Process evaluation results

In this chapter we will discuss:

• adherence to the intervention by volunteers and the befriending services
• acceptability of the intervention and trial procedures and processes.

Intervention adherence

Intervention adherence by volunteers

Volunteers were asked to meet their befriendee once per week for 1 hour, over a period of 6 months (24 visits). Volunteers were required to document their activities with their befriendee in a structured logbook following each session. They were required to record whether or not they had had a meeting and reasons for cancellation, what activities they did with their befriendee, where they spent their time together (e.g. at the person’s home or in the community), the duration of the meetings and their reflections on the visit in terms of aspects that did or did not go well.

Six volunteers returned their structured logbooks. The total number of meetings between the volunteer and participant with ID ranged from 1 to 21. Two pairs met only once or twice (in one case because of dissatisfaction with the matching process, which was raised by a family carer, and in the other case because conflict with carers led to the breakdown of the pair’s relationship ). Two pairs completed 20 and 21 meetings. The total number of meetings by all the pairs was 71, and the average number of meetings was 11.8. Four out of the six pairs met on more than 10 occasions, which was the minimum number of stipulated meetings that was considered to be acceptable. Only six recorded contacts were not face to face (i.e. were by telephone or video call). The average duration of meetings for each pair ranged from 67 to 210 minutes, with an average duration of 118 minutes, which was well above the minimum of 60 minutes that was required for each meeting. Most volunteers met their befriendee approximately every 2 weeks, and this may be the reason why they spent a longer period of time together when they did meet. Reasons for pairs not being able to meet up included volunteers being unwell, going on leave or holiday or having university commitments. Four of the pairs have continued their relationship beyond the 6-month period and remained in contact.

Tables 8 and 9 show the types of activities that the pairs engaged in, categorised into activities that took place outside the home and inside the home. The majority of activities were outside the home (59/91 activities; 68.8%). Apart from one participant with ID who refused to leave their home, all the other participants spent over 50% of their time in the community. The most common types of activities outside the home involved going to cafes (18 meetings; 19.8%), going for a walk (12 meetings; 13.2%) and going to a restaurant (10 visits; 11.0%). The most common indoor activity was having a conversation (16 meetings; 17.6%), followed by playing games (six meetings; 6.6%) and arts and crafts activities (four meetings; 4.4%). According to the logbook entries, the majority of activities (> 90%) were described as being pleasant or enjoyable by the volunteers.

Intervention adherence by befriending services

All the volunteers who were matched were recruited by the Outward befriending scheme in Hackney. Training was completed by all the volunteers prior to matching, which included training modules on confidentiality, depression, diversity and equality, health and safety, and safeguarding of vulnerable adults. These modules were delivered through an online social care provider (Social Care TV, Hingham, UK). The volunteers also completed a 2-hour classroom-based session on volunteer induction training.

Supervision of volunteers was intended to occur on a monthly basis over the 6-month intervention and was provided face to face or by telephone. Five volunteers participated in supervision. A total of 21 supervision sessions were completed by the volunteers. The average number of sessions completed was 4.2 (range 3–6 sessions). The majority of the sessions were face to face (16; 76.2%). A supervision form was used to record discussions, which was developed by the befriending service. Volunteers were asked about their general well-being, their ability to manage their role and commitments, what they felt has gone well or they had enjoyed, if they had any concerns about their befriendee or their relationship, issues around maintaining boundaries, activities that the befriendee had requested and any support or training needs. Work or family commitments were the main reasons for volunteers not being able to attend supervision. Topics/issues that were discussed at supervision are presented in Appendix 3, Table 17. Managing the balance between work and personal commitments with the befriending role was mentioned by four volunteers [discussed in five (23.8%) sessions]. The issues that were most commonly raised in supervision were concerns about the participant’s physical health [discussed in seven (33.3%) sessions by three volunteers]; concerns about the befriendee’s finances, such as the befriendee not having enough money to participate in activities [discussed in seven sessions (33.3%) by two volunteers]; reasons for missed sessions [discussed in five sessions (23.8%) by two volunteers]; managing repetitive questioning [discussed in four sessions (19.0%) by three volunteers]; concerns about the befriendee’s mental health [discussed in four sessions (19.0%) by two volunteers]; time management [discussed in three sessions (14.1%) by three volunteers]; and dealing with carers [discussed in three sessions (14.1%) by three volunteers]. Safeguarding issues were discussed by two volunteers (in two sessions; 9.5%) and managing the ending of the relationship was raised by one volunteer (in two sessions; 9.5%).

