Quantitative sample.

The quantitative questionnaire data targeted both general perceptions regarding aspects of importance for implementing parenting interventions in prison, and specific aspects related to FOCS. Therefore, all 85 parents in both intervention and control groups of the FOCS trial were invited to respond to the questionnaire, but the control group only responded to the general items. In total, 46 parents (54%) responded to the questionnaire (22 intervention group, 24 control group), with both men and women in prisons of all security levels. The questionnaire was placed on the last page of a battery of questionnaires and went unnoticed by several of the intervention trial participants which caused the majority of the missing data. Intervention and control group participants had not been matched as group allocation was based on the set operation planning (economic planning for activities one year ahead) at each prison. Thus, the prisons that agreed to participate in the controlled intervention trial and where FOCS was carried out during the period of the trial (in accordance with the operation planning) were included in the intervention group. Prisons that agreed to participate in the trial and that planned for FOCS later were included in the control group. Group leaders recruited participating parents in the prisons that had agreed to participate in the trial.

Qualitative sample.

As the purpose of the interview data was to provide an in-depth perspective of participation in and implementation of FOCS specifically, only parents from the intervention group were invited to participate in the interviews. A purposeful sample of parents in the intervention group was identified using maximum variation of the characteristics: sex of parent, and prison in the intervention group (all security levels represented). The target sample for the interviews were 15 parents, but due to the covid-19 pandemic possibilities to reach parents in prison were limited and therefore a total of 12 parents were interviewed.

Quantitative data.

As no existing questionnaire was deemed suitable for the purpose of studying aspects of intervention implementation with parents in a prison context, a new questionnaire was developed for the study, based on CFIR [24], and with a focus on being parsimounious to keep participant burden at a minimum. The authors first derived an initial pool of items. The pool was inspired by two existing questionnaires that had been developed to capture some of the CFIR domains in health care settings [25, 26]. This initial pool of 38 items was subsequently reviewed by experts on implementation research and the SPPS organization, which resulted in a revised pool of 22 items with increased relevance and comprehensibility for the target group. The following step comprised a pilot test of the revised pool with five parents in two prisons to elicit comprehensibility and relevance of the items. Suggestions that arose in the pilot test, accompanied by discussions with experts within the field, resulted in a final scale with seven items for intervention group parents and four items for control group parents. The items targeting intervention group parents covered four of the CFIR domains, ‘intervention characteristics’ with two items, ‘outer setting’ with one item, ‘inner setting’ with two items, and ‘characteristics of individuals/deliverers’ with two items. The items targeting control group parents covered three of the CFIR domains, ‘intervention characteristics’ with one item, ‘outer setting’ with one item, and ‘inner setting’ with two items. All items were responded to on a response-scale from 1—disagree completely, 2—slightly agree, 3 moderately agree, 4 mostly agree to 5—agree completely. The questionnaire was distributed in paper to the parents at the measurement after intervention for both intervention and control groups.

Qualitative data.

Semi-structured interviews were conducted after the intervention was finished. The interviews were audio-recorded and conducted in Swedish by ÅN (PhD, female, researcher experienced in qualitative methods, and former prison counsellor) using interview guides with open-ended questions based on CFIR [24] (S1 File). Eight of the interviews were conducted via telephone and four were conducted face-to-face in the prison visiting premises and lasted for an average of 51 minutes. The Consolidated criteria for REporting Qualitative research (COREQ (S2 File) has been followed in the reporting of the qualitative data.

Quantitative.

Analyses of the questionnaire data were undertaken for each specific item as the intervention and control groups had been exposed to items corresponding to their different experience of FOCS (i.e., the intervention group was exposed to items specifically related to FOCS whereas the control group was exposed to items with a general wording). The differences in items also prohibited exploration of internal consistency of the sub-scales corresponding to the CFIR domains of factors influencing implementation. Group means for each item were calculated. When the groups had been exposed to the same items, comparison between groups means were calculated using the non-parametric Mann-Whitney U test. Due to the small group samples, mean comparisons were merely conducted with the intention to gain a broader descriptive view of differences between groups and provide a quantitative view to the qualitative findings in this convergent mixed-method study.

Qualitative.

