A systematic review of the effectiveness and cost-effectiveness of peer-based interventions to maintain and improve offender health in prison settings

Search strategy and information sources

For the systematic review of effectiveness the following databases were searched: MEDLINE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, International Bibliography of the Social Sciences (IBSS), Applied Social Sciences Index and Abstracts (ASSIA), Web of Science, Social Sciences Citation Index, National Criminal Justice Reference Service Abstracts, Social Services Abstracts, Sociological Abstracts, Database of Abstracts of Reviews of Effects, Trials Register of Promoting Health Interventions (TRoPHI), Database of Promoting Health Effectiveness Reviews (DoPHER), Social Care Online, Academic Search Complete and The Cochrane and Campbell Collaboration databases.

Search terms drew on the results of an earlier systematic scoping review97 with further search terms identified in consultation with the project steering group. Appendix 2 provides the search strategies and results.

The search was limited to papers published since 1985 and was not restricted to English-language papers. Listener schemes were implemented in the early 1990s and so a cut-off date of 1985 was chosen to capture any preliminary studies, for example pilot schemes. Electronic contents lists of key journals (Journal of Correctional Health Care, Health Education & Behavior, Criminal Justice and Behavior) were searched. 110

Unpublished (grey) literature was identified from contacts with experts, including at the expert symposium, conference and dissertation abstracts, reference lists of identified and key papers, hand searches of relevant book chapters and searches of websites such as Google Scholar and Google and websites of relevant organisations (e.g. the Home Office). Contact was made with national and international experts including Offender Health Research Networks, Prison and Offender Research in Social Care and Health, the Samaritans (Listener scheme), Volunteering England, NOMS, primary care trusts (health trainers), the Ministry of Justice, the Prison Officers’ Association (POA), Action for Prisoners’ Families, CLINKS, the Prison Governors Association, the Shannon Trust, HM Inspectorate of Prisons, the Prisons and Probation Ombudsman, the National Network of Forensic Nurses and private sector prison organisations, for example Serco, Kalyx, the Prison Reform Trust and the Howard League for Penal Reform.

Practitioners and academics with expertise were contacted through appropriate academic and practice mailing lists (public-health@jiscmail, health-services-research@jiscmail, health-promotion-academics@jiscmail and health-equity-network@jiscmail).

A hand search of the reference lists of included papers was performed.

To keep to the project time plan, there was a cut-off date for submission of the end of August 2012, after which any research arriving was not included in the review. If necessary, study authors were contacted for additional or missing information.

Study selection

Data extraction

Data were extracted onto a piloted electronic form (see Appendix 3). The data extraction form was piloted by four reviewers (AMB, JW, GR, KK) who independently extracted data from the same two studies (one qualitative and one quantitative) and met to compare results, which led to some changes in the form to ensure consistency. All studies were categorised according to the type(s) of data they contained and which review question(s) they addressed. Data extraction fields included:

• bibliographic details

• population details, for example age, sex, length of sentence/length of stay, stage (e.g. just arrived/about to leave), existing health problems (whether reported for peer helpers, programme recipients or both), whether on remand or sentenced, other details such as sex offenders or taking drugs

• setting/institution details, for example high-security/open prison, YOI, country

• intervention details, for example health or social issue, method of delivery, intervention components, theoretical model if given, number/length of contacts, definition of peer if given, definition of programme recipient if given, details of training and provider of training (e.g. NHS, the Samaritans), recruitment (methods and criteria), support given and level of supervision (and who supports/supervises), rewards

• outcomes – all reported health-related outcomes, including negative outcomes, experienced by peer deliverers, programme recipients and prison staff.

Detailed extraction of qualitative data took place in NVivo 9 software (QSR International, Southport, UK), using text conversion of PDF files to import the whole paper. Coding was then applied to methodological and other potential sources of variation (such as population, intervention and settings), as well as results, to allow data to be assembled in the most appropriate way. Data were extracted by one reviewer and checked by a second reviewer, with disagreements resolved by consensus, with reference to the original papers and to a third reviewer and/or other experts as required. The data extraction tables were used to create evidence tables for each included study (see Appendix 4).

Validity assessment/risk of bias

Appropriate validity assessment criteria were developed for each included study design. Checklists were updated based on National Institute for Health and Care Excellence (NICE) public health methods guidance for quantitative studies109 and Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) expertise for qualitative reviews111 (see Appendix 5). Unpublished data from grey literature were assessed using the same criteria as for published data.

Two reviewers assessed each study for validity on piloted forms using pre-agreed criteria. Validity assessment forms were piloted in the same way as the data extraction forms. Disagreements were resolved by consensus with reference to the original papers and a third reviewer if necessary. The decision-making process was recorded in a Microsoft Excel spreadsheet (version 14; Microsoft Corporation, Redmond, WA, USA), which was updated by all reviewers throughout the review process.

Each validity assessment form required the reviewer to make an overall assessment of internal validity and relevance, based on answers to the questions on the form. These were translated into a numerical score of 1–3 for internal validity (where 1 = good internal validity/low risk of bias, 2 = moderate internal validity/moderate risk of bias and 3 = poor internal validity/high risk of bias) combined with an alphabetical score of a–c for relevance (where a = highly relevant, b = of some relevance and c = not very relevant).

Quantitative analysis and synthesis

Detailed extraction of quantitative data took place into Microsoft Word tables and meta-analysis software (RevMan 5.0, The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark). Synthesis of quantitative data was carried out by two reviewers (AMB and GR) and, after discussion with the advisory and steering groups, findings were presented combined in a narrative synthesis, grouped by review question and then by intervention mode. When data were suitable for statistical meta-analysis, studies were combined using a fixed-effect model to give relative risks with 95% confidence intervals (CIs) for binary outcomes and weighted or standardised mean differences (MDs) with 95% CIs for continuous outcomes. Statistical heterogeneity was examined using the chi-squared and I² statistics, with a chi-squared p-value of > 0.1 and a I² value of > 50% indicating statistical heterogeneity, in which case reasons for the heterogeneity would be investigated and a random-effects model would be used to determine whether or not the findings were robust to the choice of model.

When pooling was not appropriate because of clinical heterogeneity, it was still possible to display some quantitative results in forest plots to illustrate the spread of data.

Qualitative analysis and synthesis

A thematic synthesis of qualitative studies was undertaken to combine the evidence, based on the methods described by Thomas and Harden112 and using NVivo software to manage the data and ensure a transparent process. Figure 2 provides an overview of the data management, analysis and quality processes. All studies reporting qualitative data were first uploaded into NVivo as PDF files. An inductive approach was used to produce a complete set of descriptive codes (managed as NVivo nodes) that summarised the themes in the data. The initial coding framework was developed from a process of familiarisation with the studies and piloting of qualitative data analysis methods with a sample of papers, each reviewed by four members of the review team (JW,KK, AMB, JS). Two reviewers (JW,KK) then worked independently to undertake free coding of all of the text reporting qualitative findings, labelling the text with single or multiple nodes for sentences and paragraphs respectively (including verbatim quotations from respondents presented in the studies). 112 The coding framework was expanded as open coding of the text allowed new codes to be added until a complete set of descriptive codes was generated that covered all of the textual data.

FIGURE 2.

Process of qualitative analysis and synthesis.

To ensure consistency of interpretation, the two reviewers (JW, KK) met to review codes on a number of occasions and to check coded text in a sample of papers as the coding framework was built. A third reviewer (JS) checked the inter-rater reliability of the coding process and the development of the final set of codes. This checking process involved first reading the full papers/reports of a sample of qualitative studies and making notes of themes. The sample, representing at least 25% of the qualitative studies (n = 10 studies/11 papers), was selected to reflect variation in terms of type of publication, methods, intervention type and primary reviewer. The reviewer then checked codes as displayed on NVivo for a sample of studies to ensure consistency both of the coding process between reviewers and of interpretations between studies. During this stage a reflexive team e-mail journal was used and frequent meetings of the review team were held to agree the application of codes.

To develop analytical themes,112 the complete set of descriptive codes (n = 99) was organised into a set of themes and then grouped into thematic categories using an iterative process to obtain the best fit to explain the data. Themes were then mapped back to the review questions113 (see Appendix 6). For review question 1 on effectiveness, themes on outcomes were further split into subcategories according to intervention mode and a narrative synthesis produced. For review questions 2 and 3, a thematic narrative synthesis was written by one reviewer (JW), checking back to the coded text to avoid decontextualising the data. The authenticity of the final account was agreed by the other two reviewers (KK, JS). 114

Evidence synthesis of the results

A mixed-methods systematic review design similar to that used by the EPPI-Centre112 was used to combine data from different study designs. Evidence was initially synthesised by study type into two streams: quantitative and qualitative (for studies that use mixed methods, qualitative and quantitative data were extracted and treated separately in the relevant streams).

For review question 1, studies were grouped according to intervention mode to produce evidence statements summarising the effectiveness of interventions. Intervention modes were derived by checking the information recorded on data extraction sheets, which gave an initial categorisation of the intervention and any theoretical models as reported by the study. An intervention typology, developed as part of the review process (see following section), was then applied to categorise all of the included studies until a best fit with the reported intervention mode was achieved.

For review questions 1 and 3, qualitative themes on outcomes for peer deliverers and recipients were mapped to quantitative results grouped by intervention mode and then type of outcome. 115

For review question 2, a thematic synthesis was produced that combined results across heterogeneous studies. 116 The narrative account of the qualitative results was pooled with quantitative results using the themes generated inductively by qualitative analysis as a framework for reporting.

Because of the lack of detail provided in the included studies, it was not possible to look at the modifying effects of type of institution, prisoner pathway or gender.

Development of a typology of peer-based interventions

The typology of peer-based interventions, which was used to group interventions for the evidence synthesis, was developed as a heuristic tool because there was no existing categorisation that could be used to group very heterogeneous studies. Preliminary definitions of the types of intervention mode (e.g. peer education, health trainers) were developed by one reviewer (JS) using key background papers and theoretical literature matched to any definitions and ‘thick description’ of interventions when these were available in the included studies (as indicated from data extraction sheets). The final typology was derived by an iterative process of comparing definitions with reported intervention modes in the included studies until the best fit was obtained. Both the final typology and the categorisation of included studies was agreed by all members of the review team (see Chapter 4). The full definitions of interventions used for the evidence synthesis, with sources referenced, can be found in Appendix 7.

Search strategy

All databases were searched using an adaptation of the economics search filters developed by the NHS Centre for Reviews and Dissemination combined with the search terms used in the effectiveness literature search strategy. The overall search strategy drew on work on retrieving cost information previously conducted at the NHS Centre for Reviews and Dissemination107 and used the terms ‘cost benefit’, ‘cost effectiveness’, ‘cost utility’, ‘cost consequences’, ‘cost minimisation’, ‘economic evaluation’, ‘quality of life’, ‘utility’, ‘incremental cost effectiveness analysis’, ‘incremental cost effectiveness ratio’, ‘net present value’ and ‘incremental net benefit’ combined with the search terms used in the clinical literature search strategy. Sensitive searching [e.g. economics (ec) as a floating subheading] was used. Mirroring the effectiveness review, terms were developed with input from experts in the field.

In April and May 2012 a search was conducted in the following databases for studies of peer interventions in prisons that included economic evaluations, health utilities or other cost information: ASSIA, The Campbell Collaboration Library, Cost-effectiveness Analysis Registry, CINAHL, Conference Papers Index, Dissertations & Theses, EMBASE Classic, EMBASE, Research Papers in Economics (RePEc) (IDEAS), IBSS, MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, National Criminal Justice Reference Service Abstracts, NHS Economic Evaluation Database (NHS EED), PsycINFO, Social Services Abstracts, Sociological Abstracts, Science Citation Index Expanded, Social Sciences Citation Index Expanded, Conference Proceedings Citation Index– Science, Conference Proceedings Citation Index – Social Science & Humanities. Full details of database hosts and database search dates are available in Appendix 8. The searches identified 1347 references, which were reduced to 1157 following deduplication.

Databases were selected that were likely to contain economic evaluations and cost and health utility studies, along with a range of health and social databases that include prison- and young offender-based studies. Grey (unpublished) literature was sought from conference, dissertation and working paper databases. The selection of databases was consistent with and complementary to those used for the effectiveness review searches. The search strategies were devised in collaboration with the effectiveness review information specialist. The searches were constructed around three concepts: prisoners, peer interventions and cost/health utility studies. The effectiveness review project team supplied potential search terms for ‘peer interventions for prisoners’. A draft MEDLINE search strategy for the effectiveness review was checked by project team members and the search modified accordingly. The strategies comprised both text word searches and subject heading searches. For pragmatic reasons proximity operators (adjacency) were used between prison and peer intervention text word searches to improve the search precision. Some databases had the subject heading ‘peer intervention’ but it was discovered that this did not appear in some known relevant references. Therefore, a number of subject headings (e.g. ‘focus groups’, ‘social support’) were included in our search to retrieve references with relevant peer intervention content but without the ‘peer intervention’ subject heading. Searches were not limited by language or publication date.

The final MEDLINE ‘peer interventions for prisoners’ search was translated as closely as possible to all other databases. The cost search for most databases consisted of the ‘peer interventions for prisoners’ search plus a search for cost or health utility studies. We used previously designed searches to identify cost and health utility studies, which were adaptations of the NHS EED search strategies [see https://sites.google.com/a/york.ac.uk/issg-search-filters-resource/filters-to-find-i (accessed June 2014)]. Searches of economic databases were developed separately from but consistently with the effectiveness review searches. Full details of all search strategies are provided in Appendix 8.

Bibliographies of articles selected for inclusion were hand searched for relevant studies, and the wider research group was also contacted for advice, for peer review and to identify additional published and unpublished references. Any additional papers were subjected to the abstract review process before inclusion in or exclusion from the quality assessment process.

Study selection

The cost-effectiveness review inclusion and exclusion criteria were developed in line with those of the effectiveness review. Additionally, the inclusion criteria included papers reporting resource use/cost and/or outcome comparisons between peer-based interventions and standard care. Economic evaluations were therefore considered for inclusion if they reported resource use/cost and/or outcome comparisons or presented a systematic review of either.

Titles and abstracts identified by the search strategy were assessed for possible eligibility by two reviewers independently. The full texts of relevant papers were then obtained and inclusion criteria were again applied by two reviewers independently. Any disagreements over eligibility were resolved by consensus or through consultation with a third reviewer. Data were extracted by both reviewers independently using a data extraction form, which was checked by the third reviewer.

The following data were extracted from the included studies:

• study characteristics – type of economic evaluation, aims and objectives, intervention, comparison, setting, country and/or currency, basis of costing, source of cost data, cost year and discounting

• characteristics of the study population – adult or youth and male or female inmates

• duration of follow-up

• results – summary of effectiveness and costs and cost-effectiveness/utility, sensitivity analysis

• conclusions as reported by the authors.

Inclusion criteria

• Population: studies of prisoners resident in prisons and YOIs in any country, all ages, male and female were eligible for inclusion in the review. Studies involving the whole prison population, including staff, were eligible for inclusion.

• Intervention: studies of peer-based interventions including peer education, peer support, peer mentoring, popular opinion leaders, befriending, peer counselling and self-help groups, operating within prisons and YOIs in any country, were eligible for inclusion in the review. Interventions aimed at improving or maintaining prisoner physical or mental health and well-being either directly (e.g. HIV awareness, Listener schemes) or indirectly by addressing determinants of health within prison settings (e.g. basic literacy and life skills) were included. Multicomponent interventions that include a peer-to-peer element were included. ‘Peer’ includes prisoners and ex-prisoners delivering interventions to prisoners.

• Comparators: studies with any comparator intervention were eligible for inclusion.

• Outcomes: studies reporting any effects of peer-based interventions on prisoner health or determinants were eligible for inclusion, for example changes in physical or mental health or health behaviours or in determinants of health within the prison setting, such as social support, (literacy) skills, education or service delivery. Studies that report only reoffending or other non-health outcomes were not included.

• Types of studies: cost-effectiveness analyses, cost–utility analyses, cost–benefit analyses, cost–consequence analyses and cost analysis.

• Data synthesis: data were synthesised through a narrative review with tabulation of results of all included studies. Full data extraction forms are presented in Appendix 9.

Validity assessment

The included studies were summarised and critically appraised by two reviewers. The quality of each paper was assessed using a modified version of the checklist of Drummond and colleagues. 117 For papers reporting economic evaluations alongside clinical trials, this was supplemented with reference to the good practice guidance produced by the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Task Force on economic evaluations alongside clinical trials. 118 For papers reporting cost-effectiveness models, the checklist was supplemented with reference to the checklist proposed by Drummond and colleagues117 and the good practice guidance. 118 The results of the cost-effectiveness review together with the results of the effectiveness review were used to inform the economic model.

Knowledge

In total, 10 studies101,123,129–131,134,143,158,162,164 contained quantitative findings about the effects of peer education on prisoner knowledge; seven101,123,130,131,158,162,164 of these were aimed at the prevention of HIV infection, one134 was aimed at the prevention of hepatitis C virus infection, one129 was aimed at parenting and one was aimed at literacy. 143 There was no standard outcome measure used, even within the HIV studies. Four studies131,134,158,164 recorded the number or percentage of correct answers to a set of questions; however, different questions were asked in each study, giving a total of 43 questions, only three of which were asked by more than one of the four studies. Four studies101,123,158,162 presented knowledge scores, although not all gave enough information for meta-analysis; however, standard deviations (SDs)123 and numbers in group162 were estimated when necessary. 108 Other studies presented the percentages agreeing with statements on literacy and other skills143 and the resuIts of statistical analysis. 130 A study on parenting skills129 presented information from questionnaires about fathers’ knowledge of their children. It was therefore not possible to pool the findings of the studies in this category, although effect measures [risk ratios (RRs) and MDs] with 95% CIs were calculated for studies when possible and displayed in forest plots.