Monitoring sessions were also held with participants with ID who were receiving the befriending intervention. The volunteer co-ordinator was able to make contact (face-to-face meetings or telephone contact) with five out of the six participants who were matched. There were 12 monitoring contacts in total. The number of monitoring sessions for each participant ranged from 1 to 4 (average 2.4 sessions). The reasons for monitoring contacts not taking place included participants not being contactable, declining to meet up or being unable to meet up because they were busy with other commitments. The befriending service developed their own monitoring forms. Nine monitoring forms were completed with four participants. During these sessions, participants were asked about any issues that they had and to rate their satisfaction with the intervention on a three-point scale (yes, no, sometimes). They were asked questions about whether or not the volunteer visited when they expected them to (rated ‘yes’ on all nine forms), about satisfaction with the matching process (rated ‘yes’ on all the forms), about feeling comfortable talking to the volunteer (rated ‘yes’ on all the forms except one, which was rated as ‘sometimes’) and if the volunteer had helped them to do something new or to go out (rated as ‘yes’ on seven forms and ‘no’ on two forms). No major concerns were raised by participants.

Acceptability of the intervention and study processes

Twenty-five participants (12 participants with ID, five volunteers, five carers and three volunteer co-ordinators) were approached and 21 agreed to take part in interviews. Four declined participation or were unavailable to take part (three participants and one family carer). There was a total of 20 interviews (one interview was carried out with two volunteer co-ordinators at the Suffolk service owing to time constraints, as one staff member was leaving her job). There were nine interviews with participants with ID (involving five participants in the control group and four participants in the intervention group); six participants were female and three were male. There were five interviews with volunteers who had been matched (four females and one male). The three volunteer co-ordinators and four carers who were interviewed were all female (three were paid carers and one was a family member). The duration of the interviews ranged from 7.3 to 31.2 (mean 18.1) minutes for participants with ID, from 19.3 to 40.4 (mean 32.6) minutes for volunteers, from 59.1 to 89.5 (mean 74.3) minutes for staff at befriending services and from 11.2 to 44.5 (mean 31.5) minutes for carers.

Results

We discuss the findings in relation to the three broad areas of acceptability of trial processes, acceptability of the befriending intervention (including perceived benefits) and suggestions for improvements to the intervention and study processes.

Acceptability of trial processes (information about the study and randomisation)

There were some concerns that participants had not understood the process of randomisation or what the study entailed:

They understood it in the fact that they would either get a befriender or not but I don’t think there was a huge understanding about the randomisation processes, control and that sort of thing.

The customer said she didn’t understand what it was all about because she didn’t understand it was a study. Although the staff understood what they were doing, but the customers didn’t have a lot of information about it. To them they were getting somebody for them to go out and do activities and for them that was the main focus.

Participants had mixed feelings about the randomisation process. Two participants with ID reported feeling worried about which group they would be allocated to and one participant reported being unhappy about being in the control group:

Other participants stated that they thought that the randomisation process was fair, even if they were disappointed at not being allocated a befriender:

Yeah that’s the only thing you know, that did disappoint me a little bit because, you know, I think we should have the choice to choose which group we are in. But if that’s what the rules are then that’s the rules.

Acceptability of the intervention

Recruitment process

During the trial, volunteers and participants were recruited concurrently. The volunteer co-ordinator at the Outward scheme commented that it would have been helpful if participants with ID had been recruited first before recruiting volunteers, as volunteers lost interest or dropped out while they were waiting for a suitable match:

I suppose one of the – we had a lot of interest at the beginning – one of the problems that we did have was that we recruited quite early and then we lost people because people weren’t ready to be matched.

Matching process

The limited pool of volunteers and participants meant that there was limited choice in relation to finding matches based on interests and hobbies. One of the matches was rejected by a carer who did not feel that the volunteer’s interests were aligned to those of the participant. It was felt that carers could act as a barrier or hindrance to the matching process. This left the volunteer feeling dismayed by the process and the person with ID without a suitable alternative match:

But I suppose one of the difficulties really was just having the support and care team on board with befriending – the reasons for it and how it could benefit somebody and how they are not a member of staff . . . But I think she felt a little bit disheartened by the experience, so, which is understandable, but it was just a big learning curve, I think, with that matching.

