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Abstract

Considerable health inequities occur among people who are incarcerated, with ripple effects into broader community health. The Indiana Peer Education Program uses the Extension for Community Health Outcomes (ECHO) model to train people who are incarcerated as peer health educators. This analysis sought to evaluate the effectiveness of this program and explore emergent themes not covered in survey instruments. Survey data for both peer educators and their students were assessed using multivariate regression. Qualitative data were used to triangulate survey findings and explore additional themes via thematic analysis. Students showed improvements in knowledge scores and postrelease behavior intentions; peer educators improved in knowledge, health attitudes, and self-efficacy. Qualitative data affirmed survey findings and pointed toward peer educators acquiring expertise in the content they teach, and how to teach it, and that positive results likely expand beyond participants to others in prison, their families, and the communities to which they return. Though preliminary, the results confirm an earlier analysis of the New Mexico Peer Education Program ECHO, adding to the evidence that training individuals who are incarcerated as peer educators on relevant public health topics increases health knowledge and behavior intentions and likely results in improvements in personal and public health outcomes.

Introduction

Despite the constitutional duty of the U.S. government to protect the health of those incarcerated under their authority (Friedman, 1992; Klein, 1978; Westhoff & O’Keefe, 2008), incarcerated populations experience a spectrum of health disparities. People who are incarcerated are disproportionately affected by communicable diseases, such as hepatitis C virus (HCV) (Spaudling et al. 2023; Varan et al., 2014), HIV (Freudenberg, 2011), and tuberculosis (TB) (Baussano et al., 2010; MacNeil et al., 2005) compared with nonincarcerated populations.

Higher burdens are also observed in chronic diseases, such as hypertension, asthma, and cancer (Binswanger et al., 2012; Blankenship et al., 2018), as well as mental health and substance use disorders (SUDs; Binswanger et al., 2012; Sugarman et al., 2020). The COVID-19 pandemic further highlighted these disparities with high rates of transmission within correctional facilities (Kinner et al., 2020).

Any involvement with the criminal legal system can have downstream health implications (Ferguson, 2018), and in the United States, social drivers associated with poor health—“being non-white, low-income, undereducated, homeless, and uninsured” (Macmadu & Rich, 2014, p. 65)—overlap with risk factors for criminal legal system involvement (Ferguson, 2018; Sugarman et al., 2020).¹ Some scholars cite an “epidemic of incarceration,” in which medically underserved communities are also subjected to the most punitive criminal policies, thus compounding structural issues that worsen health outcomes (Dumont et al., 2012; Kinner & Young, 2018).

One approach to addressing health disparities intertwined with justice involvement is to improve health education for people who are incarcerated (Robertson et al., 2011; Watson et al., 2004). Peer education is a method of teaching health information that taps into individuals’ shared lived experiences to foster trust, establish credibility, and increase acceptance (Bagnall et al., 2015).

Researchers and practitioners have designed peer-led educational models within a variety of settings (Bagnall et al., 2015; Devilly et al., 2005). The New Mexico Peer Education Program (NMPEP) Extension for Community Health Outcomes (ECHO) was developed at the University of New Mexico ECHO Institute to address health education gaps within state prison populations using a peer-educator framework. Research has shown that the model improved health knowledge and attitudes for both peer educators and students, positively impacted behavior intentions for students, and increased self-efficacy among peer educators (Thornton et al., 2018).

The Indiana Peer Education Program ECHO

The Indiana Peer Education Program (INPEP) ECHO is a partnership between the Indiana Department of Health, Indiana University–Indianapolis ECHO Center at the Richard M. Fairbanks School of Public Health, and Step-Up, Inc. The program is a replication of NMPEP ECHO and aims to expand health knowledge among residents in Indiana Department of Correction (IDOC) facilities. The initial stage of INPEP ECHO, which this study evaluated, used NMPEP ECHO materials verbatim, given the positive empirical results that Thornton et al. (2018) demonstrated. Over several years of implementation in Indiana, INPEP ECHO has focused on continuous quality improvement and incurred slight variations, yet it retains the core features of the peer education program and fidelity to the Project ECHO model.