Statistically significant improvements favouring peer education were seen in the number of correct answers to 22 of the 43 questions asked (Table 5), with negative effects of peer education seen in the answers to one of the 43 questions. For the remaining 20 questions there was no evidence of an effect of the intervention. RRs ranged from 0.43 (95% CI 0.33 to 0.56; one study, n = 949), in favour of peer education, for the question ‘HIV can be transmitted by bloody fights’ to 3.06 (95% CI 1.91 to 4.91; one study, n = 200), against peer education, for the question ‘All forms of hepatitis can be transmitted by sex’.

Continuous data on knowledge scores that were suitable for meta-analysis came from four studies101,123,158,162 and positive results were seen in all four studies; however, it should be noted that some data were imputed for two123,162 of these studies so the results should be treated with caution. When results from two studies101,123 were combined, the pooled MD was 0.46 (95% CI 0.36 to 0.56; two studies, n = 2494); however, there was substantial statistical heterogeneity in this result (I² = 94%) (Figure 4).

FIGURE 4.

Knowledge scores.

There was also qualitative evidence to suggest that peer educators improved their own knowledge of health issues as a result of the training that they received. 121,131,159 In the study by Scott and colleagues,131 HIV-related knowledge gained as a result of training increased individuals’ knowledge and there was also evidence that this information was diffused to those outside the prison, such as family members and children.

In one study,130 after the intervention detainees were significantly more knowledgeable about the danger of blood transfusions (p = 0.01). On assessment after the intervention, the detainees were significantly less afraid of daily activities such as sharing a spoon or fork with another person (p = 0.03). Detainees more often identified friends as a major source of knowledge and information about HIV/AIDS [χ² (1, n = 69) = 4.73, p = 0.029]. Finally, detainees became much more aware that if they did not use a condom during sexual intercourse their chances of getting HIV/AIDS were greatly increased [χ² (1, n = 69) = 4.996, p = 0.025].

In the study on parenting skills129 there was no statistically significant effect of the intervention on fathers’ knowledge of their children (MD –0.80, 95% CI –1.61 to 0.01).

In the study on literacy,143 questionnaire responses showed that > 90% of the programme recipients (learners) agreed that their reading and communication skills had improved, 92% agreed that they would go on to do more learning and 99% would recommend the programme to others. Sixteen learners who returned questionnaires had gained a total of 30 qualifications. All of the mentors who took part agreed that the programme had given them new skills, improved their communication skills, allowed them to understand others better, been a good use of their time in prison and helped them feel more positive about their future. In total, 98% agreed that they would go on to do more learning and 100% would recommend mentoring in the programme to others.

One study164 reported that prisoners with less than full primary school education were significantly less likely than those with more schooling to respond correctly to all questions both before (43% vs. 69%, p < 0.00001) and after (84% vs. 94%, p < 0.00001) the peer education intervention. However, the less educated group showed a greater improvement in the proportion of correct answers for all questions (41% vs. 24%, p < 0.00001).

Intentions

Four studies101,123,130,162 contained quantitative data on intentions. One RCT123 reported improvements in four out of five outcomes measured: interest in taking a HIV test for the first time (RR 1.49, 95% CI 1.12 to 1.97), interest in taking a HIV test now (RR 1.82, 95% CI 1.33 to 2.49), intention to use condoms (RR 1.15, 95% CI 1.08 to 1.22) and intention never to use condoms (RR 0.59, 95% CI 0.48 to 0.72). The fifth outcome, intention of injecting drug users to use bleach, showed no improvement after the intervention (RR 1.06, 95% CI 0.97 to 1.16). Another study101 found no improvement in the number of students intending to take a HIV test (RR 1.24, 95% CI 0.75 to 2.05) and a negative effect on the number of peer educators intending to take a HIV test (RR 0.62, 95% CI 0.41 to 0.95). A study in South Africa162 found positive effects of the peer education programme on intentions in two of the three included prisons, both in the short term and 3–6 months after release (Figure 5).

FIGURE 5.

Effect of peer education on intentions in three South African prisons.

In a chi-squared comparison of pre-project and post-project assessments,130 responses to two items on the AIDS Risk Reduction Model questionnaire approached significance with regard to an increase in knowledge of their participation in high-risk behaviours [χ² (10, N = 69) = 16.533, p = 0.08], but did not show any evidence of a commitment to change their behaviours [χ² (10, N = 69) = 10.934, p = 0.36].

Analysis of intentions by ethnicity in one RCT123 appears to show that peer education has the most effect on white prisoners (Figures 6 and 7).

FIGURE 6.

Intention to ever use condoms (by ethnicity).

FIGURE 7.

Intention to always use condoms (by ethnicity).

Attitudes/beliefs

Four studies131,134,158,162 contained quantitative data on the effects of peer education on prisoner attitudes. No changes were seen in prisoner attitudes after peer education in one study131 whereas in another study158 improvements were seen in the number of prisoners agreeing to all three of the following statements: ‘HIV-positive inmates should be separated’ (RR 2.55, 95% CI 1.94 to 3.33), ‘I feel safe in the same wing as an inmate who is HIV positive’ (RR 0.74, 95% CI 0.68 to 0.84) and ‘I know enough to protect myself from catching HIV/AIDS’ (RR 0.54, 95% CI 0.50 to 0.59). The South African study162 showed no changes in attitude after peer education.

Behaviour

In total, 11 studies23,27,101,106,125,126,129,134,144,160,162 contained quantitative data on the effects of peer education on behaviour.

Figure 8 shows positive effects on/reductions in the following behaviours after peer education: not using a condom at first intercourse after release from prison (RR 0.73, 95% CI 0.61 to 0.88; two studies, n = 400), injecting drugs after release from prison (RR 0.66, 95% CI 0.53 to 0.82; two studies, n = 400), injected drugs in the past 4 weeks (RR 0.11, 95% CI 0.01 to 0.85; one study, n = 241), sharing injection equipment after release from prison (RR 0.33, 95% CI 0.20 to 0.54; two studies, n = 400) and peer educators never having had an HIV test (RR 0.31, 95% CI 0.12 to 0.78; one study, n = 847).

FIGURE 8.

Effects of peer education on behaviour: binary outcome.

One study160 also reported that the prevalence of tattooing in a prison in the Russian Federation significantly decreased over the study period (42% vs. 19%, p = 0.03) and of those who were tattooed the proportion using a new needle increased from 23% to 50%.

Positive effects on behaviour were seen in all three studies in which behaviour was measured on a scale,106,134,162 although in the South African study162 positive effects were seen only in the longer term and only in prisoners from two of the three prisons that received the intervention (Figure 9).

FIGURE 9.

Effects of peer education on behaviour: scale outcomes.

One study106 reported that older prisoners were more likely than younger prisoners to engage in peer education behaviour (p < 0.05).

One study125 presented adjusted odds ratios (ORs) for voluntary peer-led policy. Having HIV tests in prison was associated with having attended a HIV prevention programme while in the study prison (OR = 2.81, 95% CI 1.09 to 7.24). The rate of HIV testing was significantly lower in the prison in which HIV testing was offered after a peer-led health education programme at intake (peer led, voluntary 46%, medical, voluntary 86%, mandatory 78%, p = 0.05).

One study144 found that the number of under-25s being screened for chlamydia rose from 13 to 83 in the 6-month period after beginning a peer education intervention. Similarly, the number being screened for hepatitis C increased from 9 to 46 and it was also stated that more participants were screened for HIV and underwent hepatitis B vaccination, although these numbers were not reported. Conversely, the number declining hepatitis C screening rose from 13 to 115.

The study on parenting skills129 found statistically significant improvements in father/child contact (Figure 10), particularly in terms of the total contact with children per year (MD 41.3, 95% CI 6.47 to 76.13), although this was not supported by data from caregivers (Figure 11).

FIGURE 10.

Effects of peer education on father/child contact.

FIGURE 11.

Effects of peer education on father/child contact: data from caregivers.

Self-efficacy/locus of control

One study162 reported quantitative data on the effects of peer education on self-efficacy. No significant differences were seen in the short or longer term in any of the three prisons involved.

Mental health

The study of parenting skills also measured anger and frustration and found no effect of the intervention on these outcomes, either immediately post intervention (MD 0.20, 95% CI –1.42 to 1.82) or at longer follow-up (MD 1.40, 95% CI –0.03 to 2.83).

Teacher preference

In the South African study162 both HIV-negative and HIV-positive peer educators were used. In the short term no statistically significant differences were found between the group taught by HIV-negative educators and the group taught by HIV-positive educators except for the knowledge variable in one prison (p < 0.01). In the longer term the group with the HIV-negative peer educators had higher average scores than both the HIV-positive peer educator group and the control group for both attitudes towards condom use and sexual communication.

In an American RCT123 there was a strong preference among inmates for being taught by a HIV-positive inmate rather than by an HIV/AIDS (professional) educator. This was most marked in the group who had received education from a peer (68% preferred to be taught by an inmate with HIV and 11% preferred to be taught by a HIV/AIDS educator).

Additional themes from qualitative evidence

Qualitative evidence suggested that prisoners involved in delivering peer education programmes had gained from the experience of being a peer deliverer and found the experience personally rewarding, giving their time in prison meaning and purpose. 121,131 In one study129 this included improved listening and communication skills as a result of their participation. Collica’s121 research suggested that being a peer educator also enabled the difficulties of prison life to be offset through the supportive network of other trained peer educators. There were indications that prisoners involved in the AIDS, Counselling & Education (ACE) programme saw other trained prisoners in the programme as a pseudo-family who could be utilised in time of crises:

We were very close, tight knit. I looked upon many of them as an extended family. Early on, most of us were long termers and we were at the beginning of our sentences. ACE was a safe place to go to share our struggles together.

p. 328121

Self-esteem/confidence

Three studies151,153,155 used the Rosenberg Self-Esteem Scale to measure prisoners’ self-esteem. No statistically significant effect of the peer intervention was seen when the findings from the three studies were pooled (weighted MD 1.51, 95% CI –0.84 to 3.86; three studies, n = 83), although the sample size was small and there was substantial heterogeneity (I² = 81%), meaning that the result should be treated with caution (Figure 12).

FIGURE 12.

Peer Support Team intervention: self-esteem.

Strong qualitative evidence was also apparent in relation to improvements in the peer deliverers’ self-esteem, self-worth and confidence as a result of the role. 38,151–154,156 The sense of being trusted by the prison authorities to counsel and support prisoners in distress was reported to enable peer deliverers to regain their self-respect. 25,152 The notion that peers became more empowered consequentially was alluded to. 151–153,155,156

Perceptions of the prison environment

The Correctional Environment Status Inventory assesses prisoners’ perceptions of the prison environment. Responses were measured before and after the PST intervention in three studies. 151,153,155 Domains assessed were staff involvement, staff treatment, staff cohesion, orientation and offender relationships. No statistically significant effect of the PST was seen in the pooled results of the three studies across any of the 16 questions asked.

Satisfaction

Two studies152,154 reported quantitative findings on satisfaction with the PST model; data were not suitable for meta-analysis. One study152 found that 81% of 35 respondents valued the existence of the PST even if they had never used a peer counsellor in a crisis situation. In this study the average rating for helpfulness of peer counsellors was 4 on a scale of 1–5.

The other study154 reported that inmates in the intake unit were very satisfied with the quality of the information delivered by PST members during their weekly visits (mean = 4.05 on a 5-point scale) and rated PST members highly in terms of their listening skills (mean = 4.58), problem-solving skills (mean = 3.94), approachability (mean = 4.56) and communication skills (mean = 4.22). Expectations of the PST were also well met (mean = 4.28) and those who had previously requested peer support reported that the sessions were very useful (mean = 4.43) in helping them deal with their issues.

Staff reported that PST members were effective in handling crisis interventions (mean = 4.00), providing services to inmates (mean = 3.62) and serving as role models (mean = 3.73). It was also felt that the PST programme training was efficient in preparing PST members for PST duties (mean = 3.77) and in reinforcing the positive effects of other programmes for PST members (mean = 3.62) and for other inmates (mean = 3.62). Staff were moderately satisfied with the sharing of PST procedures (mean = 3.62) and PST activities and schedules (mean = 3.58) with key institutional personnel.

Hours of support delivered per week

In one study154 PST members estimated that they provided 3–5 hours of support to others per week on average.

Time to response

In one study154 staff responded to inmate calls for peer support within 11–30 minutes and PST members were reported to respond within the same timescale.

Level of trust

In one study154 a fairly high level of trust in PST members was reported (mean = 3.79 on a 5-point scale) and staff generally felt confident in referring an inmate to a PST member. However, 75% of staff surveyed indicated that their trust level varied depending on individual PST members.

Knowledge

For prisoners trained to be peer support workers/counsellors, there were qualitative data from two studies151,153 that showed reported increases in knowledge. Indeed, in one of these studies151 a number of respondents noted that knowledge acquired from the training was applicable to improving relationships with their children, partners and others in the community.

Effects on recipients

As well as the impacts on the trained peer support workers/counsellors, there were indications of positive effects for the recipients of the intervention. Peer support was reported to have helped prisoners practically, emotionally or both151 and in one study140 it was demonstrated that this type of intervention could be particularly beneficial for prisoners during the early part of their sentence. Those who had used peer support reported using it as an avenue to vent and to overcome feelings of anxiety, loneliness, depression and self-injury151,152,156 and there were indications that this may be potentially beneficial in preventing suicides in prison. 38

One study indicated attitudinal and behaviour changes in the recipients of a peer counselling intervention. Player and Martin’s145 research showed that a drug treatment intervention (that included the support of trained prison counsellors) had caused changes in prisoners’ reported attitudes to drugs and alcohol. This translated to a self-reported reduction in drug and alcohol use. The one-to-one sessions with trained peer counsellors were regarded as the most ‘helpful aspect’ of the recovery process (p. 3).

Additional themes from qualitative research

In several studies25,151–153,156 there were indications of peer deliverers gaining a better self-awareness and perspective on their life as well as developing the skills to deal with their own health and offending issues. There was limited information on the impact that the role would have on future reoffending. Only in one study25 was it suggested that the experiences of being a peer support worker would be beneficial in reducing the likelihood of reoffending.

The demands placed on peer support workers/counsellors by other prisoners gave individuals a sense of purpose in prison25,38,149 and this was beneficial for combating boredom while serving the prison sentence. 25,38 However, there were indications that the role could be challenging and onerous and the burden of care of supporting many prisoners could be problematic. 38

Effects on listeners

An area in which there was strong qualitative evidence was for individual health gains for those trained as listeners or befrienders. Trained individuals reported that they were ‘giving something back’, doing something constructive with their time in prison and being of benefit to the system; this consequently had an effect on their self-esteem, self-worth and confidence. 25,31,32,36,137,138 The study by Dhaliwal and Harrower137 also demonstrated individual changes in those trained in the listener role. Being less judgemental and changing attitudes and behaviour towards help-seeking within the prison (i.e. from regarding it as a display of weakness to seeing it as a sensible coping strategy) were discussed. Moreover, having enhanced skills as a result of being a peer deliverer, such as better listening and communication skills, was mentioned by two studies137,138 and there was evidence that prisoners felt able to put these skills into practice on release from the institution. 137

There were some negative health effects reported in some studies31,137,138,146 and these related to the emotional burden of listening to other prisoners’ problems and issues. Discussions relating to suicidal intentions and other distressing topics could be particularly burdensome for peer deliverers to manage, as exemplified by this participant in Foster’s study138 of listeners:

And that is quite challenging being a Listener and listening to someone who for instance his radio is telling him to have sex with it and stuff like that. . . . we’re in there for twenty minutes listening to them and some of the things they do come out with, it can quite affect you.

p. 22

There were also reports of peer deliverers experiencing ‘burnout’ and mental exhaustion as a result of the demands placed on their time by other prisoners. 138,146

In one quantitative study146 64% of 22 prisoners claimed that, by becoming a listener, friends and family had noticed a difference in their demeanour, finding them more relaxed, responsible and optimistic, able to speak more and more able to listen. In total, 73% agreed that their new responsibilities would allow them to ‘adjust better’ on release and 55% agreed that the ‘prison authorities’ appreciated their work. In addition, 77% said that there was a difference in how immediate staff interacted with them (being trusted more, staff talking more to them, staff being grateful for the work they do) and 86% said that fellow prisoners behaved differently towards them.

Perceived benefits for service users

One of the over-riding issues to emerge from the qualitative studies31,36,138 is the reported impact that trained peers have on reducing depression and anxiety in distressed prisoners and improving their mental state. For example, prisoners interviewed in Foster’s138 comprehensive study of the Listener scheme suggested that, through talking to a trained peer, they had the opportunity to vent their frustration and anxieties and this was reported to have a calming and uplifting effect, making it much less likely that they would become violent towards themselves. Health-care professionals also acknowledged the role of listeners in improving the emotional health of prisoners.