Intervention: training for volunteers

Volunteers found the face-to-face training helpful, but also appreciated being able to complete the online training in their own time:

I think the one . . . online was really helpful because I kind of just got to look at that in my own time. But then I also thought that the training with [name of person] was really, really helpful, just because it was a nice informal setting where she explain to me how the study would work, what befriending would entail and questions that I did have she was able to answer really well, so I thought that was a really, really helpful experience, just because it kind of cleared up any questions and any concerns and any preferences that I may have had in terms of the befriending; it was really, really helpful.

Volunteers also commented that the training did not prepare them for some situations in which they had to make rapid decisions and when it involved going against the advice they were given:

There were certain situations where the training said I am not allowed to, let’s say, handle money for the person, but we came into a situation where I had to do it if that makes sense. So maybe those kind of details where you have to have a quick decision-making skills, I think that was a bit tricky.

Intervention duration

Some interviewees thought that the duration of the intervention, 6 months, may have deterred some potential volunteers from taking part, as they were unable to commit this amount of time:

Potentially, at the beginning, when we said it was 6 months that may have put some people off, but I mean, obviously, that was the whole point of the study. I think when people come in to volunteering, sometimes they only want to dip their toe in the water and just see whether they like it rather than having to commit to something.

Volunteers and participants generally commented that the 6-month time frame was appropriate:

I think the 6-month period, I think it went quite quickly to be honest, it did go quite quickly so I think the 6 months is a good amount what time.

Only one participant commented that the duration was too long. One participant with ID and two carers commented that they thought that the duration of the intervention should be longer. One carer commented that they were worried about the visits ending and the impact on the participant as she was fond of the volunteer’s dog and they spent many sessions walking the dog (they are continuing to meet):

I think it should be ongoing rather than 6 months. She looks forward to seeing the dog every week even though it’s not her dog, it’s kind of like she’s a dog keeper, you know going with [person’s name] to take dog for a walk and back not far from here. I think that’s where they normally go to and then she looks forward to that. If that stops in 6 months, I think that will dishearten and you know she’s not going to be – it will be devastating for her.

Intervention: frequency of visits

Volunteers reported that weekly visits were difficult to maintain, with visits often being scheduled every 2 weeks. They felt that it was important to have flexibility over the frequency of visits because of other commitments:

So yeah, I found it better if it wasn’t weekly, if it was every other week. I think because, for me, it had to be after work, so it just made it a bit tricky in terms of meeting up in the evening. I suppose sometimes I was a bit tired from work and that kind of thing. Because we met up on weekends as well – but that wasn’t as much, tended to be on the sort of mid-week in the evening, which was bit better for me.

We didn’t meet every week, so we met every second week, this was something that was kind of decided between myself and his mum. She felt that every second week would be best and it worked for me as well, so that was that.

One volunteer reported that it was difficult scheduling meetings during the week as the participant was busy with other activities:

Yeah, it was difficult because [name of person] – well I work during the week but I could – sort of met [name of person] early evening and sort of in the morning and stuff. But [name of person] is quite busy Monday to Friday – she goes out to her activities, so we only had the opportunity to meet on a Saturday or Sunday, which was difficult for me to do every week. So we kind of got into a pattern of meeting for a whole afternoon every 2 or 3 weeks and just sort of putting the time together really to go out and drive somewhere, go for lunch, go for a walk.

Intervention: duration of sessions

Sessions often went on longer than planned because of the nature and type of activities that the pair had decided to embark on. Activities involving long-distance travelling, such as visits to the museum, took longer. One volunteer reported that he had difficulty managing his time and balancing other commitments, but this improved over time:

So in the first 1 to 2 months I actually found it quite demanding because of the time management and the things that we done together have changed quite a lot throughout the programme. The first few times – not few times, I mean six to seven times – what we usually did was we travel around London, and sometimes I found it quite hard to really manage the time because of queuing up and stuff, so I found it really demanding in terms of balancing between school and travelling round. Luckily in later times, because of the weather and things, my befriendee asked if we could do things indoors more . . . I got more hold of how to manage time better and I actually felt more comfortable after that, yeah.

