Using peer educators to deliver IBA (alcohol harm)in offender settings

1. Using peer educators to deliver IBA (alcohol harm)in offender settings Sara Mitchell Programme Lead Offender Health DH

2. Project Context • Unique settings/challenges • Unique statistics to start from • Explicit need • Absolute fidelity-compelling evidence HTs /IBA (now peer educators if no HTs) Project Development • Early brief adapted to fit need • WCC/QIPP principles

3. Outputs • Bespoke training tools • Service specification • Pathways Outcomes • Increased alcohol awareness in offender population • Reduced alcohol related crime • OASys • Pre and adapted Post test Audit (quantitaive) • Summaries/reviews (qualitative) • Longtitudinal study…?

4. What is a Health Trainer? Sue Green East of England Health Trainer Lead sgreen@s-norfolk.gov.uk

5. A Health Trainer is someone recruited from a deprived community (e.g. Prison or probation service) to work with that deprived community to reduce health inequalities. • They offer peer support. • When trained to RSPH level 2 they signpost to services. • At City and Guilds level 3 they are trained to do 1-1 behaviour change using psychological techniques.

6. Aims:- To Develop a healthy prison/ probation population. Through assessment, signposting and education delivered by peers. To help prisoners change their behaviours to a healthier style. To support them through these changes. To address health issues highlighted in the national targets and PSA indicators. To provide prisoners with a transferable qualification and work experience. To help reduce re-offending, by employing ex-offenders.

7. Health inequalities • Health Trainers help people to work on:- • 1. Reducing alcohol levels • 2. Quit smoking • 3. Exercise more • 4. Eat healthier • 5. Sexual health

8. How many Prison and Probation services are there in the East of England? • Wayland (21), Chelmsford (10), Norwich (10), and Littlehay (14) have active offender HT services. • Peterborough, Whitemoor, Bedford, and the Mount have all obtained Board permission to have a HT service and are in the early stage of development. • Norfolk has a Probation HT service employing 4 ex-offenders (undergoing CRB checks).

9. Peer Led Alcohol Identification and Brief Advice Pilot Brief and Evaluation HMP/YOI Chelmsford Eric Pudaloff Eric.Pudaloff@midessexpct.nhs.uk

10. Background - HMP & YOI Chelmsford • The Prison is used as a long-term category B & Young Offenders Institution (18-21) and local/remand prison (prior to court sentencing) for adult males; • The Prison has a capacity for 695 prisoners and is consistently full or near to capacity; • The average stay in YOI is 57 days, for adults in Prison is 64 days;

11. Background - Health Trainer Champions Peer led Health Improvement Brief Advice on various health topics and sign post prisoners to relevant health services: Current Focus: • Alcohol Screening and Intervention; • Smoking Cessation Brief Advice; • Oral Health Advice; • Health Needs Assessment: • Sexual Health: • Health Promotion as a whole with evidence of activity in: Smoking Cessation, Healthy Eating & Nutrition, Mental Wellbeing, Healthy Lifestyles including Relationships, Drug & Other Substance Misuse;

12. Prison Care – Alcohol IBA Pathway Health Trainer Champions Trained in Alcohol IBA Locality Resettlement Centre IDTS Wing Gym Other Locality Opportunistic IBA delivered by Prison Health Trainer

13. Prison Care – Alcohol IBA Pathway - Continued IBA Alcohol Education (Information Leaflet) Audit not required FAST Score 0-3 Score 4+ IBA Alcohol Education (Information Leaflet) Lower Risk Score 4-7 AUDIT IBA Alcohol Education (Verbal Brief Advice & Information Leaflet) Higher/ Increasing Risk Score 8-19 Score 20+ Signpost to CARATs and AAs IBA Alcohol Education (Verbal Brief Advice & Information Leaflet) Possible Dependence

14. The Research Experiment (1) The primary objective of the research is to determine the relative effectiveness of brief verbal and non verbal advice/information provided by prisoner health trainers to other prisoners. Advice intended to positively influence prisoners’ future intentions concerning their use of alcohol upon their release into the community. The research project involved the participation of prisoner volunteers being processed through the Prison’s induction wing. Eligible participants were those who scored 8+ on the FAST/Audit test and were divided into two groups each of 40 prisoners.