Qualitative data were analysed by inductive qualitative content analysis in accordance with the procedure described by Elo & Kyngäs [27]. Data were collected in Swedish and translated into English during the final stages of analysis. Transcriptions were undertaken using an external transcription service. ÅN and PE (PhD, female, researcher, psychologist) conducted the analysis following a stepwise process: first, in order to gain a holistic view of the data ÅN listened to the audio recordings, and both ÅN and PE read the transcripts until a comprehensive view of the data had been established. In the second step, both analysts marked chunks of text that related to the study aim and identified meaning units in the marked text. In the third step, both analysts applied open coding to the meaning units. Then analysts compared their codes and discussed core meanings of different codes to gain a joint understanding of the data and to initiate an understanding of underlying patterns in the data. In the fourth step, ÅN drafted a code book which comprised patterns found in the open codes based on the joint discussion. PE reviewed the code book and applied it to three of the interviews after which a new discussion between the analysts took place. The discussion rendered revision of the code book, after which ÅN applied the code book to all interviews and drafted sub-categories identified from the patterns. In a fifth step, discussion on sub-categories and the merging of sub-categories into generic categories took place. In the sixth and final step, both authors discussed a latent, overarching theme that covered all manifest categories, until consensus was reached. The quotes which illustrate the findings include ellipses, modifications, and explanations within square brackets to enhance comprehensibility. Also, parents who expressed the quotes have been labelled “parent” with a subsequent number to ensure anonymity.

Integrated analysis.

In a final analytical step, qualitative and quantitative results were merged into a joint display to reflect an in-depth understanding derived from both types of results [23]. This analysis was undertaken by thoroughly reading and comparing the qualitative and quantitative results to gain an understanding of common patterns and essence. This was undertaken by ÅN in an iterative process, where patterns were formed and revised, and reviewed by PE. A joint display was finally created to illustrate joint concepts in both qualitative and quantitative results.

Personal significance of the intervention.

The participants described, in positive terms only, an experience of significance and meaning of taking part in FOCS, partly based on the function that FOCS fulfilled for them in their personal situations both as inmates in prison and as parents, and partly related to the traces that FOCS has left in their lives, through e.g., changed relationships or insights.

Function of the intervention for the participant as a parent and as an inmate. The participants described in positive terms how FOCS fulfilled functions for them as both inmates in prisons and as parents, on several levels and beyond the formal purpose stated in the intervention’s manual. As inmates, the participants described that FOCS provided a breathing space in the otherwise harsh prison environment, where the feeling of just being a parent, not an inmate, has prevailed. A respite that served as a reminder about the children, where it was impossible to distract oneself from, or contain, the stressful thoughts and feelings. Instead, this breathing space catalysed thoughts about the importance of changing one’s life to be a better parent.

“…the problem doesn’t disappear just because you keep distracted […] I could react towards other inmates if they said something, [I] was hypersensitive and annoyed. And then when we came to [FOCS], sat down and started thinking about these matters, then I realised that I had been keeping myself distracted. […T]he [child] matters are really tough, but I didn’t touch them kind of [by keeping distracted]. So [FOCS] was a break from all the distractions.”

Parent 1

As a parent and at the same time prison inmate, FOCS also had the function of creating a sense of fellowship around the stress of being physically away from the children and also to realize how the parent’s own criminality has affected the children. Parents described how they realized that they were not alone in difficulties linked to parenthood, and that they could gain perspectives on and support in their own situations and behaviours, e.g., being honest with their children. Also, getting concrete information about e.g. The CRC and rights and parental obligations served as an important function. Parents also described how FOCS’s primary focus on the children also infused a feeling of the child being present.

“Sitting there in the parent group talking about your child and others’ children, then I felt like [the child] was present”

Parent 2

Own experience of the influence of the intervention. The participants described how they, on a personal level, experienced that participating in FOCS had affected them positively in relation to insight into their own childhood, their own parental ability, and understanding of the child. They also described how they felt that FOCS had influenced changes in the relationship with the child and in their own practice of parenthood.

Participants experienced that FOCS generated insights into how their own childhood had affected their life and their own parenting, e.g., repeating patterns of a criminal parent, and what different parenting situations can entail, e.g., to always give children what they want because you want to be kind. At the same time, FOCS generated insight into being valuable as a parent, where participants identified that everything you do for your child is not bad even though you are in prison. Participants also described how they, after FOCS, sought to understand the child’s perspective, experiences, and needs in various situations, e.g., reading the child’s feelings through the tone of voice. The parents identified changes in their own parenting behavior, e.g., by being mentally present with the children on the phone or during visits, listening, asking question, and daring to talk to the child about difficult topics. Parents also described how they let the child’s emotions be present and worked to manage the child’s emotions in a calmer way e.g., by affirming the child’s feelings. This in turn, influenced calmer and closer parent-child relationships, where parents experienced that their presence, calm responses and understanding brought about calmer children, longer parent-child conversations, and increased child trust in the parent.

“I got the thought that the child may be thinking ‘why do I have to move to [to foster care] and not my sibling? Doesn’t [the other parent] want me?’ And then I told [the child] ‘I want you to know that I and the social services believed that this was the best for you. [The other parent] didn’t want you to move’ And after that [the child] has become calm and confident. I think [the child] felt guilty, and disappointed in being rejected. And I would never have realised those thoughts if I hadn’t joined [FOCS].”