Use of resource booklet

None of the volunteers and participants reported that they used the resource booklet of activities to plan activities. Volunteers used their own knowledge or asked the participant what they wanted to do:

. . . because I live anyway in [name of area] and I know the area where [name of person] really well so we just chatted about what we knew was around and yeah, what [name of person] wanted to do.

One volunteer co-ordinator commented that the activities in the booklet were not all appropriate and recommended some changes:

I think it’s useful to have so, but maybe suggestion of activities rather than specific ones so could you find bowling in your local area or could you do this.

Intervention: types of activities

One volunteer commented that they were able to engage their befriendee in a range of activities at home and outside:

We have done quite a lot of things actually, we have done origami . . . we have done some drawings before, and then actually more recently we did cooking, yeah we have done actually two or three times, cooking and bakery, that was really good . . . traveling around London a bit . . . and also Bible study, I forgot.

One participant with ID commented that he was pleased with the activities:

It was great, it was absolutely great, having a befriender that communicates, that can take me out. We would be going to cinema, we were going to bowling . . . erm . . . museums, we were going to the bookstore. It’s been absolutely great.

A couple of volunteers reported having difficulties deciding on and planning activities with their befriendee and feeling uncertain about what they should be doing:

But I think I expected to kind of, to have more of a clear understanding of the kind of activities we were supposed to be doing and I think everyone involved had this idea that someone else would figure out what activities we would be doing with this person to integrate them back into the society kind of . . . But I think there was just no clear effort on anyone’s side to kind of say ‘this is what you could do with the person each weekend or every second weekend’.

One volunteer commented that there were not many options in the person’s local area, which was not helped by the weather at the time:

We basically just went into the cafe near his house and we had some food and just a chat. But the weather wasn’t great back then, I think it was November, December, so it was quite grim honestly. There wasn’t a lot to do, if this was now it would be a lot different.

Intervention: supervision and support

All the volunteers reported that they had felt supported throughout the study:

Yeah definitely. Every session I was asked if there is anything wrong or anything that I have any concerns about. So yeah, I definitely felt comfortable to, you know, mention any concerns or if I needed any support.

However, one volunteer reported that they did not feel supported:

Just before I was about to go to my first session, the first aid kit I got sent in the post, I received too late. I know that [volunteer co-ordinator] didn’t always respond on time and things like that.

Volunteers commented that they were satisfied with the supervision sessions and that they felt supported by the volunteer co-ordinators. They felt that the frequency was adequate:

I think it was really nice to have just a monthly meeting catch-up and just talk about how the experience was going. And I think just overall it was nice to have that kind of support and especially it being monthly, I thought it was a good balance.

One volunteer commented that she would have preferred to have had the supervision sessions when she needed them, as she did not have much to report:

So I don’t know – like, I didn’t find it that beneficial for me because things hadn’t changed that much month to month. So maybe it would be more – I would probably find it more useful if I could say to them when would be good for me to sort of have a check-in, it didn’t necessarily need to be every month, maybe it could have been every other month or something like that.

Ending of the relationship

Four pairs were continuing to meet after the 6-month period and, therefore, no significant issues were identified in relation to the ending. Carers reported some concerns about how participants may react. Two participants with ID did express that they may feel unhappy when the befriending came to an end:

It would be a pity when it does, because I will be . . . I might [not] be alright, you know what I mean.

Other themes

There were a number of other themes that were related to the intervention. These included ‘motivations for taking part’, ‘managing expectations’ and ‘communication is crucial’.

Motivations for taking part

Most of the volunteers cited gaining experience for career progression as their main motivation for becoming a befriender:

I was thinking of doing something related to psychology, which is my university course, and I guess it aligns with my career prospects because I want to work in future in jobs that interact with people.

Some volunteers noted that they enjoyed befriending as it allowed them to meet new people or that they wished to do something useful with their free time:

Have done some befriending before doing this befriending and I sort of really enjoyed meeting that individual.

I wanted to do something to sort of interact with people a bit more and use a bit more of my free time.

