Multi-method findings of a participatory approach to developing preventative health tools for BC individuals with

incarceration experience

CPHA, Toronto28th May, 2014

The Project TeamProject Staff: Debra Hanberg, Renee Turner, Marnie Scow, Larry Howett and Wendy Sproule.Co-Investigators: Ruth Elwood Martin, Lara-Lisa Condello, Janusz Kaczorowski, Carl Leggo, John Oliffe, Marla Buchanan, Vivian Ramsden, Jane Buxton, & Lynn Fels. Project Advisory Committee: BC Centre for Disease Control – Gail Butt Associate Director, Hepatitis Services; BC Cancer Agency – Andy Coldman, Provincial Lead for Population and Preventive Oncology & Ritinder Harry, Screening Promotions Manager; First Nations and Inuit Health Canada – Naomi Dove, Director of Health Promotion & Prevention, Pacific Region; BC Corrections Branch, MPSSG – Amanda Slater, Infectious Disease Lead, Sentry Correctional Health Services Inc; Correctional Services Canada – Jeff Strange, Regional Coordinator, Health Programs (Pacific); Long-Term-Inmates Now in the Community (L.I.N.C.) – Sherry Flett and Glen Flett; Women in2 Healing – Mo Korchinski; Aboriginal Health Program, PHSA – Nancy Laliberte; BC Ministry of Health – Perry Kendall, Provincial Health Officer; Positive Living Society of BC – Susan Craigie, Lead, Prison Outreach Program; The John Howard Society of the Lower Mainland; Elizabeth Fry Society of Greater Vancouver – Jodi Sturge.

Overview of CCPHE projectsP4H -Vancouver Foundation, January/11 – January/14 • Preventive health: Cancer, HIV/AIDS, Hepatitis

C, Mental Health, Addiction • Men and women with incarceration experience

enrolled in Greater Vancouver area. P4C- Public Health Agency of Canada, April/12 – March/14

• Prevention and screening of breast, cervical and colon cancers

• Men and women with incarceration experience enrolled in two geographical locations: Greater Vancouver area and Nanaimo.

Prison Participatory Preventive Health Project (P4H)

OVERALL GOALS:• Goal 1: To use participatory approaches to

develop preventive health tools, and methods of evaluation, for men and women with incarceration experience

• Goal 2: To pilot preventive health tools/programs, developed using participatory approaches, among men and women with incarceration experience.

• Goal 3: To promote the uptake and evaluation by health and correctional organizations of successfully piloted preventive health tools/programs.

Prison Participatory Cancer Prevention Project (P4C)

OVERALL GOAL: Promote participation in cancer screening and early detection among individuals with incarceration experience (IIE) in BC.

1. Inclusive participation of individuals with incarceration experience (IIE) throughout the project’s entirety.

2. Increased trust between health care practitioners (HCP) and individuals with incarceration experience (IIE).

3. Acceptable, accessible and available self-advocacy, peer support and cancer screening tools for individuals with incarceration experience (IIE).

4. Increased knowledge of barriers to cancer screening for IIE, and increased knowledge of participatory action research processes.

5. Increased feasibility of uptake of self-advocacy, self-management, peer support and cancer screening programs nationally and with correctional institutions.

Guiding ValuesDeveloped collaboratively by Project Advisory Committee members

PartnershipEqual participation of all relevant stakeholders

VoiceEncourage all people to share their opinions and ideas

Active ListeningHear what others have to say

RespectAcknowledge that everyone has something to offer

Reciprocal LearningLearn from one another

Cultural SafetyNo judgement

TransparencyHonesty and accountability in all actions

Iceberg Analogy of Health Priorities and their Underlying Causes

O’Gorman CM, Martin MS, Oliffe JL, Leggo C, Korchinski M, Martin RE. Community Voices in Program Development: The Wisdom of Individuals with Incarceration Experience Can J Public Health, 2012: Sep/Oct: 379-383

What we did • Hired project coordinators• Hired project assistants with incarceration

experience• UBC Research Ethics Board certificates• Enrolled and consented 183 participants with

incarceration experience: – 107 Greater Vancouver – 76 Nanaimo

• Participants invited to (develop), pilot and evaluate preventive health tools and workshops

Multi-Method Evaluationconsensus - all members of project team

1. Workshop evaluation• Number of workshops (&, numbers of

participants)• Post-workshop satisfaction surveys (Likert scales) • Focus group discussions with workshop

participants• Open ended questions (e.g. Tell us how you think this

workshop would work inside prison? What aspects would you change?)