During its first year of operation, INPEP ECHO was launched in 4 of Indiana’s 17 state prisons, including 2 medium security, 1 mixed medium/maximum, and 1 maximum security facility. INPEP ECHO staff provided 40 hours of on-site, intensive training on health education and adult learning theory to the selected candidates at the participating facilities. The staff facilitating INPEP ECHO training have professional backgrounds in public health, social work, and epidemiology, as well as experience facilitating ECHO sessions, providing reentry services and case management, and operationalizing harm reduction programs. INPEP ECHO staff members also trained directly with the NMPEP ECHO team in New Mexico correctional facilities before initiating INPEP ECHO.

To establish the program at each of the four sites, INPEP ECHO staff worked with IDOC Central Office administrators to connect with wardens and facility leadership. As part of the recruitment process, informational fliers and sign-up sheets were made available in residential dorms and IDOC staff nominated candidates to interview for the INPEP ECHO peer educator positions. INPEP ECHO staff met with wardens and the IDOC staff who were appointed INPEP liaisons before the recruitment process to emphasize the importance of including individuals with diversity in age, race/ethnicity, and background.

Interview days were organized at each location before the start of a 40-hour training. Peer candidates met with a panel of two to three INPEP ECHO staff members to discuss the program goals, position requirements, and the candidate’s interest in becoming a peer health educator. Because of the substantial investment of time and resources to host 40-hour trainings and to promote the sustainability of the program at each facility, peer candidates were asked about the time remaining on their sentences and any disciplinary reports within the past year. Individuals with at least 1 year until their earliest possible release date and limited disciplinary reports were preferred; however, applicants who did not meet these criteria were not disqualified from their candidacy and were accepted on a case-by-case basis.

The 40-hour trainings had between 10 and 20 individuals per class. Each facility differed in the number of applicants and in the capacity of available teaching space. It was identified that 15 peer educators per workshop was a more suitable minimum for program sustainability, given the eventual attrition of the group size over time.

During 40-hour trainings, peer educators not only studied the health topics covered in 10-hour workshops but also learned best practices in teaching methodologies. Peer educators give practice presentations on each of the 5 days of the training and receive robust feedback from the INPEP ECHO staff. These skill-building exercises focus on planning and preparing for presentations; teaching to different learning styles; using visual aids, personal stories, and skits to engage the audience; demonstrating credibility and shared lived experiences to build trust; refining cofacilitation and effective communication skills; and understanding the importance of using person-first and nonstigmatizing language.

Once peer educators graduated from the 40-hour training, they began hosting health education workshops with 10 hours of instruction covering a range of health topics. Initially, there was a stronger emphasis on communicable conditions, including viral hepatitis, sexually transmitted infections (STIs), Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), and TB. However, the curriculum evolved to include a more inclusive focus on mental health, behavioral health, and noncommunicable diseases given the health challenges most commonly experienced by the peer educators and students who interacted with the program. Therefore, SUDs, harm reduction, stages of change, motivational interviewing, and noncommunicable diseases, such as diabetes, became an integral part of the 10-hour curriculum.

Peer educators were responsible for performing all ongoing tasks associated with the program’s operation inside their facilities with the assistance of an IDOC-appointed liaison. INPEP ECHO staff supported peer educator teams through monthly site visits to assess activities and ensure fidelity to the program’s core components.

Peer educators also participated in monthly virtual sessions called “teleECHOs” hosted by the INPEP ECHO staff on Zoom for continuing education. In each session, peer educators from each INPEP-participating facility collectively engaged in evidence-based didactics and exchanged ideas using case-based learning (Nkhoma et al., 2017). In accordance with the ECHO model, peer educators presented cases of real-world challenges they had experienced in their work (Arora et al., 2019). TeleECHO sessions provided opportunities for peer educators to develop problem-solving skills and to learn new, relevant information to share with their students and, when appropriate, DOC staff (e.g., correctional personnel; Thornton et al., 2018).

Facilities participating in the program were offered technology purchased by INPEP ECHO to ensure the appropriate infrastructure was available for peer educators to join the synchronous teleECHO sessions. In the first year, two facilities accepted INPEP ECHO technology carts, a third used existing technology to join teleECHO sessions, and a fourth facility was not authorized to utilize INPEP ECHO equipment or attend the virtual continuing education.