Most of the participants with ID mentioned that getting a befriender was their main motivation for taking part in the study as this option was not readily available:

Having the befriender.

One participant stated that they wanted to experience something new:

The reason I wanted to take part is because I think it would be useful for me to find out different things and learn different things.

Managing expectations

Participants, volunteers and carers had misconceptions about befriending. Some participants with ID had unrealistic expectations about their befrienders. One participant mistook the role of the befriender for a romantic partner:

She was expecting a male because I think just the word befriender some kind of, you know, erm, made out to feel like it was going to maybe pair her up with a male figure . . . she wants a boyfriend, she’s interested in having a boyfriend.

When discussing the role of the befriender, some volunteers reported that they were unsure of what was expected of them:

I mean, if we could know more about how we – like as befriender[s] – it may be better in some ways. Because like the programme has fixed meeting times, like as a normal friend we wouldn’t have like fixed meeting times right, so I guess in a sense my expectation of befriending wasn’t really that clear at first.

It was also apparent that carers also misunderstood the role of the befriender. Some carers believed that volunteers were like support workers, and they expected them to take responsibility for many things that did not concern them. The lack of understanding of the befriender’s role resulted in a conflict whereby a volunteer dropped out of the study:

They also went to Pizza Express [Uxbridge, UK] together and as a result of them going to Pizza Express together the staff threatened to raise a safeguarding against [befriender] for putting [befriendee]’s health in danger [. . .] there is only so much that a volunteer can stop somebody from doing without policing them; there has to be that understanding.

Communication is crucial

This theme encompasses the importance of communication. Participants with ID valued the communication they had with their befrienders, as they were often socially isolated; thus, befriending gave them the opportunity to talk to someone. Almost all participants spoke about having a positive experience in terms of communication with their befrienders:

The good thing is about having a befriender is someone who’s there for you, someone who understands you, someone who will communicate with you, someone who will always be beside you.

A carer spoke about the importance of having someone independent of the care staff for the befrienders to talk to:

Because of the nature of the clients that I work with, they don’t have families, so it gives them somebody to talk to, somebody to trust, somebody to vent out. Like sometimes you don’t want to talk to staff and you don’t want to talk to your housemate, so that’s [an] extra person you can talk to, someone independent who’s not connected to the staff.

On the other hand, there were occasions when there had been a lack of communication between the befriending services, carers and volunteers. Carers complained that there was little or no communication between them and the volunteers, and this caused some tension. This manifested as concerns about the health and safety of the participant and also led to conflict.

Several carers mentioned that they did not get the chance to meet the befrienders and they were concerned about the befriendee’s safety:

Because they would meet up outside the service, because [befriendee] is independent, he goes out in the community by himself, but then it’s also a risk because we don’t know who [befriendee] is meeting out there. At least we should have a picture of who [befriendee] is meeting in case, you know.

One carer felt that conflicts could have been avoided if there had been early communication, but recognised that this was a learning experience:

If it, the communication, was open, if it was discussed openly from the beginning maybe things would have worked better . . . I see it as a learning curve, because befriender to us, the service was new, it was new to the customers, it was new to the staff and I think now that we know more about what is expected and what can go wrong, so risks would be looked at in the future.

Benefits of the intervention

All the participants in the study reported that they had gained something positive out of the experience. It was reported that participants with ID were ‘happier’ and that befriending contributed to their well-being:

I feel like every time I see her she seems – like it seems like it boosts her morale a bit when we meet up. And it feels like she has – either it may be the similar sort of stuff that we chat about, she always is very, very chatty. So it seems like she really does benefit from having someone to sort of chat about things with.

It is a positive thing for them, it lifted their moods up.

Befriending was perceived to have increased the participants’ confidence and their willingness to seek help:

He has built my confidence, he has made me feel [I want to] improve myself, to come forward, ask him anything that I wanted.

I think it kind of just brought out the confidence in him for him to be able to show me around, you know, places he is comfortable with, he knows the route of which train to take, so I think definitely, it benefited him, yeah.

She is more active in asking for help, rather than keeping all the difficulties to herself.

The befriending intervention was beneficial not only to participants, but also to volunteers and carers.

