OTROS ENFOQUES

This study has focused on the question of whether peer-based interventions are effective and cost-effective at maintaining or improving health in prison settings. Although there are evident limitations with both the review and the quality of the studies, which reduces their applicability for practice, the 58 included studies represent the best available evidence. The overall conclusion is that peer-based interventions have positive effects for both peer deliverers and recipients. Furthermore, such interventions can impact positively on the prison as an organisation, for example through improvements in prison culture or reduced demands on staff. There were very few negative outcomes reported, with the major exceptions being increased security risks and the burden of care reported by some peer workers. Although the review overall has high

relevance for health services in prisons in England and Wales, many included studies were drawn from outside the UK and therefore specific interventions may have limited transferability.

One of the implications for practice is that peer-based interventions can be considered a valuable

mechanism to maintain or improve health and well-being in the prison setting. Although the study results are broadly positive about peer delivery, it cannot be assumed that all peer interventions will be effective in all types of prison establishment. The study results confirm that there is considerable heterogeneity in the range of peer interventions, the health issues addressed, the mode of delivery and reported outcomes. Although there is undoubtedly some overlap between different intervention types, for example peer support, peer mentoring and peer education, the transferability of results from one intervention group to another is limited. The exception is the finding that taking part in a peer delivery role has positive effects, as this occurred consistently across interventions, including those that were not primarily focused on health. The implication for practice is that offering prisoners opportunities to become peer workers will enhance their individual health and well-being, as long as adequate recruitment, training and support processes are in place.

The expert symposium highlighted the variety of peer support and peer mentoring schemes in operation in the prison system in England and Wales. These inevitably reflect historical and geographical patterns of provision and many of these schemes were initiated in response to specific needs. The study provides some evidence to support the use of peer support schemes that offer prisoners social, emotional or practical support during their time in prison. Although more research is needed on the effects on recipients and the prison as an organisation, in general peer support services are valued by prisoners and may address mental health needs. Health services may wish to consider the points at which support is most usefully accessed by those experiencing distress or anxiety. For example, the study found some evidence on the value of first night schemes.

Although there are no prison-based hospices currently operating in England and Wales, the evidence on prison hospice volunteers suggests that prisoners can perform a caring role and complement professional health services in this area. This may offer a model for service user involvement in health and social care in prisons, particularly for older prisoners or those with social care needs. Finally, the Listener scheme, which is well established across most prisons in England and Wales, offers a standardised intervention in which peer workers are trained and supported to provide confidential emotional support to individual prisoners at times of need. The rationale for listeners as peers who share the experience of imprisonment is supported by the qualitative evidence reviewed in the study.

Peer education is less evident in prisons in England and Wales and this perhaps reflects more general trends with regard to traditional health education approaches. The finding that peer education can be effective at increasing knowledge and reducing risky health behaviours, particularly in relation to the prevention of HIV infection, has implications for the development of practice. Consideration should be given to whether or not it is of value to include a peer education component in other health behaviour change interventions. There is some limited evidence showing that health trainers discussed a range of lifestyle issues with clients and referred individuals to other services.

The question of the skill mix in services is an important issue in designing services. There was strong quantitative evidence that peer educators are as effective as professional educators in the prevention of HIV transmission, and the economic model, also based on the prevention of HIV transmission, showed that peers were marginally more cost-effective than professionals. The transferability of these results to other contexts is not clear; nonetheless, the implication is that peer workers can be considered a viable complementary‘workforce’for health services. There was also strong qualitative evidence on prisoner preferences for peer delivery. Recognising the value of peer health workers as a resource in prison does not negate the value of professional staff; indeed, many interventions were predicated on an integrated approach. There was no evidence in the review about the relative merits of paid peer worker compared with volunteer peer worker models. The expert symposium highlighted that, although there may be cost savings, peer interventions are not cost free.

The study identified a number of process issues concerning the implementation of peer schemes within a prison setting. The health capacity logic model (seeFigure 18) illustrates the main factors, identified through the review, that need to be considered at an individual and organisational level and could provide a framework for developing, implementing and evaluating peer interventions with the prison setting.

The recruitment of peer workers requires consideration, and retention was identified as a significant problem in some contexts. Some evidence suggested that training should be flexible, but the value of accreditation for training was also highlighted. This may help peer deliverers when moving to different prisons and when leaving prison. Overall, it was clear that training and support packages for peer interventions need to be adapted to contextual factors specific to the environment to achieve success. The dilemma, it seems, is whether training for these roles should be localised, based on prison function and average length of prisoner stay, or whether a more standardised programme across the prison estate is required so that individual prisoners can transfer their skills between institutions.

The qualitative evidence on role boundaries and security concerns indicates that both personal and operational risks need to be proactively managed to prevent unintended negative effects of peer-based interventions. There is also strong evidence about the need for institutional buy-in and for staff at all levels to embrace interventions to ensure smooth delivery, for example allowing movement of peer deliverers. Overall, the study findings suggest that peer interventions cannot be considered to be independent of the organisation and culture of a prison. This has implications for the management and implementation of peer schemes.

Critically, peer-based interventions, although premised on prisoner-to-prisoner relationships, ultimately have to be co-constructed with prison staff to be effective. Peer delivery is one means of achieving greater service user or patient involvement that is based on values of autonomy, equality and respect. The prison setting presents some unique challenges for health services, but this study has shown that there is an evidence base for engaging prisoners in peer-based health prevention and support.

T

his study was developed and overseen by a multidisciplinary research partnership. The research teams at Leeds Metropolitan University and the University of Leeds would like to thank the Steering Group for their contributions to the study: Kathy Doran, Dr Linda Harris, Ben Mitchell, Bill Penson, Lee Stephenson, Caroline Thompson, Dr Nick De Viggiani and Dr Nat Wright. We are very grateful for the expert advice and guidance given by Professor Mike Kelly, Dr Gerry Richardson and Dr James Thomas, who formed our advisory group.

The research teams would also like to thank everyone who contributed to the study, including those individuals who participated in the expert symposium. Particular thanks go to the prisoners involved in the listening exercises and the governors in those institutions for allowing the exercises to take place. Specific thanks go to Anne Cowman, Lynne Barker and Lee Stephenson for their support in facilitating these.

We are grateful for the methodological advice offered by Professor Mary Dixon-Woods, Professor Nicky Britten and Professor Rhona Campbell and would like to thank Ben Mitchell for his support with the search strategy and Dr Wu for his contribution to the economic review.

We are grateful for the support provided throughout the study by Sue Pargeter, Programme Manager, NIHR Evaluation, Trials and Studies Coordinating Centre.

Finally, we would like to acknowledge the administrative support provided by the Faculty of Health and Social Sciences, Leeds Metropolitan University. Specific thanks go to Sue Rooke, who has overseen all study communication and administration, and Angela Lowe, for financial support.

This study received approval from the National Offender Management Service National Research Committee (Ref:165–11)

In document UNIVERSIDAD COMPLUTENSE DE MADRID (página 72-78)