Method

This article examined both quantitative survey data completed by peer educators and students before and after trainings (see Appendix 1 for an instrument example) and qualitative data from prison-system email responses that peer educators shared with the INPEP ECHO staff geared toward programmatic improvement. The selected team performed a secondary analysis of the survey and qualitative data to evaluate the program’s efficacy during its first year of operation. Data used in this article were collected for quality assurance and pedagogical purposes and were deidentified before any analysis. All data were entered into a computerized system (REDCap) and given a random identifying number before transfer to the analysis team.

The analyzed dataset included 62 peer educators and 857 students. Though more people participated, the research team excluded approximately 260 student surveys with missing data to ensure quality.² As previously described, all peer educators were recruited using fliers and recommendations from IDOC staff. Peers were selected following a brief educational session about INPEP ECHO and a professional interview.

All training materials during the study period were printed in English. Although INPEP ECHO staff recognizes the benefits of adapting printed materials to other languages, such as Spanish, there was not sufficient capacity to translate materials at the time of the study. Efforts to expand infrastructure are underway and include developing INPEP ECHO peer education materials in additional languages.

Ethical Approval and Consent to Participate

All methods were carried out in accordance with relevant guidelines and regulations. The need for ethics approval as well as informed consent for this article was waived by the Indiana University Institutional Review Board, whose review determined that this article fell outside of human subject research review and was therefore exempt.

Quantitative Analysis

Independent variable

The primary independent variable for examining survey scores was whether the scores were derived from a posttraining survey as opposed to the pretraining survey. That is, regression analysis included both pre- and post-survey responses, with a binary variable indicating 0 = pre, 1 = post.

Dependent variables

Outcomes of interest were derived from surveys that were administered to peer educators immediately before and after the initial 40-hour peer educator training conducted by INPEP ECHO staff and those administered to students from the facility’s general population before and after each of the workshops taught by peer educators. Peer educator surveys contained four categories developed by NMPEP ECHO staff as measures of quality improvement and were closely related to respondents’ ability to teach health topics:

Knowledge: Twenty multiple-choice knowledge questions about infectious diseases such as HCV, STIs, SUDs, harm reduction, and noncommunicable conditions (e.g., how to prevent diabetes, how HCV can spread).

Attitudes: Five attitude questions using a 5‐point Likert scale (strongly agree to strongly disagree) to assess attitudes about issues such as drug use, HCV, and syringe services.

Behavioral intention: Five behavioral intention questions using a 5‐point Likert scale (very likely to very unlikely) to assess the likelihood that peer educators, upon release, would consistently wash their hands before meals and after using the bathroom, find a primary health care provider, get a tattoo using new ink and equipment, talk to their sex partners about STIs, and use condoms every time they have sex.

Self-efficacy: Seven self‐efficacy questions using a 5‐point Likert scale (strongly agree to strongly disagree) to assess ability to teach and retain necessary information, as well as overall confidence in their skills to be a peer educator.

Surveys of students participating in the workshops included 10 knowledge and 5 behavioral intentions questions reflective of the content discussed, including HCV, HIV, STIs, staph/MRSA, TB, and diabetes (Supplementary Appendix S1).

Control variables

Surveys for both peer educators and students included questions about race, ethnicity, age, and education level. Although surveys had a question about gender, each prison facility only houses a specific sex,³ so this characteristic folds into the covariate for the facility. In addition, the covariates may be included with models that do not include individual-level fixed effects but not those with them. Essentially, these fixed effects serve as control variables for each individual. Thus, when they are present in the model, any other covariates would introduce multicollinearity.

Analytic model

A multivariate regression model with incrementally stricter fixed effects was used to examine survey results. Control variables for facility, date of session, a facility-times-date interaction, and individual (anonymized) identification number were added to provide a test of robustness, indicating whether results might come from variation in these factors rather than INPEP ECHO itself. As survey results skewed heavily to the right (i.e., were not normally distributed owing to a substantial portion of higher scores), outcome data were monotonically transformed using a natural log.

Standard errors were clustered at the facility level to deal with any spillover effect between participants at the same facility, which would violate a core regression assumption: stable unit treatment values (Wing et al., 2018). As the sample of peer educators is much smaller than the sample of students, the date of assessment cannot be used as a fixed effect in the same model as the $post$ variable as this would introduce multicollinearity. Thus, two models for peer educators are presented that include facility fixed effects and all control variables and another with facility and individual fixed effects. Four models for students are presented using graduating levels of fixed effects.