Two of the qualitative studies that focused on the Listener scheme31,138 provide anecdotal evidence that suicide and self-harm are reduced as a result of the support offered by peers acting in this role. A similar intervention model implemented in southern Alberta (SAMS in the Pen)36 also shows the importance of the service not only for addressing suicide but also for helping those who are depressed, who are feeling alone, who are suffering from a loss, who have received bad news from outside or who are having problems adjusting to the institution. Indeed, this study showed evidence that trained prisoners had increased their knowledge of suicide and depression and had become better able to identify suicide risk in other people. 36

In terms of perceived benefit, a quantitative study37 found that 44% of users of the Listener scheme reported that they always felt better after confiding in a listener and 52% felt better at least sometimes. Furthermore, 84% said that they had always found the experience helpful (data collected from 28 users of the Listener scheme and 44 non-users).

Approachability and availability of listeners

In one study37 61% of those surveyed said that they could talk to a listener about anything that was worrying them and 74% had no problems contacting a listener when they had requested help.

Future use of the Listener scheme

One study37 reported that 57% of users thought that they would seek the help of a listener if they faced a similar problem in the future. This was taken to be an indication that they were satisfied with the support that they had received.

Adherence

At 3 months, 38/44 participants (86%) were receiving outpatient psychiatric services and 40/44 (91%) were successfully managing their medication. At 6 months, 36/44 participants (82%) were medication compliant and 35/44 (80%) demonstrated symptom reduction. In total, 12/44 (27%) had not maintained sobriety at the 6-month time point. 122

Reoffending

In the study by Goldstein and colleagues,122 17/22 (77%) participants released for at least 12 months had not been rearrested.

A qualitative evaluation study of Routes out of Prison, which uses life coaches (many of whom were ex-offenders), showed positive effects on recipients’ propensity to reoffend. Many attributed this change in attitude and behaviour to the relationship developed with the life coach and viewing the life coach as a credible role model. 147

Behaviour

In total, 16/22 participants (73%) in the study by Goldstein and colleagues122 who had been released for at least 12 months were abstinent in the use of alcohol or illegal drugs or the misuse of prescription drugs.

Employment

In total, 16/22 (73%) participants in the study by Goldstein and colleagues122 who had been released for at least 12 months were employed, were enrolled in an educational programme or had completed the application process for disability benefits.

Housing

In the study by Goldstein and colleagues,122 18/22 (82%) participants who had been released for at least 12 months had secured treatment, transitional housing or a permanent place to live.

Confidence

Health trainers seemed most confident in signposting to exercise, smoking cessation and drugs services and least confident in signposting to self-harm, immunisation and dental services (Table 6). 136

From qualitative research it was evident that training as a health trainer had been a huge boost to prisoners’ confidence, self-esteem and self-worth,136 although this was not specifically reported by prisoners themselves but by key staff involved in the programme. There was, however, evidence of health trainers bolstering other prisoners’ reported self-esteem and confidence through listening and supporting individuals. 136

Knowledge

Two qualitative studies showed that the health trainer training programme appeared to have successfully increased individuals’ knowledge on a variety of topics, including drugs, sexual health, nutrition, alcohol and mental health issues. 136 Attitudinal change, often as a result of increased knowledge, was seen primarily in the area of smoking and diet136 and this resulted in behavioural changes. 136,148 For example, health trainers reported eating more fruit and vegetables and one health trainer had given up smoking. 136,148

Improvements were seen in mean knowledge scores in all areas in one study136 but it was not possible to ascertain whether or not these improvements were statistically significant as no measure of variance was given.

Attitudes

In one study136 > 50% of health trainers stated that their attitude had changed in the areas of healthy eating/diet, sexual health, smoking cessation, exercise and mental health. In total, 75% of health trainers stated that they would like to get a job as a health trainer on release from prison.

Prisoner outcomes: issues discussed with health trainers

Issues most likely to be discussed with health trainers were reported in one study136 to be exercise, weight and healthy eating (Table 7).

Onward referrals

Health trainers in one study136 were most likely to refer clients to gym staff or health-care staff (Table 8). Referrals were also made to Counselling, Assessment, Referral, Advice and Throughcare Services (CARATS), counsellors, dentists and opticians.

In total, 75% of clients stated that they would like another appointment with a health trainer. 136

Additional themes from qualitative research

Two qualitative studies examined health trainers in prisons. 136,148 Both studies had evidence of increased health knowledge and attitudinal and behavioural change in prisoners, although this was more frequently reported for the health trainers than for the recipients of the programme.

Participants suggested that the skills developed in the health trainer role were applicable outside of the prison context and could be transferable to the community. Both health trainers and health trainer tutors reported that health trainers had developed effective communication and listening skills as well as fostering attributes essential for team working and future employment after release from prison. 136 It was reported that, for those prisoners who completed the health trainer course, the recognised qualification that they attained could support efforts to find employment as a health trainer post release. 136

Peer observers

The impact of peer observers was examined in one study as part of a suicide prevention initiative. 124 Peer observers observed prisoners who were on suicide watch, that is, at risk of suicide. They undertook active listening but the role did not involve counselling.

This quantitative controlled study124 found a statistically significant decrease [t (71.55) = 2.14, p = 0.036] in the mean number of hours on watch following the implementation of the Inmate Observer Program.

No studies presented qualitative evidence on peer observers.

Peer training (violence)

The Alternatives to Violence Project (AVP) involves prisoners training and then facilitating training on conflict resolution techniques with young offenders. The project includes a formal five-step programme: basic training, advanced training, training for trainers, facilitation and management council membership. 132 Although it involves peer education in terms of using a cascade training model, it entails a high degree of involvement and is described as ‘inmate run’.

One non-randomised controlled before-and-after study presented quantitative data on the effects of the AVP intervention on prisoner health. 132 No statistically significant effect of the intervention was seen on anger (MD –4.01, 95% CI –9.40 to 1.38), measured with the Anger Expression Scale.

Small but statistically significant negative effects of the interventions were seen on self-esteem (MD –2.15, 95% CI –4.20 to –0.10), measured with the Rosenberg Self-Esteem Scale but not on optimism (MD 1.30, 95% CI –0.83 to 3.43), measured with the life orientation text.

In terms of behaviour, the incidence rate ratio for the number of confrontations post intervention, controlling for the number of confrontations pre intervention, was statistically significantly reduced at 0.432 (95% CI 0.319 to 0.583, p < 0.0005).

No studies presented qualitative data on peer training.

Peer outreach (harm reduction)

No included studies presented quantitative evidence on peer outreach.

A harm reduction programme in Moldovan prisons involved peer volunteers in distributing condoms, supplies for needle exchange and information booklets to fellow prisoners. 163 This qualitative study suggested that peer volunteers felt that their role was worthwhile and that they were making a difference to the health of the prison population. 163

Peer advisors (housing)

Peer advisors provide housing advice to fellow prisoners within prisons, particularly new prisoners and those planning for resettlement. Some peer advisors support prisoners ‘through the gate’.

No studies presented quantitative evidence on peer advisors. Two studies135,139 presented qualitative data on a peer-delivered housing advice service to support prisoners in keeping their accommodation whilst imprisoned. The studies reported the difference that the intervention had made to the trained peer advisors with regard to increased self-esteem and self-confidence through activities such as talking on the telephone with housing agencies or liaising with staff from prison and probation teams. This was coupled with peer deliverers reporting that they were building a work ethic and a sense of control over their lives. The role was perceived by the volunteers to be worthwhile and purposeful as well as enabling social interaction with others and offering ‘structure’ to the prison day:139

I just thought it would be a good thing to do especially in prison because there’s some pretty dead end jobs in prison . . . all the other jobs, cleaning and working in the laundry or in the store, you’re not doing anything really. You’re just passing the time. But with the peer advising job, I personally felt that I was helping and it was helping other people.

p. 123139

There was qualitative evidence to suggest that the peer advisor role provided ‘real-world’ employment skills and this was regarded as being beneficial for future employment opportunities. However, both studies alluded to the difficulties that trained peer advisors could face on release from prison as a result of their status as ex-offenders. 135,139

Peer support and counselling

One study161 looked at the effects of peer support (Narcotics Anonymous meetings) and counselling (12-step programme) compared with peer support alone (Narcotics Anonymous meetings only) on mental health, namely coherence, meaning in life, anxiety, depression and hostility. Improvements with the combined interventions were seen for all outcomes (coherence: MD –0.31, 95% CI –0.48 to –0.14; meaning in life: MD –0.42, 95% CI –0.65 to –0.19; anxiety: MD –0.42, 95% CI –0.66 to –0.18; depression: MD –0.35, 95% CI –0.52 to –0.18; hostility: MD –0.11, 95% CI –0.18 to –0.04).

Peer education

The evidence suggests that peer education can improve knowledge of HIV (although outcome measures need to be standardised) and literacy. Improved attitudes were seen in one of three peer education studies reporting this outcome. Improved intentions to use condoms after peer education were seen in one RCT but this was not reproduced in another study. Nevertheless, evidence from 11 studies showed positive effects on behaviour, including condom use, screening for STIs, safer injecting and tattooing behaviour and increased parental contact. Although one quantitative study showed no effect on self-esteem, strong qualitative evidence reported that peer deliverers found the role rewarding – it improved their skills, gave their time in prison meaning and purpose and provided a supportive network. In one study prisoners preferred to be taught by a HIV-positive peer than a professional; in another, prisoners scored higher on knowledge tests with a HIV-negative peer educator than with a HIV-positive peer educator or a professional.

Peer support

There was strong evidence from qualitative studies that the peer support role led to increased self-esteem (although this was not seen when measured quantitatively), increased knowledge and improvements in wider relationships. No effect of the PST model was seen on perceptions of the prison environment, but two studies indicated that prisoners were satisfied with peer support interventions. Several qualitative studies also contributed evidence that peer deliverers gained a better self-awareness and perspective on their lives, and a sense of purpose inside prison, as well as developing the skills to deal with their own health and offending issues. However, the role could be challenging and burdensome.

Listeners

There was evidence to suggest that listeners had improved self-esteem, self-worth and confidence. Other positive effects included enhanced listening and communication skills, which prisoners felt they could also use on release from prison, improved relationships with staff and changing attitudes and behaviour towards help seeking in the prison. There was good evidence from qualitative studies that listeners were able to reduce levels of depression and anxiety in distressed prisoners and improve their mental state. There was a suggestion that suicide and self-harm were reduced as a result of listener support, perhaps through listeners being better able to identify suicide risk in other people. Negative effects reported were the emotional burden on listeners.

Prisoner hospice volunteers

Qualitative evidence suggested that volunteers experienced increases in self-esteem and self-worth, an enhanced sense of compassion for other people and a sense of ‘giving something back’. Recipients felt supported and some had been enabled to overcome depression.

Peer mentoring

Positive effects of peer mentoring were seen on reoffending, medication adherence, misuse of drugs, employment and housing.

Health trainers

Improvements in health trainers’ self-esteem, self-worth and confidence were noted by staff, whereas recipients’ self-esteem and confidence were boosted by being supported by health trainers. Health trainers were confident in signposting to prison services. Improvements in knowledge and attitudes were noted, although more frequently for the health trainers than for the recipients.

Communication and listening skills developed by health trainers were thought to be potentially transferable to future employment on release from prison.

Peer observers

The only outcome reported for peer observers was a decrease in the number of hours on suicide watch.

Peer training

No effect of peer training on anger levels was seen but there was evidence of a reduction in confrontations. Small reductions were seen in self-esteem and optimism over the course of the evaluation.

Peer outreach

Peer volunteers felt that their role was worthwhile and that they were making a difference to the health of prisoners.

Peer advisors

There was evidence of increased self-esteem and self-confidence in peer advisors. Peer advisors reported building a work ethic and sense of control over their lives and the peer advisor role was seen as worthwhile and purposeful and offering ‘structure’ to the prison day.

Peer support and counselling

In one study peer counselling (12-step programme) combined with peer support (Narcotics Anonymous meetings) led to improvements in mental health over and above those seen in the Narcotics Anonymous meetings-only group.

Intentions

One study123 found no significant difference between peer-led and professional-led groups for the outcome of intention to use a condom (RR 1.00, 95% CI 0.96 to 1.04) and intention to never use a condom (RR 0.99, 95% CI 0.79 to 1.24) (Figure 13). When intention to use a condom was broken down by ethnicity, no significant differences were seen between groups taught by peers and groups taught by professionals except for African American men’s intention to always use a condom, which was statistically significantly greater in the peer-led than in the professional-led group (RR 1.12, 95% CI 1.01 to 1.24).

FIGURE 13.

Intentions: peer-led vs. professional-led groups.

Intention to use bleach (for injecting drug users) in the same study123 was not statistically significantly different between peer-led and professional-led groups (RR 1.01, 95% CI 0.96 to 1.05), nor was interest in taking a HIV test for the first time (RR 1.00, 95% CI 0.80 to 1.25) and interest in taking a HIV test ‘now’ (RR 1.02, 95% CI 0.82 to 1.27) (see Figure 13).

Preference for teacher

In an American RCT on HIV123 there was a strong preference among inmates for being taught by a HIV-positive inmate rather than an HIV/AIDS (professional) educator. This was most marked in the group who had received education from a peer (68% preferred to be taught by a HIV-positive inmate and 11% preferred to be taught by a HIV/AIDS educator).

Behaviour

One RCT126 compared ‘standard practice’ HIV education with a peer education DVD and found that peer education did have a positive effect on condom use but the effect was not statistically significant (RR 0.71, 95% CI 0.50 to 1.02).

Knowledge

Mean scores for HIV knowledge in one RCT123 were 8.1 in the peer-led group and 8.3 in the professional-led group, but it was not possible to ascertain whether or not there was a statistically significant difference between groups as no measure of variance was provided. The study authors did not report a statistically significant difference between groups using the chi-squared test.

Number of hours on suicide watch

The study of the impact of using peer observers for suicide watch124 reported a significant decrease in the mean number of hours that inmates remained on watch following the implementation of the Inmate Observer Program, from 108.88 hours (SD 126.06 hours) using staff observers to 64.05 hours (SD 59.82 hours) using inmate observers (p = 0.036). On subgroup analysis it was found that this effect was seen only in individuals with a psychotic diagnosis (p = 0.001).

It was also reported that the number of suicide watches dropped by 31.25%, from 48 in the 12 weeks pre Inmate Observer Program to 33 in the 12 weeks post Inmate Observer Program; however, this difference was not found to be statistically significant (p = 0.096).

It was also reported that there was a significant reduction in the number of people with personality disorders placed on suicide watch following the implementation of the Inmate Observer Program (25 vs. 12, p = 0.033), although the reasons for this were unclear.

The integration of peer interventions into the prison setting

In some cases the integration of peer interventions in prison was inhibited by an element of resistance from prison staff. 31,40,131,135,155,156,163 This could include delays in unlocking peer deliverers or other problems concerning prisoner movement around the institution. 143 In one study25 staff were particularly resistant to the confidentiality protocol deployed by prison listeners, which staff suggested made the institution less safe. In another study145 it was reported that staff felt that the peer intervention, which involved the presence of ex-offenders, caused security issues. In three studies31,131,135 initial staff resistance did later recede after recognition of the valuable service provided by peers.

The difficulties of integrating peer interventions within prisons that hold sex offenders within a vulnerable prisoner unit was noted in two studies. 25,138

The contribution of peers to the wider prison workforce and service delivery

In 10 studies25,31,38,128,135,138–140,155,156 reference was made to the way that prisoners in peer delivery roles can divert demand from paid staff and potentially allow staff time to be deployed elsewhere to conduct other duties: ‘Once officers see it working, they see that it takes a lot of pressure off them. They know they can send prisoners to talk to the peer advisors, so the officers benefit’ (p. 45). 25

Moreover, in four studies38,137,155,156 peers were seen as acting as mediators between the prison population and staff, often creating more effective communication processes, and in one further study136 health trainers reported filling a gap in service provision in terms of offering advice to improve prisoners’ self-esteem and to help with stress management and coping with a prison sentence.

Peer interventions contributing to prison performance targets

In one study of health trainers in prisons136 there was a suggestion that the intervention could be contributing to addressing the prisons’ key performance indicators and targets. These targets included time purposefully active outside of the cell, reducing self-inflicted injuries, reducing suicides, reducing the number of serious assaults and ensuring that prisoners have a job, training or education outcome on release. It was acknowledged in several studies that measuring these kinds of effects is problematic,25,26,135,136 but Hall and Gabor36 reported that in the 5 years before the SAMS in the Pen intervention began there were four completed suicides (rate 131.0/100,000), which reduced to two (rate 65.5/100,000) in the next 5 years (while the intervention was in place). There were a further two suicides in the next 2 years (rate 164.9/100,000) after the intervention had finished.

Power and risk

Peer deliverers were often seen as being in positions of trust and power and often had close relationships with staff. Because of this, two studies suggested that peer deliverers were often susceptible to criticism and abuse from other prisoners by virtue of their role and their alignment to staff. 146,151

Eleven studies25,31,36,135,136,138,148,151,153,155,156 described either possible opportunities that prisoners in peer delivery roles had to abuse their position of trust or actual instances when they had abused their position of trust. The distribution of drugs, tobacco and mobile telephones was reported as a primary concern as peer deliverers often had enhanced freedom and access around the institution. 25,31,36,135,138,155 In three studies36,38,135 these security threats had an effect on how interventions were managed and delivered. In three studies25,31,135 the challenge for prison staff of facilitating peer interventions and managing risks at the same time was noted, emphasised here by a participant in the study by Davies:31 ‘Every now and again people are going to become Listeners for the wrong reasons, and they will get involved in drug trafficking. I see that as an acceptable risk in the whole business’ (p. 130).