2. Pre- and post- project surveys• Changes in participant health knowledge,

attitudes and practices over the duration of the project

Additional Evaluation3. Participant narratives• “Tell us about the experience of participating

in this project”4. Members of the Project Team, including

the Project Advisory Committee (PAC)– Shared their reflections about their own

learning processes5. Health Care Practitioners – Pre- and post- Knowledge and Attitudes

survey for documentary viewers

Data Collection and Analysis

• Qualitative Data: Audio-recordings transcribed verbatim, identifiers removed. NVivoTM 10 used to organize the data. Interpretative Description analysis approach (S. Thorne). Coded, placed into categories, generated overall themes. • Quotes selected to illuminate the major themes.

• Quantitative Data: survey data entered into Fluid Survey software and exported to SASS. Descriptive statistics were used, with tests of association:• Categorical variables: Chi-square (or , Fisher's exact test if cell size

<=5). • Ordinal variables: Wilcoxon's 2-sample test. • Continuous variables: t-test. Tests results with p-value <0.05 statistically significant. Test results with p-value 0.05 – 0.1 approach statistical significance

Community Organization Health Care Provider Peer-led Academic expert Multimedia Experiential Learning Interactive theatre activity

C

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Preventive Health Workshops

Mental Health

Finding Our

Voices

Hepatitis C

Navigating the Health Care

System

Addiction

HIV

Cancer Preventi

on

C E

H T

A P

C EP

MC P

HC P

P M

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Cancer Screenin

gC EP

Activities:Facebook GroupCancer feedback sessionActivity: barriers to being healthyReminder cards and posterMarnie’s Health TipsMemo-to-Myself

Preventive Health Workshop Evaluation

Satisfaction Likert Surveys

0

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70

80

I found this workshop useful to me

Strongly Disagree Somewhat Disagree Neither Agree nor Disagree Somewhat Agree Strongly Agree

Preventive Health Workshops

% o

f Pa

rtici

pant

s

Peer S

upport

Naviga

ting the H

ealth

care S

...Hep

C HIV

Mental

Health

Addiction

Cancer

preven

tion0

10

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I will share this information with my friends and family

Strongly Disagree Somewhat Disagree Neither Agree nor Disagree Somewhat AgreeStrongly Agree N/A

Preventive Health Workshops

% o

f Par

ticip

ants

Peer S

upport

Naviga

ting the H

ealth

care..

.Hep

C HIV

Mental

Health

Addiction

Cancer

Preven

tion0

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I think people in prison(s) would find this workshop useful

Strongly Disagree Somewhat Disagree Neither Agree nor Disagree Somewhat Agree Strongly Agree

Preventive Health Workshops

% o

f Par

ticip

ants

Preventive Health Workshop Evaluation

Focus Group Findings Cancer prevention workshop focus

groups(n=41) reported here.

Three themes emerged.

Workshop Logistics and Structure• Variety

– “Switching it up a bit and having different people doing it in different ways helped to keep me paying attention ‘cause I’ll lose focus really quickly”

-Vancouver participant• Peer-led learning

– “It’s not something you just learned out of a textbook alright. It’s actual life experiences that people are talking about.”

-Vancouver participant• Recommendations

– More time for sharing information: “I learn the most and digest the most information when there’s questions and discussions” -Vancouver participant

Health Outcomes• Control

– “The biggest thing I learned is that I am in control of my own destiny…when it comes to your health and everything, that’s solely me.” –Vancouver participant

• Information sharing– “just to remind your friends, especially if they’re getting into their

like 50s that all the screening, whether for male issues or female issues, to go get the screens and you know, save their life type thing”

–Nanaimo participant• Goal-setting

– “I’m going to be drinking less pop. I have high blood pressure, and it’s not good to have too much sugar for me.” –Nanaimo participant