Qualitative Analysis

The primary data source for qualitative analysis was peer educators’ email responses to questions about their experience with INPEP ECHO. As the suspension of visitation during the COVID-19 pandemic severely limited contact between INPEP ECHO staff and peer educators, the IDOC allowed staff to communicate with peer educators through the prison email system. A convenience sampling method was used to generate responses and included the peer educators who were active with the INPEP ECHO program at the time. Specifically, peer educators were asked:

Can you tell me your general opinion of INPEP ECHO?

What would you say are our successes?

Do you think there has been any impact on your facility generally?

How about with people specifically (like yourself)?

Are there any skills you have gained from being a part of the INPEP ECHO team?

What challenges or barriers have you faced as a peer educator?

Do you have any suggestions for us to do better?

Is there anything you would like to share that is not covered in these questions?

Three coders independently evaluated deidentified data from 21 peer educators, then met to discuss their findings and general themes, and attain consensus (AJ, PH, MM).

A thematic analysis of qualitative data was performed, looking for common constructions of peer educator experiences (Creswell, 2007). Two of the three authors who reviewed the qualitative data have operational connections with INPEP ECHO, so a third reviewer with little preliminary knowledge of the program was engaged to guard against bias.

Results

Sample Characteristics

As of March 2021, INPEP ECHO operated in four Indiana prisons and had trained 64 peer educators who then taught nearly 2,000 students. This analysis included 62 peer educators and 857 students with paired and complete pre- and post-survey responses. Table 1 shows descriptive statistics for both peer educators and students included in this article. Black/African American participants comprised the largest racial group for peer educators and were less represented in the student group. Peer educators also tended to be a bit older than students with mean ages of 39.88 years and 37.03 years, respectively. Students represented a wider range of ages with participants aged 18 to 72 years. Table 1 does not include a variable for gender (constructed as “sex” by prisons) as this is also contained in the facility variable. The only facility housing females-at-birth in this sample is the Indiana Women’s Prison.

Table 1.

Descriptive Statistics

	Peers	Students
Age (Mean, at time of pretraining survey)	39.88 (range: 21–69)	37.03 (range: 18–72)
Race (%)
Asian	0.00	0.47
Black	46.77	28.94
Native American	1.61	2.80
Pacific Islander	0.00	0.47
White	35.48	58.11
Other/Multiple races	14.52	9.10
No answer	1.61	0.00
Ethnicity (%)
Hispanic	3.48	5.83
Facility (%)
CIF	17.74	69.10
IWP	30.65	11.29
Pendleton	19.35	7.79
Plainfield	32.26	11.82

Quantitative Analysis

Survey score averages are reported in Table 2 as well as the highest possible test score. Student surveys did not include questions about self-efficacy or health attitudes. In all cases, post-training surveys returned higher scores than pre-surveys.

Table 2.

Outcome Statistics

	Peers		Students
	Pre	Post	Pre	Post
Knowledge scores	11.52/20	15.40/20	4.65/10	6.58/10
Self-efficacy	27.34/35	33.11/35	—	—
Behavior intentions	24.02/25	24.32/25	21.54/25	22.66/25
Health attitudes	23.66/25	24.99/25	—	—

Peer educators

Regression analysis of peer educator pre- and post-training surveys collected during the 40-hour training was done using two models (Table 3). After accounting for individual characteristics (Model 2), increases were seen in the knowledge scores (31.6%; p = 0.000), health attitudes scores (10.4%; p = 0.001), and self-efficacy scores (24.6% increase; p = 0.016). Only behavioral intentions scores did not change significantly.

Table 3.

Peer Scores

	(1)	(2)
Knowledge scores
Post coefficient	0.217* (0.024)	0.274*** (0.000)
Post %	24.12%	31.57%
Within-R2	0.411	0.673
N	62	62
Self-efficacy
Post coefficient	0.191* (0.014)	0.222* (0.016)
Post %	21.00%	24.63%
Within-R2	0.191	0.318
N	62	62
Behavior intentions
Post coefficient	0.012 (0.196)	0.008 (0.674)
Post %	1.29%	0.08%
Within-R2	0.164	0.007
N	62	62
Health attitudes
Post coefficient	0.029 (0.532)	0.099** (0.001)
Post %	2.94%	10.37%
Within-R2	0.146	0.119
N	62	62
Control variables	All	Limited
Fixed effects	Facility	Facility, ID number

Bolded values refer to percentage change.

p scores in parentheses; standard errors available upon request.