Impact on prison ethos and culture

In three studies25,135,136 there was evidence that peer interventions were providing more fulfilling work opportunities within the prison setting, offering individuals the chance to gain real-world skills and, in some instances, qualifications. This was in stark contrast to other prison work such as cleaning or working in the laundry room. One prisoner in the study by Boyce and colleagues135 commented:

I just thought it would be a good thing to do especially in prison because there’s some pretty dead end jobs in prisons . . . all the other jobs, cleaning and working in the laundry or in the store, you’re not doing anything really. You’re just passing the time. But with the peer advising job, I personally felt that I was helping and it was helping other people.

p. 13

The positive impact on institutional culture and ethos of peer interventions being delivered within prison settings was reported in seven studies. 25,31,40,133,138,151,156 This impact included creating a more caring and humane atmosphere; peer deliverers being able to diffuse volatile situations, preventing the escalation of minor problems into potentially serious disorder; and creating more cohesion between staff and prisoners. The introduction of a peer-led hospice programme was regarded as providing a transformative impact on the institutional climate. 133 Two studies,136,153 however, suggested that peer interventions had very little impact (positive or negative) on the prison regime.

Commentary

There is a growing body of economic evidence which suggests that correctional interventions show economic benefits that often exceed the economic costs. 172 Economic studies in this field consistently find robust results related to the positive net economic benefits of crime reduction (i.e. avoided incarceration and victimisation costs). A recent review of pre-release substance abuse treatment programmes concluded that ‘in-prison treatment can be both effective and cost-effective in reducing recidivism, possibly with greatest impact for the most serious offenders. Moreover, in-prison treatment coupled with aftercare in the community returns the greatest clinical and economic outcomes’ (p. 40). 172 However, such studies were outside the scope of this systematic review given that the remit of the study was peer-based interventions to improve and maintain health in prisons and YOIs rather than a focus on recidivism per se. Similarly, the majority of correctional interventions were delivered by trained professionals not peers and therefore did not meet the said remit.

One of the most widely applied treatment models for substance misuse is the TC. The informal measures of social control, as promoted through the group processes and peer-to-peer confrontation, are believed to promote prosocial attitudes and behaviour. 173 Many studies attest to the effectiveness of prison-based TC programmes in reducing recidivism and drug use among participants. 174 Although the effectiveness review excluded TCs post hoc, for the cost-effectiveness review the decision was made to include TC programmes, in part because of the paucity of cost-effectiveness data and given the importance placed on the role of peers in TCs. It is noteworthy that the role of community care and follow-up after release does seem to have a large influence on the results of evaluations of TCs. McCollister and colleagues175 found ‘that offenders who participated in prison-based TC treatment followed by community aftercare had better outcomes than those who received no treatment or that received prison-based treatment alone’ (p. 406). 175

The cost analysis included in this review attempts to contribute to an understanding of whether or not a therapeutic environments result in lower management costs as a result of improved prisoner behaviour. Although the study does not explicitly refer to health outcomes, this is implicit in both the raison d’être of the TC and the body of evidence cited by the authors, which points to reduced drug use among TC participants together with potential costs savings that could offset the cost of the TC programme. Zhang and colleagues171 are interested in the shorter-term benefits – the impact on disruptive behaviour, prisoner–staff conflict and management costs – which appear to be a more neglected area of research. They highlight a previous study176 which found that a TC environment was thought to promote fewer inmate disciplinary problems. Although the intervention was described, clarity on the anticipated health outcome(s) would have been useful. Indeed, there was no clear statement of the aim of the TC under investigation in this study.

The study in this review uses three indicators or proxies for disruptive behaviour: infractions, grievances and major incidents. All of these appear to be reasonable; however, further discussion around why they were chosen would have been beneficial. The source of measurement and valuation of the costs for the first two indicators are presented but for major incidents no costs are assigned because of a lack of appropriate data. The authors also acknowledge that there are important areas of cost that have not been captured within this analysis, particularly health-care costs resulting from inmate-on-inmate violence.

The results are presented in a disaggregated manner that lacks clarity. It is difficult to draw conclusions from, for example, the total savings accrued from fewer infractions and grievances compared with the apportioned total cost of provision of the TC programme. It would have been useful if the costs savings had been compared directly with the cost of providing the TC programme, albeit this is referred to briefly in the discussion, in which the authors highlight that the savings are relatively small in the context of the overall TC cost. In addition, no statistical comparisons are undertaken.

The authors mention that costs such as staff bonuses were not included and, although they control for characteristics associated with disruptive behaviour (demographics), the issue of uncertainty in their estimates was not addressed. There is, however, a short discussion regarding bias. The authors point to the greater proportion of serious infractions in the TC group. The explanation for this may lie in the more confrontational environment of the TC but the authors also suggest that this might be influenced by the extra surveillance by trained counsellors in the TC. Further research would be needed to explore the dynamics between staff and inmates in the TC yard and their impact on inmate misconduct, or to tease out whether or not the observed differences in prison infractions were due to increased staff surveillance.

Overall, the study included in the review is limited in its generalisability as the costs and resources are likely to be specific to a specialist US facility setting and funding model. The study is set in a dedicated substance abuse facility rather than a ‘general’ prison and there may be economies of scale associated with this. Similarly, the TC programme was provided by two large not-for-profit health-care providers specialising in addiction, which might not be available in other settings.

The population covered may also be context specific. For example, the TC programme itself was not rolled out across all categories of prisoners (only those classified at level II). In addition, the race/ethnicity of participants is likely to differ from the race/ethnicity of the prison population in the UK.

Aim

The economic model aimed to establish the cost-effectiveness of a peer-led educational intervention compared with two relevant alternatives, a ‘do nothing’ (no intervention) scenario and a professionally led educational intervention, to prevent future HIV infections among offenders in prison settings and their partners when they are released from prison.

The structure of the model is informed by the results of a literature review of cost-effectiveness models of HIV prevention interventions. This review differs to the review reported in Chapter 8 as it includes economic models of the prevention of HIV transmission in various settings.

One-way sensitivity analysis and probabilistic sensitivity analysis

It is important to highlight that the findings of the model might be surrounded by considerable uncertainty because of the quality of the data that populated it. We conducted a one-way sensitivity analysis to examine how costs saved and QALY loss averted change over a range of values for each parameter. When available, the range was identified using the CIs of the parameters (e.g. HIV prevalence at population level and QALYs); in other cases ranges were chosen as appropriate.

The uncertainty surrounding the cost-effectiveness dominance of the peer-led intervention compared with the two alternatives was also explored using PSA. We made probabilistic all of the parameters for which it was possible to assign a probabilistic distribution. The model was run for 1000 iterations with values sampled from the probability distributions assigned to each parameter.

Sampling strategy

The process of sampling experts to contribute to the symposium comprised two stages. In the first stage direct contact was made with individuals with known expertise in policy or practice and/or with academic expertise concerning peer interventions in prison. A list of possible experts was drawn up through the contacts made through the systematic review of literature, through personal contacts and through individuals identified by the project steering and advisory group. This approach followed what Patton233 describes as ‘critical case sampling’ whereby critical cases are selected as they offer particularly important insights or knowledge on the issue being studied. Experts were targeted from different fields including prison health services, NOMS, academic research and third-sector organisations.

The second phase of the sampling strategy consisted of contacting experts through e-mail networks, websites and organisations. Those individuals who responded were asked to express their interest in participating and to then complete a proforma that asked participants to briefly indicate their particular expertise. The final sample was drawn up in consultation with the research team and steering group with the aim of purposively selecting individuals who could provide expert insight into peer-based interventions in prison. The invited experts represented a variety of organisations including NOMS, the NHS, CLINKS, User Voice and the Shannon Trust as well as academic institutions. A small number of ex-prisoners from organisations representing service users participated as lay experts. A total of 58 delegates (including 16 members of the research team and partners) were present at the expert symposium.

Process

During the symposium, four keynote presentations were delivered with the aim of stimulating discussion and dialogue amongst the delegates around the key theme of the use and effectiveness of peers in prison to maintain and improve health. In between these presentations experts were divided into three separate discussion groups. The composition of each discussion group was formulated to ensure representation of individuals with various types of expertise. The groups were facilitated by members of the research team and participants were encouraged to discuss specific issues, drawing on expert opinion and experience, relating to two key questions:

1. What factors affect whether or not and how well peer-based interventions work in prison?

2. What are the positive and negative impacts of peer-based interventions for prisoners, the prison service, the NHS and NOMS?

The discussion groups were audio-recorded after permission had been gained from the participants. Individuals were assured that they would not be identified directly and no direct quotations would be used in the presentation of the emerging themes.

Data analysis

The verbatim transcripts of the discussion groups along with the accompanying notes were analysed using framework analysis. Framework analysis was considered an appropriate method given the applied nature of this element of the study and the emphasis on policy and practice. 234 The term ‘framework’ relates to the central part of the analytical process, that is, the development of a framework or matrix. Concepts and themes in the data are then summarised and charted in the matrix. The matrix was constructed using five main thematic categories and several subthemes. All of the data were charted and the final matrix and themes were agreed by members of the research team (JW, KK, JS). A narrative account summarising the themes was produced and this was checked for authenticity114 by symposium facilitators and note takers. A short accessible summary of the findings from the expert symposium was later produced. 235

Nature and types of peer intervention in UK practice

The expert symposium highlighted a variety of ways of involving prisoners (and ex-prisoners) in peer interventions and delegates discussed a plethora of peer schemes that they had either directly or indirectly experienced (Box 1). Delegates highlighted the distinctions between different peer models currently in operation. The nuances between ‘peer support’ (seen as a ‘passive’ intervention, i.e. listening) and ‘peer mentoring’ (regarded as an active role, i.e. advising, educating) were outlined by delegates and caution was raised about using such terms interchangeably.

Factors affecting whether or not and how well peer interventions work

Many experts spoke about the prison environment as a major factor in the success or otherwise of peer interventions. The need for interventions to be flexible with regard to contextual factors and the specific environment of the prison was critical for success. The variability of prison establishments in terms of governance (public vs. private prisons), function (remand, training, YOI, etc.) and security (category A, B, C or D, etc.) was consistently mentioned and the need for peer interventions to fit accordingly within those contexts was made clear. Prisoner ‘turnover’ was raised as a particular issue for remand prisons and those institutions serving the courts, resulting in these institutions facing difficulties in retaining trained peer workers (both volunteers and paid). Such contextual issues can affect the continuity of service provided, but delegates suggested that this may be mediated by placing ‘holds’ on prisoners, thus enabling peer workers to stay in post for longer. YOIs were also discussed as a specific environment that was not always conducive to peer-based models of delivery. Delegates noted how young offenders may not always be emotionally ready to mentor others and may lack the attributes required to be successful in this role, such as maturity and experience.

Effective recruitment, training and support processes were seen as prerequisites for successful peer interventions in prison settings. Key points of good practice identified by delegates are highlighted in Box 2.

Finally, delegates suggested that relationships at various levels, both within and outside the prison, were critical for effective peer-based interventions. These relationships are summarised below and represented diagrammatically in Figure 16.

1. Effective relationships are needed between peer workers (peer deliverers) and prisoners. Those in positions as peer workers must be seen as credible and trustworthy by other prisoners if an intervention is to work.

2. The relationships between peer workers and prison staff (uniformed and non-uniformed) are critical. Prison staff can make an intervention run smoothly by assisting with unlocking doors and escorting prisoners and generally managing the logistics of the intervention on the wing. When dedicated prison staff are appointed to oversee interventions, the likelihood of success is increased.

3. Institutional ‘buy-in’ and support from the governor in the prison is a major factor in whether or not peer interventions are successful. Progressive management teams inside the prison are needed for interventions to be established and flourish. Delegates suggested that interventions would be unsustainable and would struggle to have any level of success without this support.

4. When relationships are established with key organisations such as the POA and NHS, interventions are more likely to prosper.

FIGURE 16.

The importance of relationships for the sustainability and success of peer interventions in prison.

Expert views of positive and negative impacts

The positive and negative impacts of peer interventions for prisoners, the prison service and the NHS were discussed by delegates. There was a strong consensus that peer interventions in the prison setting make a positive contribution not only to the individuals concerned (i.e. mentor and mentee) but also to the overall culture and ethos of the prison. The positive and negative aspects of peer interventions in prison settings that were reported by the delegates are summarised in Boxes 3 and 4, respectively.

Expert views on costs

There was general agreement that peer-based interventions in prison are not cost free. Several delegates suggested that effective peer-based schemes often have dedicated resources, including staff time, to support the delivery of the service. Even without dedicated staff with this remit, peer-based interventions have implications for staffing in terms of unlocking and escorting prisoners. There was, however, a sense that peer interventions could be cost saving to the NHS and the prison service through improved health outcomes for prisoners and the potential for peers to absorb some of the duties that prison staff would otherwise have to undertake.

Scope of the review

The systematic review set out to examine the effects of peer-based interventions on prisoner health. Studies that reported non-health outcomes, such as reoffending, were included only if they reported health outcomes as well. The body of literature on the effects of peer interventions on reoffending and other non-health outcomes (such as housing and employment) is therefore not represented in this review. The review also did not examine the effects of non-prisoner volunteers on prisoner health, the effects of peer interventions in the probation service or the effects of staff-to-staff peer interventions, although there is a body of literature on each of these.

In total, 37 studies within the review were conducted outside the UK and therefore some caution is needed when considering the application of some of the findings to English and Welsh prisons. This may especially be the case when considering studies from countries such as Mozambique,164 where there are substantial variations in the way that the judicial and health systems operate. Indeed, others have described how the experience of prison does differ considerably country by country by virtue of cultural and historical influences. 236 However, there was a large proportion of studies included in the review that have high relevance for health services operating within prisons in England and Wales. For example, 20 studies included in the review came from the USA and, like the prison system in England and Wales, in the USA prisoners are categorised into institutions based on the gravity of their offence and level of risk. When information about a study institution was provided by authors, comparisons to the prison system in England and Wales could be made; however, these details were rarely given within the included studies.

Methodology

A decision was made to limit inclusion to studies published in 1985 or later as this is the date that the Listener scheme was introduced in the UK. Earlier studies might have included, for example, peer education interventions in the UK (which were not prominent in the search results) but, for pragmatic reasons of limited time and funding, this was a straightforward way to limit the search. Studies of interventions delivered by non-professionals and studies of prison health are not well indexed in electronic databases and early pilot searches returned impractically large numbers of hits. The searches were made more manageable by use of medical subject headings (or equivalents in other databases) and adjacent terms but this more specific search strategy may have lost some sensitivity and therefore it is possible that some relevant studies may have been missed. The cut-off date for inclusion of August 2012 may also have resulted in more recent relevant studies not being included in the review.

It was not possible to undertake much meta-analysis of the quantitative results because of clinical heterogeneity in the outcomes and interventions between the included studies. When meta-analysis was possible, often SDs or numbers of people in each group were not reported. When possible we imputed SDs using the method recommended in the Cochrane Handbook108 and, for one study, with two groups in three different prisons, we estimated the number in each group by dividing the total number of participants by six. These methods give numbers that can be used in the meta-analysis but are unlikely to be absolutely correct. If we had been able to pool more data we would have undertaken sensitivity analyses of the findings based on these imputed results to see whether or not removing these studies affected the overall result. However, as very few pooled-effect estimates were presented, we have instead indicated in the text when a result is based on imputed values and have advised caution in the interpretation of these findings.

The checklists chosen to assess the validity of the included studies have been widely used in previous systematic reviews but the quantitative checklist contained many items that were not relevant to non-randomised studies. Previous research has identified the lack of useful validity checklists for non-randomised studies. 237 There is debate over the correctness of using any checklist for the assessment of qualitative research;107 one of the reasons given is that decisions are subjective and there has been very low inter-rater reliability when empirical research has been carried out. 238

The approach taken to qualitative synthesis was decided after discussion with methodological experts in the UK and was based on finding a method that would best fit the type of data that we obtained, which was in many cases thin. However, the approach that we took to this, and the approach that we took to combining the qualitative and quantitative findings, were not the only approaches that could have been taken and, although we do not expect that the findings of this review would be substantially different had another approach been used, we cannot be sure of this.

Protocol changes

The large number of records retrieved from the electronic searches, in addition to the necessity of searching extensively for grey literature, meant that we did not have time to perform all of the searches listed in the protocol. Specifically, we did not check the reference lists of all excluded studies and we did not carry out citation searches on all included studies. A post hoc decision was made, after looking at the retrieved studies, to exclude studies of group therapy and of therapeutic communities, as these all seemed to be professionally led. We agreed to include studies of therapeutic communities if peer-to-peer interventions were mentioned in the abstract, but no studies met this criteria.

Developing a typology of peer-based interventions in prison settings

This study has confirmed that there is considerable heterogeneity in the range of peer-based interventions in the prison setting, in terms of both the health issues addressed and the mode of delivery (see Chapter 4). To group studies to review and summarise evidence it was necessary to develop a new categorisation of peer-based interventions in prison settings. The original role categories for community-based lay health workers developed through the People in Public Health study97 did not provide a good fit for the interventions described in studies included in this review, although some of the roles reflected dimensions identified in that study. For example, peer advisors, who provide housing and resettlement advice, demonstrated some aspects of bridging roles in terms of helping prisoners to access welfare services.

A new classification for peer interventions was developed that provided a better fit with the data (Table 15 and see Appendix 7).