One volunteer reported an increase in their own confidence as a result of the befriending experience, and also felt that she had benefited from attending a social group where she met other people with IDs:

I definitely felt like my confidence probably grew a bit more from meeting [name of befriendee]. And because I actually went to one – she has a social meet-up every month as part of the [name of charity] charity where it is different people in the area with learning disability sort of come together and they just meet up and play music and that kind of thing . . . I think that was quite a good one to push myself into sort of doing something slightly out of my comfort zone.

Two volunteers expressed their appreciation of the reciprocal emotional support that they had received from the befriendee during challenges they had encountered in their own lives:

I had encountered a person and he had upset my faith and then I just briefly told her what happened and she just told me that that guy doesn’t really understand me and I should be encouraged that I, because I have friends and church and stuff that shouldn’t be really that upset. I think yeah, emotional support was definitely a very unexpected thing to happen for us.

Because my mum had been very ill during the period of time and actually [name of befriendee] was a lovely support for me as well during that period.

Another volunteer reported that the experience had provided them with a different perspective of how to view life experiences:

I think I saw the world through [name of person]’s eyes, which obviously is, I think I would like to see how people experience things, how they see them. It just made me grateful as well about things that we take for granted. Especially because it is volunteering, if you are not paid for something, I think you find more meaning in what you do.

One carer commented that the presence of a befriender was beneficial to her and other staff as it enabled them to focus on other tasks or provide support to other residents:

I think for the befriender to come over, it has really helped us a lot . . . it gives me the opportunity to carry on with the paperwork, gives me the opportunity to, you know, spend time with people that live here . . . so of course, yeah, I benefit from it.

Suggestions for improvements to the study or intervention

Changes to recruitment

Volunteer co-ordinators from the Suffolk scheme suggested that events for volunteers organised by the study team could have attracted more interest in the study:

More of physical presence from the study team going out to see volunteers to try and organise events or something like that.

They also expressed some confusion about the timing of recruitment and suggested arranging events prior to recruitment to raise awareness:

We weren’t quite sure when the recruitment had started when it hadn’t so it was a bit back and forth. I think maybe the study could’ve done a few open days or a few contact days beforehand, maybe sort of raising interest before the study began so we had a bit of a buffer, sort of, that we could take some people forward at the very beginning and that way we had looked at more to work with.

Changes to study information and processes

Participants with ID reported wanting more time to decide whether or not to take part in the study and wanted shorter questionnaires. One participant also thought that the information about the study was difficult to understand and should be presented in an easier, more accessible format:

Easier read document . . . explain a bit more.

One volunteer commented that it would have been helpful if they had known not to discuss who they had been matched with, during meetings with the research assistant, as doing so would lead to unblinding:

. . . just kind of like knowing up front not to sort of mention that I had and who it was.

Changes to the intervention

Volunteers commented on the need to make training more practical as they felt unprepared to deal with certain aspects of their role.

One volunteer mentioned that the training should cover what participants with ID struggle with on a daily basis to prepare the befriender:

I guess my point here would be like, it is like the gap between how you deal with daily things and how they deal with daily things, [. . .] I guess like, in terms of decision-making, it would be better if we could know more about the difficulties, they face like decision-making.

Another volunteer commented that they would have valued the opportunity to have kept in touch with their befriendee on social media and that this should be encouraged, although they acknowledged the need for guidance:

I think I wasn’t encouraged to keep in contact with my befriendee on social media actually. So I think in the sense, in terms of intervention, I was thinking – like as a normal friend, like sometimes people exchange contacts and keep in touch on social media, and I think I am not sure whether the intervention really captures that aspect of it. And I do think that actually social media could really help these people a lot . . . if they are capable of managing it.

Summary of the main themes and findings

Overall, the interviewees reported being satisfied with the trial processes, although some participants with ID reported not understanding relevant information about the study, including randomisation. Participants, volunteers and carers reported positive experiences of the intervention and of feeling supported, and there were benefits to all three groups. However, the intervention was perceived to be too rigid and prescriptive in terms of frequency of visits (i.e. once per week was too frequent) and the nature of contacts (other types of contacts should be encouraged, e.g. via social media), and the recruitment process for volunteers could be improved through the hosting of events.

A case study (Jane’s story) illustrates how one participant and their volunteer experienced the befriending intervention and describes some of the challenges they encountered (see Appendix 4).