– “I could do more walking you know, and to start out with, cut back on my smoking till I do quit right.” –Vancouver participant

Workshops Inside Prisons• Content

– Most common suggestion was dietary information:“People who are in and out of prison, on that revolving door, are being exposed to unhealthy food and that’s the kind of habits you pick up when you come out because, you don’t know any better, right?” -Vancouver participant

• Relevance– “I think it’ll be really helpful to people inside, just to hear the same information

that I just heard, cause it meant something to me and I have been in the same situation.” -Vancouver participant

• Structure– Ideal to have combination of peer educators and professionals:

“Peer-based, peer-led is really important…when I was younger I wouldn’t listen to anybody seriously if it wasn’t somebody my age who had a similar experience”-Vancouver participant

“In a prison setting, they don’t always take their peers seriously, so it might help to have the professionals to back up what they are saying.”-Vancouver participant

Pre- and Post- projectparticipant survey findings

(Canadian Community Health Survey items, when possible)

• 6-item demographic survey (age, education, employment, gender, ethnicity, housing, etc.)

• 70-item survey about preventive health• 25-item survey about diet and exercise• 11-item survey about experiences with HCP• 13-item survey about cervical cancer• 17-item survey about breast cancer• 19-item survey about colorectal cancer

Participant DemographicsTOTAL (N= 183)

Age <40 yrs 46% (85)

≥40 yrs 54% (98)

Gender Male 67% (123)

Female 33% (60)

Highest schooling ≤Grade 8 12% (16/130)

Grade 9-10 22% (28/130)

Grade 11-13 58% (76/130)

Not employed 67% (122)

Participant DemographicsTOTAL (N= 183)

Time since last custody <1 year 30% (55)

1-5 years 40% (74)

Total time in custody <1 year 28% (52)

>20 years 11% (21)

Married, common-law 19% (35)

Self-identified as Aboriginal 23% (42)

Current housing Rent/own/family 58% (107)

Halfwayhouse/shelter/recovery/homeless

42% (76)

Participants who completed post- project surveys

• A total of 58 (32%) participants completed post-project surveys (and, pre-project surveys)

• Participants who resided in institutions/recovery houses/halfway houses at baseline were less likely to complete post-project surveys

• Participants who completed post-project surveys:– older – out of custody for longer– more likely to be from Nanaimo

Changes in hepatitis knowledge (n=58)

• Hepatitis consists of an inflammation of your liver. ‘True’ 74% -> 100% (p=0.0463)

• Would you know where to go in your neighbourhood to see a health care professional regarding hepatitis related health issues? ‘Yes’ 79% -> 100% (p=0.1050)

Changes in preventive health practices (n=58)

• Not counting carrots, potatoes or salad, how often do you usually eat other vegetables? (p=0.0107)

• How often do you usually eat potatoes, not including french fries, fried potatoes, or potato chips? (p=0.0581)

• In a typical month over the past year, how often have you participated in mod/strenuous activity? (p=0.0445)

• In a typical week in the past 3 months, how many hours did you usually spend walking to work, school or doing errands? (p=0.0713)

Changes in knowledge and beliefs about cervical screening

• All women who have ever been sexually active (touching or intercourse) are at risk of cervical cancer? ‘True’ 20% -> 70% (p=0.0698)

• You are more likely to develop cervical cancer if you have (or had) multiple partners or if you became sexually active at an early age. ‘True’ 20% -> 70% (p=0.0698)

Changes in knowledge and beliefs about colorectal screening (n=58)

• These tests (FOBT and FIT) are painful and take a long time. ‘False’ 29% -> 64% (p=0.0029)

• If I don’t have symptoms, I do not need to have colorectal cancer screening done. ‘False’ 66% -> 92% (p=0.0093)

• All men and women 50 to 74 years should be screened for colorectal cancer regularly. ‘True’ 67% ->92% (p=0.0182)

• People get colorectal cancer because they have lived a bad life. ‘False’ 74% -> 92% (p=0.0632)

Thank you Questions?

Email: prison.research@familymed.ubc.caPhone: 604-827-4976

www.facebook.com/CCPHE.UBC

@ccpheUBC