The typology includes a number of intervention models that are currently operating in the prison system in England and Wales, including the Listener scheme, which covers most prisons in England and Wales, insiders, peer advisors and health trainers. The typology broadly reflects the range of peer support schemes identified by Levenson and Farrant32 in 2002 and Edgar and colleagues25 in 2011. The range of intervention types undoubtedly reflects the review strategy, with the inclusion of an expert symposium and the emphasis on identifying UK grey literature. A limitation is that these models may not be transferable to other contexts.

The final typology is not necessarily comprehensive. The review found that there are few standard models and there is much variation in intervention design, peer roles, recruitment, training and implementation. Some of the included studies reported that peers may undertake additional roles outside of the intervention. 38 Developing the classification inductively from reported definitions limits the extent to which we have been able to group interventions. For example, it can be argued that on a theoretical level peer mentoring is not a distinct intervention but is a form of peer support as it provides appraisal support. 94 However, for the purposes of the review the typology provided a useful framework and offers a basis for further analysis of intervention modes.

Review question 1: what are the effects of peer-based interventions on prisoner health?

Review question 2: what are the positive and negative impacts on health services in prison settings of delivering peer-based interventions?

A number of factors influencing the delivery and maintenance of peer-based interventions were identified in the review. Most of this evidence came from qualitative or mixed-method studies. The issues can be grouped into process issues, which are internal to the delivery of the intervention, and contextual factors, which are external to the intervention.

Review question 3: what is the effectiveness of peer delivery compared with professional delivery?

Overall, only a limited number of studies compared peer delivery with professional delivery and it was not possible to triangulate the quantitative and qualitative results as the qualitative evidence related only to prisoner preferences. However, there was consistent evidence across 10 qualitative studies that peer delivery was preferred to professional delivery, with cross-cutting themes including peer deliverers demonstrating empathy because of lived experiences, being non-judgemental, being trusted by prisoners and being able to offer more time than staff. Accessibility was also a theme, with prisoners feeling more at ease talking to peer deliverers. Results support the rationales advanced for lay involvement and peer support, which emphasise lay designation and the role of peers in connecting with the community of interest. 94,244,245 The review findings were confirmed by prisoners attending the listening exercises.

Reported preferences for peers in some studies could not be linked to the four quantitative studies in which a direct comparison was made, as the intervention modes were different. There was consistent evidence from four quantitative studies that peer educators were as effective as (but not more effective than) professional educators in the prevention of HIV transmission for all of the outcomes measured. Although the peer observer intervention showed some positive effects for peers compared with professionals, this was only one study about a single intervention and there is therefore insufficient evidence to draw any conclusions.

Review question 4: what is the cost-effectiveness of peer-based interventions in prison settings?

There were two components to the economic analysis in this study, namely the systematic review of economic evaluations of peer-based interventions in prison settings and the development of an economic model. Overall, there was a dearth of robust evidence on the cost-effectiveness of peer-based interventions to improve and maintain the health of prisoners, with little economic evaluation even of schemes with evidence of effectiveness. The systematic review of economic evaluations identified only one study that assessed cost-effectiveness and here the focus of analysis was costs rather than health outcomes. 171 Evidence from this study suggests that TC activities involving peers may help to reduce or control prison management costs; however, it is difficult to draw further conclusions based on a single study. The review points to the need for more and better-quality research to estimate the economic value of peer-based interventions in prison settings. Despite the limitations of current studies, economic analysis has high relevance to the prison system in England and Wales, and to the wider criminal justice system. The expert symposium highlighted a number of resource issues and the potential for cost savings from peer delivery.

The prison setting provides an ideal opportunity for education and prevention because of the high concentration of high-risk individuals. 123 Using the review findings and an additional literature review on economic modelling of the prevention of HIV infection, it was possible to develop a limited economic model that estimated the total number of cases of HIV infection averted by a peer-led intervention compared with a professionally led intervention and a ‘do nothing’ scenario. The results, although based on data of variable quality and a number of assumptions, indicate that both peer-led and professionally led interventions prevent HIV infections and are cost saving for all parameter values implemented in the sensitivity analyses. The peer-led intervention is dominant compared with the professionally led intervention for all parameter values implemented in the sensitivity analyses. The results are most sensitive to changes in the lifetime cost of HIV treatment and to changes in QALY estimates. The model has limitations because of the assumptions made about health behaviours and costs; nonetheless, it represents an important contribution to the evidence base on the cost-effectiveness of peer education.

Revised logic model

A preliminary logic model was developed to guide the study implementation, including development of the search strategy and the inclusion/exclusion criteria. 45 This linked the wider determinants of prison health, types of peer-based interventions, the mechanisms of change and likely outcomes, both intermediate and long term. 102 The study did not use a single theoretical framework as peer interventions have been linked to a range of different theories. Instead, the logic model was an attempt to draw together theoretical perspectives based on a social model of prison health and understandings of peer support.

The review results have been used to revise the logic model to provide a better fit with the quantitative and qualitative findings and expert evidence on contextual matters. Specific areas to be incorporated were:

• delivery to include voluntary and community sector organisations

• peer intervention modes to be changed to reflect the new typology of intervention modes

• outcomes identified through the review for peer deliverers cross-referenced to intervention modes

• outcomes identified through the review for the target population cross-referenced to intervention modes

• contextual relationships and the place of the intervention in the prison system – this should reflect the four overarching thematic categories derived from the qualitative synthesis: peer recruitment, training and support; prisoner relationships; organisational support; and prison life.

Two logic models were then developed based on the study findings. The first is the logic model for the effects of peer-based interventions on the prison population (Figure 17). This uses the same programme logic as in the original model but with the additions as described above. It explains how peer-based interventions work for service recipients or prisoners in general and what outcomes result. Outcomes have been grouped into (1) harm reduction outcomes focused on health behaviour change; (2) mental health and well-being outcomes relating both to the alleviation of individual mental health needs and to the development of positive mental health, for example better coping; and (3) improvements in social determinants, for example education, skills, housing and access to services, that enable individuals to exercise healthy choices. Outcomes at an organisational level are also represented and these are grouped into (4) the uptake of services and (5) improvements in the culture and ethos of the prison.

FIGURE 17.

Revised logic model for peer-based interventions in prison settings.

The logic model shows how the interventions link to intermediate outcomes and the possible links with long-term health goals. Figure 17 represents the different mechanisms of change but these are not explicitly linked to types of intervention mode as the review showed that peer interventions may be based on more than one mechanism of change, for example insiders provide both social support and improved access to other services. The logic model, together with the typology, will help in future research as it provides the basis for the generation of specific hypotheses to test the effectiveness of peer-based interventions using the most appropriate measures and can be matched, when appropriate, by the behaviour change technique taxonomy of Michie and colleagues. 246

The second logic model (Figure 18) was developed to reflect the strong evidence around the positive effect on peer deliverers and the need to account for the wider impacts on the prison system. The original logic model was based on the assumption that effects on peer deliverers were part of a linear intervention chain. The review results show that becoming a peer health worker is associated with a range of benefits to the individual, and broadly similar positive effects are reported across different intervention types. There was very little evidence making a direct link between the effects on peer deliverers and the effects on service recipients. The implications are that the development of peer deliverers needs to be considered as a distinct component of an intervention, requiring an additional, non-linear logic model. This logic model also needed to take account of the thematic categories derived from the qualitative synthesis and the finding that peer interventions could not be considered ‘stand-alone’ interventions as there were multiple interactions between peer interventions and aspects of the prison setting. The evidence indicated that features of the context could not be represented solely as modifying factors as peer-based interventions also impacted on the wider prison as an institution. The final model has been termed a health capacity logic model as it attempts to show the inter-relationships between developing individual capacity to act as a change agent and organisational capacity to create a supportive environment for that change. It also acknowledges that peer-based interventions are ultimately coconstructed with staff. The review findings are clear that both strands need to be considered in developing and implementing peer interventions in prison. The model can be used as a platform for developing research looking at the wider impact of prisoner involvement in prison settings, as well as for process evaluations.

FIGURE 18.

A health capacity logic model for peer-based interventions in prison settings.

MEDLINE(R) (OvidSP), 1946 to April Week 1 2012

1. prisons/ or concentration camps/ (7003)

2. Criminals/ (433)

3. Prisoners/ (10,890)

4. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*)).tw. (299)

5. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities)).tw. (963)

6. or/1-5 (16,788)

7. Counseling/ (25,061)

8. Social Support/ (43,650)

9. motivation/ or life style/ (79,924)

10. Therapeutic Community/ (1923)

11. Psychotherapy, Group/ (11,093)

12. Health Education/ (48,750)

13. Friends/ (1942)

14. self efficacy/ (9437)

15. Role Playing/ (1888)

16. Peer Group/ (11,707)

17. Self-Help Groups/ (7209)

18. Focus Groups/ (12,804)

19. health promotion/ or healthy people programs/ or weight reduction programs/ (44,939)

20. or/7-19 (265,924)

21. ((prison* or jail* or penitentiar* or bastile* or offender* or reoffend* or convict or convicts or convicted or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) adj6 ((group* adj2 therap*) or (group* adj2 intervention*) or (group* adj2 treatment*) or (group* adj2 education*) or (group* adj2 work*) or (group* adj2 meeting*) or (group* adj2 session*))).tw. (76)

22. (juvenile adj1 delinquen* adj6 ((group adj2 intervention*) or (group* adj2 treatment*) or (group* adj2 education*) or (group* adj2 work*) or (group* adj2 meeting*) or (group* adj2 session*) or (group* adj2 therap*))).tw. (6)

23. ((prison* or jail* or penitentiar* or bastile* or offender* or reoffend* or convict or convicts or convicted or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) adj6 (mentor* or support* or training or “self help” or volunt* or program* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)).tw. (1445)

24. (juvenile adj1 delinquen* adj6 (mentor* or support* or training or “self help” or volunt* or program* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)).tw. (25)

25. te* or detainee* or cellmate* or incarcarated or incarcaration or felon*) adj40 peer*).tw. (84)

26. (juvenile adj1 delinquen* adj40 peer*).tw. (17)

27. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*) adj6 ((group* adj2 therap*) or (group* adj2 intervention*) or (group* adj2 treatment*) or (group* adj2 education*) or (group* adj2 work*) or (group* adj2 meeting*) or (group* adj2 session*))).tw. (1)

28. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*) adj6 (mentor* or support* or training or “self help” or volunt* or program* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)).tw. (14)

29. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities) adj6 ((group* adj2 therap*) or (group* adj2 intervention*) or (group* adj2 treatment*) or (group* adj2 education*) or (group* adj2 work*) or (group* adj2 meeting*) or (group* adj2 session*))).tw. (0)

30. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities) adj6 (mentor* or support* or training or “self help” or volunt* or program* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)).tw. (62)

31. or/21-30 (1674)

32. 6 and 20 (1347)

33. 31 or 32 (2776)

34. limit 33 to yr=“2010” (176)

Searches in Applied Social Sciences Index and Abstracts (ProQuest CSA), 1987–present

Subject search 1:

EXACT(“Offenders” OR “Dangerous offenders” OR “Recidivists” OR “Drunken offenders” OR “War criminals” OR “Juvenile offenders” OR “Young offenders” OR “Young adult offenders” OR “Violent offenders” OR “Sex offenders” OR “Remand offenders” OR “Prisoners”) (8559)

EXACT(“Penal institutions” OR “Maximum security prisons” OR “Prisons” OR “Remand prisons” OR “Secure units”) OR EXACT(“Prison sociology” OR “Prison service”) (2076)

EXACT(“Long term prisoners”) (15)

all(correctional NEAR/6 (unit OR units OR facilit* OR institution* OR centre* OR center*)) (440)

Subject search 2:

EXACT(“Therapeutic communities”) (700)

EXACT(“Selfcounselling” OR “Cognitive behavioural counselling” OR “Peer group counselling” OR “Counselling” OR “Crosscultural counselling” OR “Pretest counselling” OR “Re-evaluation counselling” OR “Rehabilitation counselling” OR “Educational guidance” OR “Group counselling” OR “Long term counselling” OR “Multicultural counselling”) (3609)

EXACT(“Counsellors”) (537)

EXACT(“Social support” OR “Perceived social support”) (3237)

EXACT(“Analytical group psychotherapy” OR “Psychodynamic group psychotherapy” OR “Group psychotherapy”) (902)

EXACT(“Lifestyle” OR “Health Promoting Lifestyle Profile”) (1106)

EXACT(“Intrinsic motivation” OR “Motivation” OR “Extrinsic motivation”) (3113)

EXACT(“Friends”) (646)

EXACT(“Peer supervision” OR “Peer instruction” OR “Peer helping programmes” OR “Peer groups”) (548)

EXACT(“Selfhelp programmes” OR “Selfhelp groups”) (488)

EXACT(“Focus groups” OR “Discussion groups” OR “Fitness groups”) (483)

EXACT(“Selfefficacy”) (1695)

EXACT(“Role models”) (150)

EXACT(“Role play”) (100)

EXACT(“Listening therapy” OR “Listening”) (230)

Search 1 and search 2 = 307

Text searches:

all((prison* or jail* or penitentiar* or bastile* or offender* or reoffend* or convict or convicts or convicted or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) near/6 ((group* near/2 therap*) or (group* near/2 intervention*) or (group* n/2 treatment*) or (group* n/2 education*) or (group* n/2 work*) or (group* n/2 meeting*) or (group* n/2 session*))) (199)

all((juvenile n/1 delinquen*) n/6 ((group* NEAR/2 therap*) OR (group* NEAR/2 intervention*) OR (group* NEAR/2 treatment*) OR (group* NEAR/2 education*) OR (group* NEAR/2 work*) OR (group* NEAR/2 meeting*) OR (group* NEAR/2 session*))) (3)

all((prison* OR jail* OR penitentiar* OR bastile* OR offender* OR reoffend* OR convict OR convicts OR convicted OR inmate* OR detainee* OR cellmate* OR incarcarated OR incarcaration OR felon*) NEAR/40 peer*) (196)

all((juvenile n/1 delinquen*) NEAR/40 peer*) (42)

all((secure n/2 (unit or units or facility or institution* or facilities or centre* or center*)) NEAR/6 ((group* NEAR/2 therap*) OR (group* NEAR/2 intervention*) OR (group* NEAR/2 treatment*) OR (group* NEAR/2 education*) OR (group* NEAR/2 work*) OR (group* NEAR/2 meeting*) OR (group* NEAR/2 session*))) (1)

all((correctional n/2 (units or unit or facility or institution* or centre* or center* or system or facilities)) NEAR/6 ((group* NEAR/2 therap*) OR (group* NEAR/2 intervention*) OR (group* NEAR/2 treatment*) OR (group* NEAR/2 education*) OR (group* NEAR/2 work*) OR (group* NEAR/2 meeting*) OR (group* NEAR/2 session*))) (2)

all((secure NEAR/2 (unit OR units OR facility OR institution* OR facilities OR centre* OR center*)) NEAR/40 peer* ) (4)

all((correctional n/2 (units or unit or facility or institution* or centre* or center* or system or facilities)) NEAR/40 peer*) (11)

all((prison* OR jail* OR penitentiar* OR bastile* OR offender* OR reoffend* OR convict OR convicts OR convicted OR inmate* OR detainee* OR cellmate* OR incarcarated OR incarcaration OR felon*) NEAR/6 (mentor* OR support* OR training OR “self help” OR volunt* OR “focus group” OR listen* OR buddy OR buddies OR friend* OR befriend* OR bridging OR “lay people”)) (815)

all((juvenile NEAR/1 delinquen*) NEAR/6 (mentor* OR support* OR training OR “self help” OR volunt* OR “focus group” OR listen* OR buddy OR buddies OR friend* OR befriend* OR bridging OR “lay people”)) (15)

all((correctional NEAR/2 (units OR unit OR facility OR institution* OR centre* OR center* OR system OR facilities)) NEAR/6 (mentor* OR support* OR training OR “self help” OR volunt* OR “focus group” OR listen* OR buddy OR buddies OR friend* OR befriend* OR bridging OR “lay people”)) (12)

all((secure NEAR/2 (unit OR units OR facility OR institution* OR facilities OR centre* OR center*)) NEAR/6 (mentor* OR support* OR training OR “self help” OR volunt* OR “focus group” OR listen* OR buddy OR buddies OR friend* OR befriend* OR bridging OR “lay people”)) (25)