Parent 3

Participating in sessions with manual-based material about children and parenting.

The participants described in both positive and negative terms how the intervention structure worked and how the content could touch them strongly, and sometimes be demanding to handle.

Structure of the intervention. FOCS’s structured sessions, based on themes with a workbook to follow, provided clarity that was perceived as positive. At the same time, the parts of the FOCS’ structure that involved sending home material to share with the child were difficult to pursue for parents if the contact with the co-parent was poor, e.g., as the co-parent may be needed to give the material to the child, or topics that involved the co-parent could be difficult to touch upon. In general, the time allocated to each session was perceived as short at times where some activities had to be excluded as the group needed time to discuss the theme and specific discussion topics in length. To further cater to parent and child needs, participants suggested that the structure of FOCS could integrate family interaction by allowing children and possibly the other parent to participate in some of the sessions, e.g., at the beginning and the end of the programme. In addition, individual meetings with group leaders as a complement to the group meetings, could provide opportunity to talk more openly about sensitive topics, such as severe guilt and shame, own experiences of abuse, or specific problems in the relationship with the child or co-parent.

“Of course, when you work with a theme, then feelings and questions arise. [And] it is as if the prison gives you crazy notions, and you can get bad confidence from the guilt and shame, which can hinder change. That you don’t dare to say it [in the group], and then individual sessions can be good.”

Parent 4

Management of the intervention content. Parents perceived the material as stringent and relevant, although it did not always fit the parent’s personal situation, e.g., as the child was of a different age, or the communication with the co-parent was very well functioning without need for improvement. Both the text, but especially the films included in some sessions were seen as very illustrative and apt. Some themes were perceived as heavy and difficult to manage but at the same time very rewarding where films and discussions forced the participants to face stressful insights and feelings about their children’s situation and their own childhood.

“It was a cartoon. The father was taken by the police and the son and daughter blamed themselves… that [session] was the best and the worst. That stirred up a lot. I recognised myself both as a child and as a father […] That was tough but rewarding at the same time. […] It was tough to feel how I let [my child] down in the same way that I had been let down myself. It was in black and white. It is exactly the same thing that I expose [my child] to as what I was exposed to myself.”

Parent 5

For the themes that were perceived as very heavy to manage, e.g., due to their own experiences of abuse, participants recommended that extra support, e.g., from a psychologist, or group leaders could be helpful or even necessary to prevent drop-out. Furthermore, additional topics such as honour-related oppression, gender equality and more material about children’s emotional development and parenting practices were called for. Also, parents suggested that the material should be adapted to differences in the parental situation experienced by e.g., mothers and fathers.

Being part of the group.

Being part of the FOCS group signified the importance of a trusting and secure relationship with both group leaders and participants to be able to openly reflect on the sensitive topic of children.

Relationship and trust in the group leaders. Gaining confidence in the group leaders in the FOCS group was described as very important for discussions and reflections to be profound and rewarding. The confidence was influenced by various factors, one being the group leaders being parents themselves which enhanced the participants’ ability to relate. Another factor was that group leaders worked in pairs, and if possible, provided perspective from both a mother and a father, and complemented each other in the discussion. Also, having the same group leaders throughout all sessions was essential, as a replacement in a session generated stalled discussions with vigilant participants. Group leaders who thoroughly directed the discussions to focus on the session theme and not on other prison matters, e.g., telephone permits, and who were supportive in discussions with a warm and accepting atmosphere were appreciated and built trust. Group leaders who had a personal attitude and shared their own childhood or parenting experiences were appreciated by participants, whereas group leaders who kept a distance and refrained from showing a personal side, influenced the group to be more restrictive in their exchange of experiences.

“It’s a confidence, that [the group leader] is a little personal and that we are a little personal. But they kept a distance, because there is a line between a warder and an inmate, and I can understand that. [But] it would have been helpful for the group [if the group leaders had been more personal]. Other than that, they were good, and good that they were two, so that one could continue the discussion if it halted, or you didn’t know what to say. The most important part was that they were the same two group leaders throughout [FOCS]. At some sessions there could be a substitute that no one had seen before and then we just sat and wondered who that person was the entire session.”