*p < 0.05, **p < 0.01, ***p < 0.001.

Students

Analysis of the student pre- and post-education surveys found increases in behavior intentions (6%; p = 0.000) and knowledge scores (59%; p = 0.000) after attending workshops facilitated by peer educators (Table 4).

Table 4.

Student Scores

	(1)	(2)	(3)	(4)
Knowledge scores
Post coefficient	0.442** (0.009)	0.456*** (0.000)	0.462*** (0.000)	0.463*** (0.000)
Post %	55.62%	57.87%	58.73%	58.93%
Within-R2	0.127	0.095	0.093	0.185
N	857	857	857	857
Behavior intentions
Post coefficient	0.055** (0.002)	0.070*** (0.000)	0.067*** (0.000)	0.058*** (0.000)
Post %	5.65%	7.25%	6.90%	6%
Within-R2	0.058	0.056	0.053	0.050
N	857	857	857	857
Control variables	All	All	All	Limited
Fixed effects	Facility	Facility, date	Facility, date, Facility × date	Facility, date, Facility × date, ID number

Bolded values refer to percentage change.

Standard error in parentheses.

**p < 0.01, ***p < 0.001.

Qualitative Analysis

Twenty-one peer educators emailed comments about their experience in INPEP ECHO. Peer comments were organized thematically and classified into two categories: personal and community impact (Table 5). Of the 21 peer respondents, 17 mentioned improved health knowledge for themselves and the students they taught, and also felt there was a strong likelihood of future health benefits. “My general opinion of INPEP ECHO would be that it saves people’s lives. Whether it be with harm prevention tools we share [or] how important it is to get tested” (P3).

Table 5.

Qualitative: Personal Benefits

Skills		Beliefs
Health knowledge	17	Belonging	11
Communication	9	Empathy/Altruism	11
Teamwork	6	Hope	5
Confidence	7
Leadership	4

The development of several professional skills was mentioned as a personal benefit, with communication and public speaking among the most commonly reported responses. One peer educator said, “I’ve never been able to talk without stuttering in front of people and I can do that now, also feeling I’m able to connect with people who need this information” (P15). Other skills discussed included teamwork, confidence, and leadership capabilities.

Many peer respondents described improvements in less tangible beliefs, such as a stronger sense of belonging: “I am not just an inmate but play an important role in helping people…” (P2). Over half expressed gaining perspective outside themselves, as evidenced by mentions of empathy, altruism, or generativity. One peer provided a strong example of this by describing how participation helps peer educators “to care about ourselves, and in turn caring about others.” (P19). Another shared that “INPEP [ECHO] has given me… the chance to make amends through serving and helping others” (P16). Five respondents mentioned the word “hope.”

Another theme that emerged from the data was self-efficacy. Not only did peer educators indicate an improved sense of self-efficacy, but many also tied this change to two potential mechanisms of action: having expertise in a specific topic (health knowledge) and feeling a sense of purpose and usefulness. One participant stated, “[INPEP ECHO] aids in building our self-worth…it adds to our skillset, it helps us and lends hope to the lost, forgotten, overlooked, and marginalized” (P16). More than half of the respondents (n = 12; 57%) used self-efficacy language, 38% (n = 8) described gaining new expertise and a sense of purpose, and 20% (n = 4) of the respondents mentioned both (Table 6).

Table 6.

Qualitative: Self-Efficacy and Broad Benefits

		Broad Benefits
Self-efficacy	12	Prison	8
→Expertise	8	Families	4
→Purpose	8	Communities	4

Peer educators also talked about the impact of INPEP ECHO extending beyond those who were engaged in this program to families and to the larger community (Table 6). One participant provided a vignette about a conversation in which a student shared they had learned their son was diagnosed with type 1 diabetes. “Because of INPEP, I was able to answer questions that [they] had about [their] son’s condition.” (P12).

Discussion

Findings from this evaluation demonstrate that participation in INPEP ECHO as either a peer educator or as a student resulted in positive and significant changes in knowledge and health attitudes. Self-efficacy was also improved among peer educators. The survey results from students who took the 10-hour workshop hosted by peer educators demonstrated an even greater increase in knowledge improvement, and a lesser, yet still significant, change in behavioral intention.