Subject searches + text searches = 1465

Data extraction table: quantitative results

Search strategy

(((prison* OR jail* OR penitentiar* OR bastile* OR offender* OR reoffend* OR convict OR convicts OR convicted OR inmate* OR detainee* OR cellmate* OR incarcarated OR incarcaration OR felon*) NEAR/6 ((group* NEAR/2 therap*) OR (group* NEAR/2 intervention*) OR (group* NEAR/2 treatment*) OR (group* NEAR/2 education*) OR (group* NEAR/2 work*) OR (group* NEAR/2 meeting*) OR (group* NEAR/2 session*))) OR

all((juvenile NEAR/1 delinquen*) NEAR/6 ((group* NEAR/2 therap*) OR (group* NEAR/2 intervention*) OR (group* NEAR/2 treatment*) OR (group* NEAR/2 education*) OR (group* NEAR/2 work*) OR (group* NEAR/2 meeting*) OR (group* NEAR/2 session*))) OR

all((prison* OR jail* OR penitentiar* OR bastile* OR offender* OR reoffend* OR convict OR convicts OR convicted OR inmate* OR detainee* OR cellmate* OR incarcarated OR incarcaration OR felon*) NEAR/40 peer*) OR

all((juvenile NEAR/1 delinquen*) NEAR/40 peer*) OR

all((secure NEAR/2 (unit OR units OR facility OR institution* OR facilities OR centre* OR center*)) NEAR/6 ((group* NEAR/2 therap*) OR (group* NEAR/2 intervention*) OR (group* NEAR/2 treatment*) OR (group* NEAR/2 education*) OR (group* NEAR/2 work*) OR (group* NEAR/2 meeting*) OR (group* NEAR/2 session*))) OR

all((correctional NEAR/2 (units OR unit OR facility OR institution* OR centre* OR center* OR system OR facilities)) NEAR/6 ((group* NEAR/2 therap*) OR (group* NEAR/2 intervention*) OR (group* NEAR/2 treatment*) OR (group* NEAR/2 education*) OR (group* NEAR/2 work*) OR (group* NEAR/2 meeting*) OR (group* NEAR/2 session*))) OR

all((secure NEAR/2 (unit OR units OR facility OR institution* OR facilities OR centre* OR center*)) NEAR/40 peer*) OR

all((correctional NEAR/2 (units OR unit OR facility OR institution* OR centre* OR center* OR system OR facilities)) NEAR/40 peer*) OR

all((prison* OR jail* OR penitentiar* OR bastile* OR offender* OR reoffend* OR convict OR convicts OR convicted OR inmate* OR detainee* OR cellmate* OR incarcarated OR incarcaration OR felon*) NEAR/6 (mentor* OR support* OR training OR “self help” OR volunt* OR “focus group” OR listen* OR buddy OR buddies OR friend* OR befriend* OR bridging OR “lay people”)) OR

all((juvenile NEAR/1 delinquen*) NEAR/6 (mentor* OR support* OR training OR “self help” OR volunt* OR “focus group” OR listen* OR buddy OR buddies OR friend* OR befriend* OR bridging OR “lay people”)) OR

all((correctional NEAR/2 (units OR unit OR facility OR institution* OR centre* OR center* OR system OR facilities)) NEAR/6 (mentor* OR support* OR training OR “self help” OR volunt* OR “focus group” OR listen* OR buddy OR buddies OR friend* OR befriend* OR bridging OR “lay people”)) OR

all((secure NEAR/2 (unit OR units OR facility OR institution* OR facilities OR centre* OR center*)) NEAR/6 (mentor* OR support* OR training OR “self help” OR volunt* OR “focus group” OR listen* OR buddy OR buddies OR friend* OR befriend* OR bridging OR “lay people”))) OR

(correctional NEAR/2 (units OR unit OR facility OR institution* OR centre* OR center* OR system OR facilities) NEAR/6 ((program* NEAR/2 therap*) OR (program* NEAR/2 intervention*) OR (program* NEAR/2 educat*) OR (program* NEAR/2 group*) OR (program* NEAR/2 commun*) OR (program* NEAR/2 parent*))) OR

(secure NEAR/2 (unit OR units OR facility OR institution* OR facilities OR centre* OR center*) NEAR/6 ((program* NEAR/2 therap*) OR (program* NEAR/2 intervention*) OR (program* NEAR/2 educat*) OR (program* NEAR/2 group*) OR (program* NEAR/2 commun*) OR (program* NEAR/2 parent*))) OR

(juvenile NEAR/1 delinquen* NEAR/6 ((program* NEAR/2 therap*) OR (program* NEAR/2 intervention*) OR (program* NEAR/2 educat*) OR (program* NEAR/2 group*) OR (program* NEAR/2 commun*) OR (program* NEAR/2 parent*))) OR

((prison* OR jail* OR penitentiar* OR bastile* OR offender* OR reoffend* OR convict OR convicts OR convicted OR inmate* OR detainee* OR cellmate* OR incarcarated OR incarcaration OR felon*) NEAR/6 ((program* NEAR/2 Therap*) OR (program* NEAR/2 Interventon*) OR (program* NEAR/2 educat*) OR (program* NEAR/2 group*) OR (program* NEAR/2 commun*) OR (program* NEAR/2 parent*)))

AND

all((cost* OR economic* OR financ* OR budget* OR price* OR pricing* OR monetary OR fee*) AND (medic* OR health* OR clinic* OR psych* OR mental*)) OR all((qaly OR hui* OR hrqol OR eq5d OR “quality adjusted life” OR “value of life” sf36 OR sf6d OR “short form*” OR markov*) OR (utility OR utilities OR preference* OR instrument*) NEAR/5 (hrql OR qol OR “quality of life” OR health* OR score* OR weight*)) OR ti(Cost*)

Search strategy

1. (prison* or jail* or penitentiar* or bastile* or offender* or reoffend* or convict or convicts or convicted or inmate* or detainee* or cellmate* or incarcerated or incarceration or felon* or secure unit* or secure facilit* or correctional institution* or correctional unit* or correctional facilit* or correctional cent* or juvenille delinquen*) in all text (90)

2. (peer* or mentor* or support* or train* or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or lay person or lay people or self help) in all text (205)

3. (group and (therap* or intervention* or treatment* or educat* or work* or meeting* or session*)) in all text (205)

4. (groups and (therap* or intervention* or treatment* or educat* or work* or meeting* or session*)) in all text (189)

5. 2 or 3 or 4 (207)

6. 1 and 5 (90)

7. (cost* or economic* or financ* or budget* or price* or pricing or monetary or qaly or hui* or hrqol or eq5d or utility or utilities or preference* of sf36 or sf6d) in all text (165)

8. 6 and 7 (79)

Search strategy

S74 S73 and S71

S73 S72 or S55

S72 S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9 or S10 or S11 or S12 or S13 or S14 or S15 or S16 or S17 or S18 or S19 or S20 or S21 or S22 or S23 or S24 or S25 or S26 or S27 or S28 or S29 or S30 or S31 or S32

S71 S56 or S57 or S58 or S59 or S60 or S61 or S62 or S63 or S64 or S65 or S66 or S67or S68 or S69 or S70

S70 TI ( hql or hqol or h qol or hrqol or hr qol or pqol or qls ) or AB ( hql or hqol or h qol or hrqol or hr qol or pqol or qls )

S69 AB (value n2 (money or monetary)) or economic model* or markov* or quality adjusted life or qaly* or qald* or qale* or qtime* or disability adjusted life or daly* or SF6D or sf 6d or short form 6d or shortform6d or health* year* equivalent* or hye or hyes or health utilit* or hui or hui1 or hui2 or hui3 or disutil* or standard gamble* or time trade off or time tradeoff or tto

S68 AB (cost* n2 (effective* or utilit* or benefit* or minimi* or evaluat* or analy* or study or studies or consequenc* or compar* or efficienc*))

S67 AB pharmacoeconomic* or pharmaco-economic* or economic* or price* or pricing* or budget* or euroquol* or eq5d or eq-5d or finance* or financial* or fee or fees

S66 TI (value n2 money) or (value n2 monetary) or (“economic model*” or markov* or “quality adjusted life” or qaly* or qald* or qale* or qtime* or “disability adjusted life” or daly*) or (“health* year* equivalent*” or hye or hyes or hui or hui1 or hui2 or hui3 or disutil* or “standard gamble*” or “time trade off” or “time tradeoff” or tto)

S65 TI cost* or pharmacoeconomic* or pharmaco-economic* or economic* or price* or pricing* or budget* or euroquol* or eq5d or eq-5d or finance* or financial* or fee or fees

S64 (MH “Costs and Cost Analysis+”) or (MH “Fees and Charges+”) or (MH “Health Resource Utilization”) or (MH “Health Resource Allocation”)

S63 (MH “Economics”) or (MH “Economic Value of Life”) or (MH “Economics, Dental”) or (MH “Economics, Pharmaceutical”) or (MH “Economic Aspects of Illness”)

S62 (MH “Health Status Indicators”) OR (MH “Severity of Illness Indices”) OR (MH “Trauma Severity Indices”) OR (MH “Apache”)

S61 TI ( ((instrument or instruments) n5 (hrql or qol or “quality of life” or health* or score* or weight*)) ) OR AB ( ((instrument or instruments) n5 (hrql or qol or “quality of life” or health* or score* or weight*)) )

S60 TI ( “nottingham health profile*” or “sickness impact profile*” ) OR AB ( “nottingham health profile*” or “sickness impact profile*” )

S59 TI ( “quality of wellbeing” or “quality of well being” or qwb ) OR AB ( “quality of wellbeing” or “quality of well being” or qwb )

S58 TI ( (sf6d or “sf 6d” or “sf sixd” or “sf six d” or sf36 or “sf 36” or “short form” or shortform or “sf thirtysix” or “sf thirty six” or “short from thirty*” or “short from six*”) ) OR AB ( (sf6d or “sf 6d” or “sf sixd” or “sf six d” or sf36 or “sf 36” or “short form” or shortform or “sf thirtysix” or “sf thirty six” or “short from thirty*” or “short from six*”) )

S57 TI ( ((preference*) n5 (“quality of life” or health* or score* or weight*)) ) OR AB ( ((preference*) n5 (“quality of life” or health* or score* or weight*)) )

S56 TI ( ((utility or utilities) n5 (“quality of life” or health* or score* or weight*)) ) OR AB ( ((utility or utilities) n5 (“quality of life” or health* or score* or weight*)) )

S55 S54 and S53

S54 S48 or S46 or S45 or S44 or S43 or S42 or S41 or S40 or S39 or S38 or S37 or S36 or S35 or S34 or S33

S53 S52 or S51 or S50 or S49

S52 SU “Juvenile Offenders”

S51 SU “Public Offenders”

S50 SU “Correctional Facilities”

S49 SU Prisoners

S48 SU “Sexual Counseling”

S47 SU “Peer Counseling”

S46 SU Counseling

S45 SU “Support Groups”

S44 SU “Role Models”

S43 SU “Focus Groups”

S42 SU “Peer Group”

S41 SU “Health Behavior”

S40 SU “Life Style”

S39 SU “Social Support Iowa NOC”

S38 SU motivation

S37 SU “Psychotherapy, Group”

S36 SU “Health Education”

S35 SU “Self-Efficacy”

S34 SU “Role Playing”

S33 SU “Health Promotion”

S32 TI (juvenile) n1 ((delinquen*) n6 (group*N2 therap*) or (group* N2 treatment*) or (group n2 intervention*) or (group* N2 education*) OR (group* N2 work*) OR (group* N2 meeting*) OR (group* N2 session*) or (group N2 support) or (group N2 training))

S31 AB (juvenile) n1 ((delinquen*) n6 (group*N2 therap*) or (group* N2 treatment*) or (group n2 intervention*) or (group* N2 education*) OR (group* N2 work*) OR (group* N2 meeting*) OR (group* N2 session*) or (group N2 support) or (group N2 training))

S30 AB (juvenile) n1 ((delinquen*) n6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”))

S29 TI (juvenile) n1 ((delinquen*) n6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”))

S28 AU (juvenile) n1 ((delinquen*) n6 (program* n2 educat*) or (program* n2 group*) or (program* n2 commun*) or (program* n2 parent*))

S27 TI (juvenile) n1 ((delinquen*) n6 (program* n2 educat*) or (program* n2 group*) or (program* n2 commun*) or (program* n2 parent*))

S26 TI (juvenile) n1 ((delinquen*) n40 (peer))

S25 AB (juvenile) n1 ((delinquen*) n40 (peer))

S24 AB (correctional) n2 ((units or unit or facility or institution* or centre* or center* or system or facilities) n40 (peer))

S23 TI (correctional) n2 ((units or unit or facility or institution* or centre* or center* or system or facilities) n40 (peer))

S22 TI (correctional) n2 ((units or unit or facility or institution* or centre* or center* or system or facilities) n6 (program* n2 educat*) or (program* n2 group*) or (program* n2 commun*) or (program* n2 parent*))

S21 AB (correctional) n2 ((units or unit or facility or institution* or centre* or center* or system or facilities) n6 (program* n2 educat*) or (program* n2 group*) or (program* n2 commun*) or (program* n2 parent*))

S20 AB (correctional) n2 ((units or unit or facility or institution* or centre* or center* or system or facilities) n6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”))

S19 TI (correctional) n2 ((units or unit or facility or institution* or centre* or center* or system or facilities) n6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”))

S18 AB (correctional) n2 ((units or unit or facility or institution* or centre* or center* or system or facilities) n6 (group*N2 therap*) or (group* N2 treatment*) or (group n2 intervention*) or (group* N2 education*) OR (group* N2 work*) OR (group* N2 meeting*) OR (group* N2 session*) or (group N2 support) or (group N2 training))

S17 TI (correctional) n2 ((units or unit or facility or institution* or centre* or center* or system or facilities) n6 (group*N2 therap*) or (group* N2 treatment*) or (group n2 intervention*) or (group* N2 education*) OR (group* N2 work*) OR (group* N2 meeting*) OR (group* N2 session*) or (group N2 support) or (group N2 training))

S16 AB (secure) n2 ((unit or units or facility or institution* or facilities or centre* or center*) n6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”))

S15 TI (secure) n2 ((unit or units or facility or institution* or facilities or centre* or center*) n6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”))

S14 AB (secure) n2 ((unit or units or facility or institution* or facilities or centre* or center*) n6 (program* n2 therap*) or (program* n2 intervention*) or (program* n2 educat*) or (program* n2 group*) or (program* n2 commun*) or (program* n2 parent*))

S13 TI (secure) n2 ((unit or units or facility or institution* or facilities or centre* or center*) n6 (program* n2 therap*) or (program* n2 intervention*) or (program* n2 educat*) or (program* n2 group*) or (program* n2 commun*) or (program* n2 parent*))

S12 AB (secure) n2 ((unit or units or facility or institution* or facilities or centre* or center*) n40 (peer)

S11 TI (secure) n2 ((unit or units or facility or institution* or facilities or centre* or center*) n40 (peer))

S10 AB (secure) n2 ((unit or units or facility or institution* or facilities or centre* or center*) n6 (group*N2 therap*) or (group* N2 treatment*) or (group n2 intervention*) or (group* N2 education*) OR (group* N2 work*) OR (group* N2 meeting*) OR (group* N2 session*) or (group N2 support) or (group N2 training))

S9 TI (secure) n2 ((unit or units or facility or institution* or facilities or centre* or center*) n6 (group*N2 therap*) or (group* N2 treatment*) or (group n2 intervention*) or (group* N2 education*) OR (group* N2 work*) OR (group* N2 meeting*) OR (group* N2 session*) or (group N2 support) or (group N2 training))

S8 AB (prison* OR jail* OR penitentiar* OR bastile* OR offender* OR reoffend* OR convict OR convicts OR convicted OR inmate* OR detainee* OR cellmate* OR incarcarated OR incarcaration OR felon*) n6 ((program* n2 therap*) or (program* n2 intervention*) or (program* n2 educat*) or (program* n2 group*) or (program* n2 commun*) or (program* n2 parent*))

S7 TI (prison* OR jail* OR penitentiar* OR bastile* OR offender* OR reoffend* OR convict OR convicts OR convicted OR inmate* OR detainee* OR cellmate* OR incarcarated OR incarcaration OR felon*) n6 ((program* n2 therap*) or (program* n2 intervention*) or (program* n2 educat*) or (program* n2 group*) or (program* n2 commun*) or (program* n2 parent*))

S6 TI (prison* OR jail* OR penitentiar* OR bastile* OR offender* OR reoffend* OR convict OR convicts OR convicted OR inmate* OR detainee* OR cellmate* OR incarcarated OR incarcaration OR felon*) n40 ((peer))

S5 AB (prison* OR jail* OR penitentiar* OR bastile* OR offender* OR reoffend* OR convict OR convicts OR convicted OR inmate* OR detainee* OR cellmate* OR incarcarated OR incarcaration OR felon*) n40 ((peer))

S4 AB (prison* OR jail* OR penitentiar* OR bastile* OR offender* OR reoffend* OR convict OR convicts OR convicted OR inmate* OR detainee* OR cellmate* OR incarcarated OR incarcaration OR felon*) n6 ((mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”))

S3 TI (prison* OR jail* OR penitentiar* OR bastile* OR offender* OR reoffend* OR convict OR convicts OR convicted OR inmate* OR detainee* OR cellmate* OR incarcarated OR incarcaration OR felon*) n6 ((mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”))

S2 AB (prison* OR jail* OR penitentiar* OR bastile* OR offender* OR reoffend* OR convict OR convicts OR convicted OR inmate* OR detainee* OR cellmate* OR incarcarated OR incarcaration OR felon*) n6 ((group*N2 therap*) or (group* N2 treatment*) or (group n2 intervention*) or (group* N2 education*) OR (group* N2 work*) OR (group* N2 meeting*) OR (group* N2 session*) or (group N2 support) or (group N2 training))

S1 TI (prison* OR jail* OR penitentiar* OR bastile* OR offender* OR reoffend* OR convict OR convicts OR convicted OR inmate* OR detainee* OR cellmate* OR incarcarated OR incarcaration OR felon*) n6 ((group*N2 therap*) or (group* N2 treatment*) or (group n2 intervention*) or (group* N2 education*) OR (group* N2 work*) OR (group* N2 meeting*) OR (group* N2 session*) or (group N2 support) or (group N2 training))

Search strategy

prison

Search strategy

1. health economics/ (31,627)

2. exp economic evaluation/ (183,857)

3. exp health care cost/ (176,539)

4. exp pharmacoeconomics/ (152,535)

5. socioeconomics/ (100,703)

6. cost*.ti. (90,919)

7. (cost$ adj2 (effective$ or utilit$ or benefit$ or minimi$ or evaluat$ or analy$ or study or studies or consequenc$ or compar$ or efficienc*)).ab. (106,887)