Parent 2

Relationship and security in the group. Being a secure group was emphasized as essential to the participants’ ability to share sensitive topics in discussions with each other. Participants described how the first sessions were tentative in the group interaction but once a feeling of security was established, the group engaged in rewarding and open conversations where all participants were open and respectful of each other, related to different experiences and accepted differences in opinions. At times, e.g., during an emotionally challenging topic such as violence, the group could have difficulties in sticking to the topic. On these occasions, the discussion could become less rewarding if participants turned defensive or aggressive. A safe and open atmosphere was positively influenced by the group composition, e.g., with participants in similar situation, which facilitated interaction and exchange. Barriers to a secure atmosphere were large groups from different wards with participants who did not know each other before, which instead generated a harsh and vigilant attitude. Also, participants with low motivation who were perceived to be present "to have something to do", who spoke in a dishonest manner or simply did not take topics seriously, had a negative influence on the atmosphere. Here, participants highlighted the responsibility and importance of the group leader to be very clear towards participants and to form a secure group. Parents called for group leaders’ to be thorough in the recruitment phase, to form a group where everyone is motivated and focused on the topic, and to be firm in directing participants who do not contribute to the discussion or infuse low motivation during the sessions. Some parents experienced that the group leaders merely picked out participants to fill a group with the result that some participants were unmotivated, which then created a mood of distrust in the group.

“Three [of the participants] were just bullshit. One was quiet the entire time […and] one wasn’t interested and that brings the whole group down. The confidence in talking and seeking support decreases. [We] set rules, and it is sensitive what we talk about, it is our kids, and in here that can make you lose it, if you hear that someone has gone around talking about your child. Then the group leaders can’t be soft, they should just expel that person immediately. That is very important. And at the beginning [of FOCS] I didn’t feel secure, and considered dropping out actually, because there were three participants who were not [in the group] for the right reasons.”

Parent 6

Prerequisites for the implementation of the intervention based on norms and rules within the SPPS.

The opportunities to work on parenting and the child-parent relationship were expressed in the light of underlying norms regarding children and parenting at the SPPS in general, and the actual rules that govern the inmate’s time in the prison specifically. The participants perceived that the general SPPS attitude did not facilitate child-parent contact during the time in prison, illustrated by e.g., long time to get telephone permission, that permission can be denied for reasons that the participants do not feel are linked to the child’s well-being, and that telephone calls are complicated to make once permission is granted. These difficulties led to frustration and hopelessness in relation to maintaining contact with the child.

The participants expressed a general view that the SPPS’ focus on children’s perspectives is weak, and not in accordance with the CRC. Participants expressed that FOCS seemed relatively invisible overall, where FOCS’ existence or the opportunity to participate was relatively invisible in most prisons and that other prisoners had very little knowledge of FOCS existence. Instead, the parents described how they themselves had to seek information, and at times push for FOCS to start. Some participants expressed that they felt lucky that they had a contact person who had knowledge of FOCS, as staff in general did not have much knowledge. At the same time, the fact that FOCS comprises a place with a clear child perspective and that there were cases where other prison staff had knowledge and were positive towards a participant taking time off from the usual prison chores to participate in FOCS, was perceived as very positive.

“During the prison stay, even if there is a focus on establishing contact between the incarcerated parent and the child, there is not enough focus on parenting according to me. The only time there was a hundred percent focus on parenting, and everything that relation to the relationship with the child, that was in the [FOCS] group.”

Parent 7

The importance of a child and parent focused intervention in prison.

This joint concept comprises the qualitative findings in the categories personal significance of the intervention and participating in manual-based sessions about children and parenting, and the quantitative domains intervention characteristics and outer setting. The qualitative findings reflect that FOCS had several positives functions beyond the intended ones, where parents also described how their lives had been positively influenced by FOCS, and that, although some of the sessions were very tough to attend with sensitive issues to face, participating in FOCS had been rewarding. The quantitative results show that all intervention group parents scored high with regard to if FOCS is positive and helpful. The scores of both groups reflect a perception that the need to work with their parenting is moderate (mean: 3.26–3.27).

Partly unsupportive organisational norms with irregular staff engagement.

This joint concept comprises the qualitative findings in the category prerequisites for the implementation of the intervention based on norms and rules within the SPPS and the quantitative domain inner setting. The qualitative results reflect parents’ views that child and parenting issues are treated at the margin by the SPPS, which frustrates the parents, and seems to make FOCS somewhat invisible in prison. This is mirrored by the quantitative scores where both groups had a partial to disagreeing perception (mean: 2.87–3.6) about the prison management being supportive towards FOCS or the child perspective. At the same time, parents voice that engaged prison staff are perceived as supportive, and this irregularity is also shown in the quantitative results where the intervention group scored significantly higher on the perception that the prison staff wanted to do their best in their work.

The importance of engagement and motivation from all participants and group leaders in the group.

This joint concept comprises the qualitative findings in the category being part of the group and the quantitative domain characteristics of individuals. The qualitative results reflect the sincere importance of creating trustful relationships in a group that includes both parents and group leaders who take the matter seriously and take responsibility for their roles in the group. The parents contribute with their experiences, thoughts and feelings in the discussions and group leaders keep the discussions on track, being thorough in recruiting and retaining parents who are interested and engaged. The quantitative results also depict high intervention group score on group leader and own engagement.