This may be related to the structure of the educational experience delivered in the 10-hour workshop compared with the 40-hour training. Peer educators who facilitated the 10-hour workshops were viewed as credible messengers of health information and were adept at presenting content in ways that acknowledge the realities and challenges related to maintaining health while incarcerated. One of the foundational goals of the INPEP ECHO program taught during the training is that only evidence-based information that can be sourced from their manuals or directly from the INPEP ECHO staff should be used in workshops.

Peer educators, however, have creative freedom to present the facts in ways that are relatable and resonate with their student audience. Peer educators often incorporate games, skits, and humor as part of their workshops. This level of trust and engagement may account for the dramatic increase in health knowledge observed by students. The increase in assessment scores also provides supporting evidence that the program is reaching the intended population.

In contrast to 10-hour workshops, 40-hour trainings include interactive conversations related to mechanisms of changing health behaviors and in-depth discussions regarding effective qualities of a peer educator (e.g., being a role model). This focus, paired with a peer candidate selection process that identified people who are likely ready and interested in change, may play a role in the differential behavioral intention results. Individuals who are selected to train as peer educators are likely to be more informed about health topics than their students when they join the program. These findings are worth exploring in subsequent studies.

INPEP ECHO achieved its initial goal of increasing health knowledge; furthermore, peer educators showed significant increases in health attitudes and self-efficacy. Qualitative data confirmed these findings in which peers invariably described improved self-efficacy as a companion to newly gained expertise in health topics and/or a new sense of purpose. Improving confidence and self-efficacy in this population offers multiple direct and indirect benefits. For example, participating in the INPEP ECHO may help build autonomy and inform decision-making around personal health and safety while incarcerated. The positive implications of improved health knowledge and strengthened self-efficacy may also be sustained through reentry and contribute to public health benefits over time.

Providing peer educators and their students with an opportunity to learn and grow may also build a sense of hope, which was reflected in the data. Given that negative outcomes (e.g., substance use, recidivism) correlate with constructs such as low self-efficacy, programs such as INPEP ECHO may begin to address underlying issues antecedent to such negative outcomes. Positive changes in self-efficacy and serving as a peer educator may also point toward tangential outcomes such as criminal desistance and long-term quality of life (Allred et al., 2013; Johnston et al., 2019). Further work is needed to explore this connection.

Peer educators also provided detailed insight about the impact INPEP ECHO had not only on themselves and their students, but also on families and community members beyond prison walls. The spread of information and benefits outside the facility illustrates a community ripple effect that likely follows investments in the health of people living in incarceration (Jordan et al., 2022). The roughly $162,000 of INPEP ECHO’s first-year budget presents a relatively inexpensive method for improving health inside and outside of prison walls.

Limitations

The article had some notable limitations. Analysis was performed on data attained for program quality improvement, not initially conceptualized in its design for generalizable research, thus limiting the ability to draw causal inferences. The evaluation instruments used INPEP ECHO-specific language (see Supplementary Appendix S1), thereby making generalizability difficult. The structure of the qualitative prompts may have introduced response and social desirability biases. Challenges existed with the data quality as the survey responses were collected using an article-based system and were not always filled out completely. As a quality control measure, 260 pre- and posttests with missing data were excluded (23% of the total sample from the first year of implementation).

Findings also indicate the need for further research. As the survey responses and qualitative data provide only indications of immediate benefits (e.g., change in health knowledge), conclusions about long-term outcomes cannot be drawn definitively. Yet, these short-term results point toward potential for mid- and long-term improvements, as findings in other contexts have demonstrated (Adams, 2010; Robertson et al., 2011; Watson et al., 2004).

Health knowledge, behavior intentions, and attitudes around health topics may lead to changes in health outcomes such as engaging in preventive care (e.g., seeking vaccination), practicing harm reduction, and treatment adherence (Robertson et al., 2011; Watson et al., 2004). Although immediate improvement in health knowledge may be associated with better health outcomes, objective examination of health and criminogenic outcomes is essential to fully understand the impact of peer education interventions.