8. (price* or pricing).tw. (29,351)

9. (economic$ or pharmacoeconomic$ or pharmaco-economic$).tw. (175,422)

10. budget$.tw. (21,434)

11. (value adj2 (money or monetary)).tw. (1461)

12. (finance$ or financia$).tw. (63,470)

13. quality adjusted life year/ (9012)

14. (eq-5d or eq5d or euroquol*).tw. (3233)

15. economic model*.tw. (1949)

16. markov*.tw. (12,369)

17. quality adjusted life.tw. (6316)

18. (qaly$ or qald$ or qale$ or qtime$).tw. (6070)

19. disability adjusted life.tw. (1103)

20. daly$.tw. (1226)

21. health* year* equivalent*.tw. (41)

22. (hye or hyes).tw. (62)

23. (hui or hui1 or hui2 or hui3).tw. (942)

24. disutil$.tw. (261)

25. (hql or hqol or h qol or hrqol or hr qol).tw. (8079)

26. standard gamble$.tw. (681)

27. (time trade off or time tradeoff or tto).tw. (1259)

28. (pqol or qls).tw. (310)

29. exp animals/ not (exp animals/ and exp humans/) (1,331,362)

30. exp nonhuman/ not (exp nonhuman/ and exp human/) (3,110,154)

31. exp experimental animal/ (433,785)

32. exp veterinary medicine/ (30,569)

33. animal experiment/ (1,614,542)

34. ((energy or oxygen$ or metaboli*) adj3 cost$).tw. (5833)

35. ((utility or utilities) adj5 (“quality of life” or health* or score* or weight*)).tw. (4780)

36. (preference* adj5 (“quality of life” or health* or score* or weight*)).tw. (3872)

37. (sf36 or sf 36 or short form 36 or shortform 36 or sf thirtysix or sf thirty six or shortform thirtysix or shortform thirty six or short from thirtysix or short form thirty six).tw. (17,373)

38. (sf6d or sf 6d or short form 6d or shortform 6d or sf sixd or sf six d).tw. (446)

39. (“quality of wellbeing” or “quality of well being” or qwb).tw. (365)

40. “nottingham health profile*”.tw. (1123)

41. ((instrument or instruments) adj5 (hrql or qol or “quality of life” or health* or score* or weight*)).tw. (9580)

42. “sickness impact profile”.tw. (1073)

43. “health status indicator*”.tw. (323)

44. APACHE/ (4904)

45. exp “severity of illness index”/ (175,389)

46. sickness impact profile/ (1681)

47. exp animal/ not (exp animal/ and exp human/) (1,331,362)

48. exp Veterinary Medicine/ (30,569)

49. exp Animal Experimentation/ (1,618,007)

50. (cost$ adj2 metaboli$).tw. (1220)

51. (cost$ adj2 energy).tw. (3529)

52. (cost* adj1 oxygen).tw. (803)

53. or/47-52 (2,963,761)

54. or/1-46 (5,920,862)

55. 54 not 53 (2,959,163)

56. offender/ (7651)

57. prison/ (11,113)

58. prisoner/ (11,123)

59. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*)).tw. (499)

60. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities)).tw. (1227)

61. or/56-60 (27,090)

62. counseling/ or peer counseling/ (34,957)

63. social support/ (48,002)

64. motivation/ (61,808)

65. lifestyle/ (60,350)

66. therapeutic community/ (2875)

67. group therapy/ (17,797)

68. health education/ (73,650)

69. friend/ (5437)

70. role playing/ (15,080)

71. peer group/ (10,259)

72. self help/ (10,452)

73. health promotion/ (60,369)

74. health program/ (74,773)

75. weight reduction/ (76,347)

76. or/62-75 (491,638)

77. ((prison* or jail* or penitentiar* or bastile* or offender* or reoffend* or convict or convicts or convicted or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) adj6 ((group* adj2 therap*) or (group* adj2 intervention*) or (group* adj2 treatment*) or (group* adj2 educat*) or (group* adj2 work*) or (group* adj2 meeting*) or (group* adj2 session*))).tw. (127)

78. ((prison* or jail* or penitentiar* or bastile* or offender* or reoffend* or convict or convicts or convicted or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) adj6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)).tw. (911)

79. ((prison* or jail* or penitentiar* or bastile* offender* or reoffend* or convict or convicted or convicts or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) adj40 peer*).tw. (94)

80. ((prison* or jail* or penitentiar* or bastile* or offender* or reoffend* or convict or convicts or convicted or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) adj6 ((program* adj2 therap*) or (program* adj2 intervention*) or (program* adj2 educat*) or (program* adj2 group*) or (program* adj2 commun*) or (program* adj2 parent*))).tw. (164)

81. (juvenile adj1 delinquen* adj6 ((group adj2 intervention*) or (group* adj2 treatment*) or (group* adj2 educat*) or (group* adj2 work*) or (group* adj2 meeting*) or (group* adj2 session*) or (group* adj2 therap*))).tw. (7)

82. (juvenile adj1 delinquen* adj6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)).tw. (19)

83. (juvenile adj1 delinquen* adj40 peer*).tw. (23)

84. (juvenile adj1 delinquen* adj6 ((program* adj2 therap*) or (program* adj2 intervention*) or (program* adj2 educat*) or (program* adj2 group*) or (program* adj2 commun*) or (program* adj2 parent*))).tw. (6)

85. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*) adj6 ((group* adj2 therap*) or (group* adj2 intervention*) or (group* adj2 treatment*) or (group* adj2 educat*) or (group* adj2 work*) or (group* adj2 meeting*) or (group* adj2 session*))).tw. (1)

86. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*) adj6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)).tw. (10)

87. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*) adj6 ((program* adj2 therap*) or (program* adj2 intervention*) or (program* adj2 educat*) or (program* adj2 group*) or (program* adj2 commun*) or (program* adj2 parent*))).tw. (1)

88. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*) adj6 peer*).tw. (0)

89. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities) adj6 ((group* adj2 therap*) or (group* adj2 intervention*) or (group* adj2 treatment*) or (group* adj2 educat*) or (group* adj2 work*) or (group* adj2 meeting*) or (group* adj2 session*))).tw. (3)

90. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities) adj6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)).tw. (36)

91. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities) adj6 ((program* adj2 therap*) or (program* adj2 intervention*) or (program* adj2 educat*) or (program* adj2 group*) or (program* adj2 commun*) or (program* adj2 parent*))).tw. (6)

92. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities) adj6 peer*).tw. (1)

93. or/77-92 (1342)

94. 61 and 76 (2753)

95. 93 or 94 (3828)

96. 55 and 95 (427)

Search strategy

1. prison and peer* not dilemma

2. prison and group* not dilemma

3. prison* and educat* not dilemma

Search strategy

1. Economics/ (26,255)

2. exp Economics, Dental/ (3850)

3. exp Economics, Nursing/ (3860)

4. exp Economics, Medical/ (13,242)

5. exp Economics, pharmaceutical/ (2316)

6. exp Economics, Hospital/ (17,845)

7. exp “Costs and Cost Analysis”/ (163,753)

8. exp “Fees and Charges”/ (25,744)

9. exp budgets/ (11,381)

10. exp “Value of Life”/ec [Economics] (214)

11. budget$.tw. (15,206)

12. cost$.ti. (67,775)

13. (cost$ adj2 (effective$ or utilit$ or benefit$ or minimi$ or evaluat$ or analy$ or study or studies or consequenc$ or compar$ or efficienc*)).ab. (75,610)

14. (economic$ or pharmacoeconomic$ or pharmaco-economic$).tw. (120,600)

15. (price$ or pricing$).tw. (19,873)

16. (finance$ or financial$).tw. (45,336)

17. (fee or fees).tw. (10,354)

18. (value adj1 (money or monetary)).tw. (278)

19. quality-adjusted life years/ (5584)

20. (eq-5d or eq5d or euroquol*).tw. (1899)

21. exp models, economic/ (8524)

22. economic model*.tw. (1304)

23. markov chains/ (7834)

24. markov*.tw. (9125)

25. quality adjusted life.tw. (4462)

26. (qaly$ or qald$ or qale$ or qtime$).tw. (3727)

27. disability adjusted life.tw. (836)

28. daly$.tw. (854)

29. health* year* equivalent*.tw. (36)

30. (hye or hyes).tw. (51)

31. (hui or hui1 or hui2 or hui3).tw. (689)

32. disutil$.tw. (164)

33. standard gamble$.tw. (575)

34. (time trade off or time tradeoff or tto).tw. (926)

35. (hql or hqol or h qol or hrqol or hr qol).tw. (5437)

36. (pqol or qls).tw. (202)

37. ((utility or utilities) adj5 (“quality of life” or health* or score* or weight*)).tw. (3284)

38. (preference* adj5 (“quality of life” or health* or score* or weight*)).tw. (2922)

39. (sf36 or sf 36 or short form 36 or shortform 36 or sf thirtysix or sf thirty six or shortform thirtysix or shortform thirty six or short from thirtysix or short form thirty six).tw. (12,234)

40. (sf6d or sf 6d or short form 6d or shortform 6d or sf sixd or sf six d).tw. (277)

41. (“quality of wellbeing” or “quality of well being” or qwb).tw. (313)

42. “nottingham health profile*”.tw. (919)

43. ((instrument or instruments) adj5 (hrql or qol or “quality of life” or health* or score* or weight*)).tw. (7112)

44. “sickness impact profile”.tw. (942)

45. health status indicators/ (17,682)

46. apache/ (3979)

47. exp “severity of illness index”/ (141,772)

48. sickness impact profile/ (5326)

49. or/1-48 (611,804)

50. exp animals/ not (exp animals/ and exp humans/) (3,702,877)

51. exp Veterinary Medicine/ (19,229)

52. exp Animal Experimentation/ (5300)

53. (cost$ adj2 metaboli$).tw. (995)

54. (cost$ adj2 energy).tw. (2615)

55. (cost* adj1 oxygen).tw. (599)

56. or/50-55 (3,719,960)

57. 49 not 56 (583,388)

58. prisons/ or concentration camps/ (7091)

59. Criminals/ (454)

60. Prisoners/ (11,077)

61. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*)).tw. (303)

62. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities)).tw. (973)

63. or/58-62 (17,046)

64. Counseling/ (25,356)

65. Social Support/ (44,313)

66. motivation/ or life style/ (80,946)

67. Therapeutic Community/ (1925)

68. Psychotherapy, Group/ (11,134)

69. Health Education/ (49,071)

70. Friends/ (2001)

71. self efficacy/ (9636)

72. Role Playing/ (1897)

73. Peer Group/ (11,914)

74. Self-Help Groups/ (7296)

75. Focus Groups/ (13,103)

76. health promotion/ or healthy people programs/ or weight reduction programs/ (45,937)

77. or/64-76 (269,542)

78. ((prison* or jail* or penitentiar* or bastile* or offender* or reoffend* or convict or convicts or convicted or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) adj6 ((group* adj2 therap*) or (group* adj2 intervention*) or (group* adj2 treatment*) or (group* adj2 educat*) or (group* adj2 work*) or (group* adj2 meeting*) or (group* adj2 session*))).tw. (78)

79. ((prison* or jail* or penitentiar* or bastile* or offender* or reoffend* or convict or convicts or convicted or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) adj6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)).tw. (616)

80. ((prison* or jail* or penitentiar* or bastile* offender* or reoffend* or convict or convicted or convicts or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) adj40 peer*).tw. (86)

81. ((prison* or jail* or penitentiar* or bastile* or offender* or reoffend* or convict or convicts or convicted or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) adj6 ((program* adj2 therap*) or (program* adj2 intervention*) or (program* adj2 educat*) or (program* adj2 group*) or (program* adj2 commun*) or (program* adj2 parent*))).tw. (123)

82. (juvenile adj1 delinquen* adj6 ((group adj2 intervention*) or (group* adj2 treatment*) or (group* adj2 educat*) or (group* adj2 work*) or (group* adj2 meeting*) or (group* adj2 session*) or (group* adj2 therap*))).tw. (6)

83. (juvenile adj1 delinquen* adj6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)).tw. (13)

84. (juvenile adj1 delinquen* adj40 peer*).tw. (17)

85. (juvenile adj1 delinquen* adj6 ((program* adj2 therap*) or (program* adj2 intervention*) or (program* adj2 educat*) or (program* adj2 group*) or (program* adj2 commun*) or (program* adj2 parent*))).tw. (1)

86. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*) adj6 ((group* adj2 therap*) or (group* adj2 intervention*) or (group* adj2 treatment*) or (group* adj2 educat*) or (group* adj2 work*) or (group* adj2 meeting*) or (group* adj2 session*))).tw. (1)

87. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*) adj6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)).tw. (6)

88. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*) adj6 ((program* adj2 therap*) or (program* adj2 intervention*) or (program* adj2 educat*) or (program* adj2 group*) or (program* adj2 commun*) or (program* adj2 parent*))).tw. (0)

89. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*) adj6 peer*).tw. (0)

90. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities) adj6 ((group* adj2 therap*) or (group* adj2 intervention*) or (group* adj2 treatment*) or (group* adj2 educat*) or (group* adj2 work*) or (group* adj2 meeting*) or (group* adj2 session*))).tw. (0)

91. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities) adj6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)).tw. (22)

92. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities) adj6 ((program* adj2 therap*) or (program* adj2 intervention*) or (program* adj2 educat*) or (program* adj2 group*) or (program* adj2 commun*) or (program* adj2 parent*))).tw. (4)

93. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities) adj6 peer*).tw. (1)

94. or/78-93 (923)

95. 63 and 77 (1364)

96. 94 or 95 (2121)

97. 57 and 96 (167)

Search strategy

1. ((prison* or jail* or penitentiar* or bastile* or offender* or reoffend* or convict or convicts or convicted or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) adj6 ((group* adj2 therap*) or (group* adj2 intervention*) or (group* adj2 treatment*) or (group* adj2 educat*) or (group* adj2 work*) or (group* adj2 meeting*) or (group* adj2 session*))).tw. (1)

2. ((prison* or jail* or penitentiar* or bastile* or offender* or reoffend* or convict or convicts or convicted or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) adj6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)).tw. (30)

3. ((prison* or jail* or penitentiar* or bastile* offender* or reoffend* or convict or convicted or convicts or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) adj40 peer*).tw. (5)

4. ((prison* or jail* or penitentiar* or bastile* or offender* or reoffend* or convict or convicts or convicted or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) adj6 ((program* adj2 therap*) or (program* adj2 intervention*) or (program* adj2 educat*) or (program* adj2 group*) or (program* adj2 commun*) or (program* adj2 parent*))).tw. (6)

5. (juvenile adj1 delinquen* adj6 ((group adj2 intervention*) or (group* adj2 treatment*) or (group* adj2 educat*) or (group* adj2 work*) or (group* adj2 meeting*) or (group* adj2 session*) or (group* adj2 therap*))).tw. (0)

6. (juvenile adj1 delinquen* adj6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)).tw. (1)

7. (juvenile adj1 delinquen* adj40 peer*).tw. (1)

8. (juvenile adj1 delinquen* adj6 ((program* adj2 therap*) or (program* adj2 intervention*) or (program* adj2 educat*) or (program* adj2 group*) or (program* adj2 commun*) or (program* adj2 parent*))).tw. (0)

9. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*) adj6 ((group* adj2 therap*) or (group* adj2 intervention*) or (group* adj2 treatment*) or (group* adj2 educat*) or (group* adj2 work*) or (group* adj2 meeting*) or (group* adj2 session*))).tw. (0)

10. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*) adj6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)).tw. (0)

11. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*) adj6 ((program* adj2 therap*) or (program* adj2 intervention*) or (program* adj2 educat*) or (program* adj2 group*) or (program* adj2 commun*) or (program* adj2 parent*))).tw. (0)

12. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*) adj6 peer*).tw. (0)

13. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities) adj6 ((group* adj2 therap*) or (group* adj2 intervention*) or (group* adj2 treatment*) or (group* adj2 educat*) or (group* adj2 work*) or (group* adj2 meeting*) or (group* adj2 session*))).tw. (0)

14. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities) adj6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)).tw. (1)

15. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities) adj6 ((program* adj2 therap*) or (program* adj2 intervention*) or (program* adj2 educat*) or (program* adj2 group*) or (program* adj2 commun*) or (program* adj2 parent*))).tw. (0)

16. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities) adj6 peer*).tw. (0)

17. or/1-16 (40)

18. exp “Costs and Cost Analysis”/ (0)

19. exp “Value of Life”/ec [Economics] (0)

20. cost$.ti. (3491)

21. (cost$ adj2 (effective$ or utilit$ or benefit$ or minimi$ or evaluat$ or analy$ or study or studies or consequenc$ or compar$ or efficienc*)).ab. (5519)

22. (economic$ or pharmacoeconomic$ or pharmaco-economic$).tw. (9172)

23. quality-adjusted life years/ (0)

24. (eq-5d or eq5d or euroquol*).tw. (155)

25. exp models, economic/ (0)

26. economic model*.tw. (120)

27. markov chains/ (0)

28. markov*.tw. (1667)

29. quality adjusted life.tw. (336)

30. (qaly$ or qald$ or qale$ or qtime$).tw. (286)

31. ec.fs. (1)

32. ((utility or utilities) adj5 (“quality of life” or health* or score* or weight*)).tw. (248)