15. The Research Experiment (2) Group 1 (Experimental group)Participants received feedback from a peer Health Trainer as to the meaning of their FAST/audit scores and provided with brief verbal and non verbal advice/information relating to alcohol use and misuse. Approximately 14 days later, participants were interviewed by the researcher and requested to complete two questionnaires. Group 2 (Control group)Participants received feedback as to the meaning of their FAST/audit scores and were immediately requested by the researcher to complete the same two questionnaires given to Group 1 participants. Upon completion of questionnaires participants were provided with brief verbal and non verbal advice/information relating to alcohol use and misuse.

16. Quantitative Questionnaire (Part 1) A quantitative questionnaire comprising of 17 questions using a Likert 0-6 scale i.e. from strongly agree (0) to strongly disagree(6) At the bottom of Part 1 Questionnaire: a test invited participants to indicate how many units there are in: a pint of strong lager, a large glass of wine and a double vodka. Additionally: a request to name 3 negative consequences of alcohol misuse.

17. Qualitative Questionnaire (Part 2) A questionnaire comprising of 5 questions • Do you think that past behaviour linked to your drinking (alcohol) has interfered with any of the plans you had for your life? • Do you think that past behaviour linked to your drinking (alcohol) may have taken something away from what you once liked about yourself? • What intentions for your own future do you have in mind concerning the role of alcohol in your life when you get out (upon your release)? • In the twelve months prior to your imprisonment, do you think that your drinking was to a safe level? • Upon your release, what do you think are the barriers that might prevent you from not drinking at all or drinking to a safe level and how confident are you of overcoming those barriers?

18. Initial Results – Quantitative (1) (Awaiting Independent Verification) Regression analysis calculations were performed in respect to both the Experimental & Control Groups using Q12 of Questionnaire Part 1 as the outcome (dependent variable) i.e. the intention or otherwise to cut down or avoid drinking in the future. From the same Questionnaire, questions below were selected as predictors (independent variables) of Q12 that focused on past reflections & future intentions Q1 My past misuse of alcohol has harmed personal relationships: Q3 I need to look at my future relationship with alcohol: Q5 My drinking in the past has worked against me: Q9 I am confident I can take better care of my health in the future; Q16 I recognise that I have misused alcohol in the past: Q17 I have a good understanding of the dangers of alcohol misuse;

19. Initial Results – Quantitative (2) (Awaiting Independent Verification) EXPERIMENTAL GROUP – SIMPLE REGRESSION An R-squared of 0.705, meant that approximately 70% of the variance of Q12 is accounted for by the predictors Q1,Q3,Q5,Q9,Q16 & Q17. Q1 (My past misuse of alcohol has harmed personal relationships) was found to be NS (b= -0.0367, p=0.057,), but only just. Next, the effect of Q3 (I need to look at my future relationship with alcohol) is (b= 0.526, p= 0.000) was significant, indicating a high proportion of participants in the experimental group saw the need to look at their future relationship with alcohol. Q5 (My drinking in the past has worked against me) was also significant (b=0.251, p=0.050). Q9 (I am confident I can take better care of my health in the future) recorded a significance of (b=0.421, p=0.001) indicated a good proportion of participants were confident they would take better care of their health in future and Q16 (I recognise that I have misused alcohol in the past) indicated the preparedness of a significant number of participants to consider their misuse of alcohol in the past (b=0.406, p=0.035). Q17 (I have a good understanding of the dangers of alcohol misuse) was NS (b=0.088, p=0.661).

