cites "Data S3" for the coding framework. This is an internal inconsistency, not about the evidence.
- index.csv marks AP6 as cascaded = No. AP6 does deliver MECC at care certificate level ("I've offered to be the main care certificate deliverer"), but avoided core MECC. This does not affect any sentence in the finding.
Summary: sentences tested 44 (plus 32 Table 1 codes); root errors 5, of which substantive 4; sentences wrong in all 9.
The three most serious root errors:
- The health care vs other settings comparison: it rests on a local authority participant and is contradicted by the health care participants (AP6, AP8, AP4).
- Second-hand accounts of other people's struggles reported as participants' own lack of confidence, and as the view of the newly exposed.
- Suggestions for pre-planning reported as an observed effect, with "imposed goals" partly contradicted (AP7).