33. (preference* adj5 (“quality of life” or health* or score* or weight*)).tw. (186)

34. (sf36 or sf 36 or short form 36 or shortform 36 or sf thirtysix or sf thirty six or shortform thirtysix or shortform thirty six or short from thirtysix or short form thirty six).tw. (705)

35. (sf6d or sf 6d or short form 6d or shortform 6d or sf sixd or sf six d).tw. (20)

36. (“quality of wellbeing” or “quality of well being” or qwb).tw. (11)

37. “nottingham health profile*”.tw. (19)

38. ((instrument or instruments) adj5 (hrql or qol or “quality of life” or health* or score* or weight*)).tw. (424)

39. “sickness impact profile”.tw. (30)

40. “health status indicators”.tw. (9)

41. apache.tw. (245)

42. “sickness impact profile*”.tw. (30)

43. “severity of illness index*”.tw. (2)

44. (animal* and human*).tw. (7167)

45. “Veterinary Medicine*”.tw. (267)

46. “Animal Experimentation*”.tw. (58)

47. (cost$ adj2 metaboli$).tw. (67)

48. (cost$ adj2 energy).tw. (240)

49. (cost* adj1 oxygen).tw. (16)

50. or/44-49 (7743)

51. or/18-43 (18999)

52. 51 not 50 (18730)

53. 52 and 17 (1)

Search strategy

((all(cost* OR economic* OR financ* OR budget* OR price* OR pricing* OR monetary OR fee*) AND all(medic* OR health* OR clinic* OR psych* OR mental*)) OR (all(qaly OR hui* OR hrqol OR eq5d OR “quality adjusted life” OR “value of life” sf36 OR sf6d OR “short form*” OR markov*) OR all ((utility OR utilities OR preference* OR instrument*) NEAR/5 (hrql OR qol OR “quality of life” OR health* OR score* OR weight*))) OR (ti(cost) OR ab(cost* NEAR/2 (effective* OR utilit* OR benefit* OR minimi* OR evaluat* OR analys* OR study OR studies OR consequenc* OR compar* OR efficien*))))

AND

(all(((prison* OR jail* OR penitentiar* OR bastile* OR offender* OR reoffend* OR convict OR convicts OR convicted OR inmate* OR detainee* OR cellmate* OR incarcarated OR incarcaration OR felon*) NEAR/6 ((group* NEAR/2 therap*) OR (group* NEAR/2 intervention*) OR (group* NEAR/2 treatment*) OR (group* NEAR/2 education*) OR (group* NEAR/2 work*) OR (group* NEAR/2 meeting*) OR (group* NEAR/2 session*) OR (group NEAR/2 support) OR (group NEAR/2 training)))) OR

((juvenile NEAR/1 delinquen*) NEAR/6 ((group* NEAR/2 therap*) OR (group* NEAR/2 intervention*) OR (group* NEAR/2 treatment*) OR (group* NEAR/2 education*) OR (group* NEAR/2 work*) OR (group* NEAR/2 meeting*) OR (group* NEAR/2 session*) OR (group NEAR/2 support) OR (group NEAR/2 training))) OR

all((prison* OR jail* OR penitentiar* OR bastile* OR offender* OR reoffend* OR convict OR convicts OR convicted OR inmate* OR detainee* OR cellmate* OR incarcarated OR incarcaration OR felon*) NEAR/40 peer*) OR

((juvenile NEAR/1 delinquen*) NEAR/6 peer*) OR

((secure NEAR/2 (unit OR units OR facility OR institution* OR facilities OR centre* OR center*)) NEAR/6 ((group* NEAR/2 therap*) OR (group* NEAR/2 intervention*) OR (group* NEAR/2 treatment*) OR (group* NEAR/2 education*) OR (group* NEAR/2 work*) OR (group* NEAR/2 meeting*) OR (group* NEAR/2 session*) OR (group NEAR/2 support) OR (group NEAR/2 training))) OR

all((correctional NEAR/2 (units OR unit OR facility OR institution* OR centre* OR center* OR system OR facilities)) NEAR/6 ((group* NEAR/2 therap*) OR (group* NEAR/2 intervention*) OR (group* NEAR/2 treatment*) OR (group* NEAR/2 education*) OR (group* NEAR/2 work*) OR (group* NEAR/2 meeting*) OR (group* NEAR/2 session*) OR (group NEAR/2 support) OR (group NEAR/2 training))) OR

((secure NEAR/2 (unit OR units OR facility OR institution* OR facilities OR centre* OR center*)) NEAR/40 peer*) OR

((correctional NEAR/2 (unit OR units OR facility OR institution* OR facilities OR centre* OR center*)) NEAR/40 peer*) OR

((prison* OR jail* OR penitentiar* OR bastile* OR offender* OR reoffend* OR convict OR convicts OR convicted OR inmate* OR detainee* OR cellmate* OR incarcarated OR incarcaration OR felon*) NEAR/6 (mentor* OR “self help” OR volunt* OR “focus group” OR listen* OR buddy OR buddies OR friend* OR befriend* OR bridging OR “lay people”)) OR

((juvenile NEAR/1 delinquen*) NEAR/6 (mentor* OR “self help” OR volunt* OR “focus group” OR listen* OR buddy OR buddies OR friend* OR befriend* OR bridging OR “lay people”)) OR

((correctional NEAR/2 (units OR unit OR facility OR institution* OR centre* OR center* OR system OR facilities)) NEAR/6 (mentor* OR “self help” OR volunt* OR “focus group” OR listen* OR buddy OR buddies OR friend* OR befriend* OR bridging OR “lay people”)) OR

((secure NEAR/2 (units OR unit OR facility OR institution* OR centre* OR center* OR system OR facilities)) NEAR/6 (mentor* OR “self help” OR volunt* OR “focus group” OR listen* OR buddy OR buddies OR friend* OR befriend* OR bridging OR “lay people”)))

Search strategy

#1 MeSH descriptor Prisoners explode all trees (173)

#2 MeSH descriptor Prisons explode all trees (66)

#3 MeSH descriptor Criminals explode all trees (12)

#4 (secure near/2 (unit or units or facility or institution* or facilities or centre* or center*)):ti,ab,kw (7)

#5 (correctional near/2 (units or unit or facility or institution* or centre* or center* or system or facilities)):ti,ab,kw (30)

#6 (#1 OR #2 OR #3 OR #4 OR #5) (248)

#7 MeSH descriptor Counseling, this term only (2368)

#8 MeSH descriptor Social Support, this term only (1940)

#9 MeSH descriptor Motivation, this term only (2518)

#10 MeSH descriptor Life Style, this term only (1618)

#11 MeSH descriptor Therapeutic Community, this term only (53)

#12 MeSH descriptor Psychotherapy, Group, this term only (1281)

#13 MeSH descriptor Health Education, this term only (2551)

#14 MeSH descriptor Friends, this term only (62)

#15 MeSH descriptor Self Efficacy, this term only (1212)

#16 MeSH descriptor Role Playing, this term only (126)

#17 MeSH descriptor Peer Group, this term only (653)

#18 MeSH descriptor Focus Groups, this term only (231)

#19 MeSH descriptor Health Promotion, this term only (2791)

#20 MeSH descriptor Healthy People Programs, this term only (11)

#21 MeSH descriptor Weight Reduction Programs, this term only (10)

#22 (#7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21) (13,954)

#23 ((prison* or jail* or penitentiar* or bastile* or offender* or reoffend* or convict or convicts or convicted or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) near/6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)):ti,ab,kw (64)

#24 ((prison* or jail* or penitentiar* or bastile* offender* or reoffend* or convict or convicted or convicts or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) near/40 peer*):ti,ab,kw (8)

#25 (juvenile near/1 delinquen* near/6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)):ti,ab,kw (9)

#26 (juvenile near/1 delinquen* near/40 peer*):ti,ab,kw (26)

#27 (secure near/2 ((unit or units or facility or institution* or facilities or centre* or center*)) near/6 ((program* or therap* or intervention* or educat* or commun*))):ti,ab,tw (2)

#28 (secure near/2 (unit or units or facility or institution* or facilities or centre* or center*) near/6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)):ti,ab,kw (0)

#29 (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*) near/6 peer*):ti,ab,kw (0)

#30 (correctional near/2 (units or unit or facility or institution* or centre* or center* or system or facilities) near/6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)):ti,ab,kw (0)

#31 (correctional near/2 (units or unit or facility or institution* or centre* or center* or system or facilities) near/6 peer*):ti,ab,kw (0)

#32 ((prison* or jail* or penitentiar* or bastile* or offender* or reoffend* or convict or convicts or convicted or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) near/6 ((group or groups))):ti,ab,kw (81)

#33 ((juvenile near/1 delinquen*) near/6 ((group or groups))):ti,ab,kw (16)

#34 (secure near/2 ((unit or units or facility or institution* or facilities or centre* or center*)) near/6 ((group or groups))):ti,ab,kw (0)

#35 ((correctional near/2 (units or unit or facility or institution* or centre* or center* or system or facilities) near/6 (group or group))):ti,ab,kw (0)

#36 (secure near/2 ((unit or units or facility or institution* or facilities or centre* or center*)) near/6 ((program* or therap* or intervention* or educat* or commun*))):ti,ab,tw (2)

#37 (correctional near/2 (units or unit or facility or institution* or centre* or center* or system or facilities) near/6 ((program* or therap* or intervention* or educat* or commun*))):ti,ab,tw (4)

#38 ((juvenile near/1 delinquen*) near/6 ((program* or therap* or intervention* or educat* or commun*))):ti,ab,tw (16)

#39 ((prison* or jail* or penitentiar* or bastile* or offender* or reoffend* or convict or convicts or convicted or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) near/6 ((program* or therap* or intervention* or educat* or commun*))):ti,ab,tw (215)

#40 (#23 OR #24 OR #25 OR #26 OR #27 OR #28 OR #29 OR #30 OR #31 OR #32 OR #33 OR #34 OR #35 OR #36 OR #37 OR #38 OR #39) (361)

#41 (#6 AND #22) (60)

#42 (#41 OR #40) (385)

Search strategy

1. exp health care economics/ (281)

2. exp “costs and cost analysis”/ (15,441)

3. exp “cost containment”/ (432)

4. exp pharmacoeconomics/ (182)

5. (economic$ adj2 (evaluat$ or analy$ or study or studies or effectiv$ or utilit$ or benefit$ or consequenc$ or compare$ or compari$ or saving$ or efficienc$)).tw. (3957)

6. (pharmcoeconomic$ or pharmaco-economic$ or “pharmaco economic$”).tw. (15)

7. budget$.tw. (4806)

8. economic$.ti. (8798)

9. (price$ or pricing$).tw. (9836)

10. ((finance$ or financial$) adj2 (evaluat$ or analy$ or study or studies or effectiv$ or utilit$ or benefit$ or consequenc$ or compare$ or compari$ or saving$ or efficienc$)).tw. (1061)

11. (fee or fees).tw. (2425)

12. (value adj1 (money or monetary)).tw. (260)

13. cost$.ti. (8462)

14. (cost$ adj2 (effective$ or utilit$ or benefit$ or minimi$ or evaluat$ or analy$ or study or studies or consequenc$ or compar$ or efficienc*)).ab. (14,383)

15. (eq-5d or eq5d or euroquol*).tw. (548)

16. quality adjusted life.tw. (552)

17. (qaly$ or qald$ or qale$ or qtime$).tw. (484)

18. disability adjusted life.tw. (147)

19. daly$.tw. (410)

20. economic model*.tw. (559)

21. markov*.tw. (2184)

22. markov chains/ (764)

23. (SF6D or sf 6d or short form 6d or shortform6d).tw. (102)

24. health* year* equivalent*.tw. (5)

25. (hye or hyes).tw. (22)

26. (hui or hui1 or hui2 or hui3).tw. (365)

27. disutil$.tw. (102)

28. standard gamble$.tw. (152)

29. (time trade off or time tradeoff or tto).tw. (203)

30. (hql or hqol or h qol or hrqol or hr qol).tw. (1876)

31. (pqol or qls).tw. (124)

32. ((utility or utilities) adj5 (“quality of life” or health* or score* or weight*)).tw. (1337)

33. (preference* adj5 (“quality of life” or health* or score* or weight*)).tw. (2328)

34. (sf36 or sf 36 or short form 36 or shortform 36 or sf thirtysix or sf thirty six or shortform thirtysix or shortform thirty six or short from thirtysix or short form thirty six).tw. (2975)

35. (sf6d or sf 6d or short form 6d or shortform 6d or sf sixd or sf six d).tw. (102)

36. (“quality of wellbeing” or “quality of well being” or qwb).tw. (186)

37. “nottingham health profile*”.tw. (202)

38. ((instrument or instruments) adj5 (hrql or qol or “quality of life” or health* or score* or weight*)).tw. (3855)

39. “sickness impact profile”.tw. (304)

40. “health status indicator*”.tw. (69)

41. apache/ (0)

42. “severity of illness index*”.tw. (5)

43. “sickness impact profile*”.tw. (304)

44. exp animals/ not (exp animals/ and exp human males/ and exp human females/) (243,722)

45. exp Veterinary Medicine/ (178)

46. “Animal Experimentation*”.tw. (256)

47. (cost$ adj2 metaboli$).tw. (118)

48. (cost$ adj2 energy).tw. (278)

49. (cost* adj1 oxygen).tw. (23)

50. or/44-49 (244,282)

51. or/1-42 (65,535)

52. 51 not 50 (63,181)

53. prisons/ or concentration camps/ (4903)

54. Criminals/ (9477)

55. Incarceration/ or Correctional Institutions/ (4643)

56. Prisoners/ (7744)

57. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*)).tw. (580)

58. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities)).tw. (2275)

59. or/53-58 (23,216)

60. Social Support/ (23,843)

61. Group Psychotherapy/ (15,791)

62. motivation/ or life style/ (31,597)

63. Peers/ or Peer Relations/ (17,906)

64. Group Discussion/ (3120)

65. Group Counseling/ or Self Help Techniques/ or Support Groups/ (10,349)

66. Therapeutic Community/ (2395)

67. Health Education/ (8513)

68. Friends/ (6462)

69. Role Playing/ (2006)

70. Group Intervention/ (605)

71. health promotion/ or healthy people programs/ or weight reduction programs/ (11,401)

72. or/60-71 (126,367)

73. ((prison* or jail* or penitentiar* or bastile* or offender* or reoffend* or convict or convicts or convicted or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) adj6 ((group* adj2 therap*) or (group* adj2 intervention*) or (group* adj2 treatment*) or (group* adj2 educat*) or (group* adj2 work*) or (group* adj2 meeting*) or (group* adj2 session*))).tw. (415)

74. ((prison* or jail* or penitentiar* or bastile* or offender* or reoffend* or convict or convicts or convicted or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) adj6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)).tw. (2139)

75. ((prison* or jail* or penitentiar* or bastile* offender* or reoffend* or convict or convicted or convicts or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) adj40 peer*).tw. (240)

76. ((prison* or jail* or penitentiar* or bastile* or offender* or reoffend* or convict or convicts or convicted or inmate* or detainee* or cellmate* or incarcarated or incarcaration or felon*) adj6 ((program* adj2 therap*) or (program* adj2 intervention*) or (program* adj2 educat*) or (program* adj2 group*) or (program* adj2 commun*) or (program* adj2 parent*))).tw. (504)

77. (juvenile adj1 delinquen* adj6 ((group adj2 intervention*) or (group* adj2 treatment*) or (group* adj2 educat*) or (group* adj2 work*) or (group* adj2 meeting*) or (group* adj2 session*) or (group*adj2 therap*))).tw. (53)

78. (juvenile adj1 delinquen* adj6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)).tw. (142)

79. (juvenile adj1 delinquen* adj40 peer*).tw. (175)

80. (juvenile adj1 delinquen* adj6 ((program* adj2 therap*) or (program* adj2 intervention*) or (program* adj2 educat*) or (program* adj2 group*) or (program* adj2 commun*) or (program* adj2 parent*))).tw. (54)

81. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*) adj6 ((group* adj2 therap*) or (group* adj2 intervention*) or (group* adj2 treatment*) or (group* adj2 educat*) or (group* adj2 work*) or (group* adj2 meeting*) or (group* adj2 session*))).tw. (1)

82. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*) adj6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)).tw. (14)

83. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*) adj6 ((program* adj2 therap*) or (program* adj2 intervention*) or (program* adj2 educat*) or (program* adj2 group*) or (program* adj2 commun*) or (program* adj2 parent*))).tw. (3)

84. (secure adj2 (unit or units or facility or institution* or facilities or centre* or center*) adj6 peer*).tw. (0)

85. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities) adj6 ((group* adj2 therap*) or (group* adj2 intervention*) or (group* adj2 treatment*) or (group* adj2 educat*) or (group* adj2 work*) or (group* adj2 meeting*) or (group* adj2 session*))).tw. (20)

86. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities) adj6 (mentor* or support* or train* or “self help” or volunt* or focus or listen* or buddy or buddies or friend* or befriend* or bridging or “lay people”)).tw. (86)

87. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities) adj6 ((program* adj2 therap*) or (program* adj2 intervention*) or (program* adj2 educat*) or (program* adj2 group*) or (program* adj2 commun*) or (program* adj2 parent*))).tw. (41)

88. (correctional adj2 (units or unit or facility or institution* or centre* or center* or system or facilities) adj6 peer*).tw. (5)

89. or/73-88 (3586)

90. 59 and 72 (1263)

91. 89 or 90 (4478)

92. 52 and 91 (89)