Evaluating the continuing education provided through virtual teleECHOs sessions is another area of opportunity, especially to better understand potential for long-term impact. In this article, changes resulting from participating in teleECHO were not assessed. Engagement in teleECHO sessions was also not uniform across all locations, and one site was not able to participate in any sessions during the article period owing to facility restrictions. In future studies, the impact of teleECHOs on sustained knowledge acquired, behavior change, program retention, and downstream health outcomes should be analyzed.

Conclusion

Peer-led programs such as the INPEP ECHO aim to achieve layered goals of improving health education and increasing confidence and self-efficacy, with the objective to positively impact long-term health and life outcomes. This analysis demonstrated improvements in health knowledge, attitudes about health topics, behavioral intentions, and self-efficacy, thus suggesting that INPEP ECHO was successful in achieving its programmatic targets. Qualitative data supported quantitative results, lending further credibility to the overall conclusion of its effectiveness.

Given the financial resources needed to address the transmission and treatment of infectious diseases that are common in correctional populations, as well as negative criminogenic outcomes (e.g., recidivism), investments in programs such as INPEP ECHO could lead to substantial savings in both direct and indirect costs. Scaling these programs to serve more people during their incarceration could continue to bolster impact and contribute to budgetary savings for state correctional facilities.

The findings of this study add to the existing literature evaluating other peer education programs using the ECHO model in correctional settings by applying robust quantitative methods and identifying emergent themes from qualitative analysis. The results also add to the broader body of peer-reviewed literature regarding peer education models in correctional populations and point to additional evidence that health education training led by people with shared lived experiences has general benefits.

Footnotes

Acknowledgments

The authors would like to thank everybody from the New Mexico Peer Education Project, especially Daniel H. Rowan, Barry Ore, Carissa B. McGee, Saul Hernandez, and Karla Thornton. Furthermore, we appreciate all of the hard work and dedication of the INPEP ECHO peer health educators and IDOC for the support they showed getting this program off the ground and helping people who are incarcerated to live healthier lives.

Authors’ Contributions

A.J., J.C., A.C., D.N., E.C., and J.D.: Conceptualization; A.J., P.H., and M.M.: Data curation; P.H.: Quantitative; M.H., P.H., and A.J.: Qualitative; D.N., J.D., and A.J.: Funding acquisition; A.J., J.C., A.C., D.N., E.C., and J.D.: Investigation; P.H., A.J., and A.C.: Methodology; J.D.: Project administration initially, then A.J. once J.D. moved to a new institution. A.J., J.D., D.N., and E.C.: Resources; P.H.: Software, used Stata for quantitative; M.H., P.H., and A.J.: used Microsoft Word and Excel for qualitative. J.D.: Supervision, initially, then A.J. once; J.D. moved to a new institution. P.H. and A.J.: Validation; P.H.: visualization; P.H. and A.J.: Writing—original draft; All authors: Writing—review and editing.

Author Disclosure Statement

The authors disclosed no conflicts of interest with respect to the research, authorship, or publication of this article.

Funding Information

The authors’ effort in the preparation of this publication was supported by CDC grant Opioid Crisis Funding Cooperative Agreement no. 32134, CDC passthrough Indiana Communities Advancing Recovery Efforts number 37851, Indiana State Grant Project ECHO number 35463, SAMHSA Indiana Peer Education Program Expansion number 50745, and HRSA Region V Public Health Training Center project number UB6HP31684, as well as grant R24DA051950 from the National Institute on Drug Abuse, National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the CDC, the State of Indiana, the HRSA, or the National Institutes of Health.

Supplementary Material

Appendix

Attitude Questions

Please fill in one bubble for each answer that best describes your attitude:

Behavioral Intentions Questions

Please fill in one bubble for each answer that best describes your attitude:

Once you are released, how likely are you to:

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Supplementary Material

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Peer Education as a Tool to Improve Health Knowledge for People Who Are Incarcerated: A Secondary Analysis of Data From the Indiana Peer Education Program ECHO

Abstract

Introduction

The Indiana Peer Education Program ECHO

Method

Ethical Approval and Consent to Participate

Quantitative Analysis

Independent variable

Dependent variables

Control variables

Analytic model

Qualitative Analysis

Results

Sample Characteristics

Quantitative Analysis

Peer educators

Students

Qualitative Analysis

Discussion

Limitations

Conclusion

Footnotes

Acknowledgments

Authors’ Contributions

Author Disclosure Statement

Funding Information

Supplementary Material

Appendix

References

Supplementary Material