20. Initial Results – Quantitative (3) (Awaiting Independent Verification) CONTROL GROUP – SIMPLE REGRESSION In respect to the Control Group, none of the independent variables (Q1,Q3,Q5,Q9,Q16 & Q17) were found to be significant predictors of Q12 (intention to cut down or avoid drinking in the future) i.e. the dependent variable. An R-squared of 0.355, meant that approximately only 36% of the variance of Q12 was accounted for by the above predictors. Results of conducted simple regressions appear to indicate that brief interventions by peer health trainers influence prisoner participants in the experimental group to positively reflect upon their past behaviour and future intentions towards alcohol consumption in comparison with the control group that experienced no such interventions.

21. Initial Results – Qualitative (1) The Experiment in Chelmsford HMP/YOI Prison had recently been completed and analysis has only just began. Qualitative data has received only cursory attention. However, in regards to qualitative data the following themes have become apparent participants responses: Q Do you think that past behaviour linked to your drinking (alcohol) has interfered with any of the plans you had for your life? Gone to jail, damaged relationships, lost job, not achieved goals (education). Q Do you think that past behaviour linked to your drinking (alcohol) may have taken something away from what you once liked about yourself? Loss of confidence & self esteem, good behaviour, being likeable, lost happiness. Q What intentions for your own future do you have in mind concerning the role of alcohol in your life when you get out (upon your release)? Going to stop, try and stop, not touch it again, cut down, go to support centres in the community, I want to be councillor alcohol misuse.

22. Initial Results – Qualitative (2) Q In the twelve months prior to your imprisonment, do you think that your drinking was to a safe level? A resounding NO with only a few exceptions - not surprising since the average Fast/audit score of all participants was 26 (the threshold dependency is 20+). QUpon your release, what do you think are the barriers that might prevent you from not drinking at all or drinking to a safe level and how confident are you of overcoming those barriers? Depression, lack of support, no where to stay, living on the streets, bad influences from the past, going to night clubs, taking drugs, failed relationships, bad company. The described experiment has been no more than a pilot conducted with a limited number of participants. However, the initial indicators are encouraging and would appear to support the effectiveness of Peer led Health Improvement Brief Advice within the context of a prison environment and the delivery of alcohol screening and brief intervention

23. Results from pre and post training evaluation sheets HMPS Norwich and HMPS and HMPS Wayland

24. N.B. The data has not been fully analyzed yet but the following patterns are emerging:-

25. Wayland –pre training • The health trainers felt they didn’t know enough and were not confident to advise people. • They didn’t feel proud of themselves, but at the same time –kept positive and looked forward to working with people who had alcohol based problems. • They were happy to ask clients questions and felt clients would expect this . • However they did not know how rewarding it would be and couldn’t judge weather they liked drinkers at that stage.

26. Wayland Post Training • The health trainers felt they knew enough and were confident to advise people with alcohol based problems. • They felt proud about what they were going to undertake. • They felt very positive and were happy to ask questions about clients drinking patterns. • They all felt the work would be rewarding. • But their was no change to weather they felt they liked drinkers or not.

27. Norwich –pre training • The health trainers felt they didn’t know enough –but were still happy to advise. • They were not sure about how confident they were. • They didn’t feel a failure though and did want to undertake this work. • They were positive and felt they had the right to ask clients questions and felt clients would expect this. • They expected the work to be rewarding and were quite favourable towards drinkers.

28. Norwich –post training • The health trainers felt they knew enough and were happy to give advice. They were still not brimming with confidence but didn’t feel a failure either. • They were keen to undertake the work, but not so positive as they were before the training. • They felt they had the right to ask clients questions but were less sure how these questions would be received. • They were also not so sure how rewarding it would be, but remained more favourable towards drinkers than offenders at Wayland were.

29. A few interesting points from other areas of the questionnaire • Wayland felt the training was all useful and over half agreed it was highly useful. They enjoyed the role play , discussion and learning about units most. • They felt Short concise adverts would promote IBA well, as would the use of statistics [positive and negative]. Positive role models and success stories were also recommended. • Barriers to the success of IBA in prisons were lack of motivation ,peer pressure, addiction, stress, lack of co-operation and general unwillingness to change. • Communication problems and lack of information –were highlighted as barriers the health trainers might encounter whilst undertaking IBA.