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Emerald Group Publishing Limited
Copyright © 2011, Emerald Group Publishing Limited
Article Type: Editorial From: International Journal of Prisoner Health, Volume 7, Issue 4
The editors of the International Journal of Prisoner Health (IJPH) are proud to announce that the journal has been acquired by Emerald Group Publishing. Emerald has over 40 years of publishing experience and believes that the journal will complement its existing portfolio. We are looking forward to working with our new production team to improve the quality of the journal and increase our audience of prison professionals worldwide. We will provide more details about our plans for the journal in forthcoming issues, but in the meantime we invite our readers to publicise the journal and encourage colleagues to submit papers for consideration. Guidelines for authors can be located at the journal web site: www.emeraldinsight.com/ijph.htm or on the inside back cover of this issue.
Later in this Editorial, Lars Møller, Alex Gatherer, Brenda van den Bergh and Andrew Fraser will share reflections on the Throughcare Conference that took place in Abano Terme, Italy in October last year. First, we would like to introduce the papers that comprise this issue.
Dixey and Woodall discuss some of the obstacles to implementing policy and strategy related to health promoting prisons by focusing on the role of prison officers. Their paper raises issues concerning their conditions of service, training and organisational culture against a background of a prison system facing security issues, overcrowding and high levels of ill-health among prisoners. The study draws on theory regarding policy implementation at the micro-level and illustrates how staff can block or speed up such implementation. The findings demonstrate the ambiguities and tensions in changing organisational cultures among prison staff. The authors conclude that prison officers are an essential part of health promoting prisons, but have been relatively ignored in the discussion of how to create healthier prisons.
Viitanen et al. report on the first comprehensive health survey of Finnish prisoners undertaken in 2006, which studied frequency and gender differences in childhood physical and sexual abuse and the connections of maltreatment in childhood to substance abuse and mental health among female and male prisoners. The authors report that both forms of abuse were more common among females than males, whereas associations of childhood abuse with substance abuse and mental health were different among males and females. In addition, among prisoners, the gender differences varied from data on populations in the community. The authors conclude that childhood sexual abuse is well known to be more common among women than men generally, but for Finnish female prisoners, physical abuse has also been a significantly more common experience.
Van Dooren et al. propose a framework to better understand ex-prisoner health by considering different stages of re-entry (from pre-incarceration through post-release), individual and structural factors influencing health, and health outcomes. The authors report on pilot-testing of the framework using qualitative interviews with a sample group who have been out of prison for two years or more. The authors conclude that structural factors are important concerns for ex-prisoners that may have to be resolved before other issues, such as drug addiction, can be addressed. Additionally, the findings suggest that it is inappropriate to view health-related experiences during re-entry as homogenous, given the diversity of individual characteristics and backgrounds among ex-prisoners, notably social status prior to incarceration.
Wright et al. report on a systematic literature review of the available material relating to the implementation of peer education to promote health and healthy behaviour in prison, noting that peer education in prisons can have an impact on attitudes, knowledge, and behaviour intention regarding HIV risk behaviour. The authors document the method adopted and note that the study indicated a paucity of research evaluating the impact of peer education upon mental ill-health, obesity, diet, smoking, or self-management of chronic physical diseases. The authors conclude that this presents opportunities for further research activity as does the lack of evaluation of models of active peer educator involvement in health service delivery and organisation.
Finally, Johnstone, Duffy and Martin consider the use of buprenorphine (Subutex) in Scottish prisons. Their study describes the recruitment of a cohort of male prisoners on detoxification programmes from seven Scottish prisons, selected from a larger investigation that included both those undergoing detoxification and maintenance. The authors report that the majority of detoxification participants within the study reported that Subutex was a more effective treatment than methadone, helping to reduce craving, ease the process of withdrawal and improve sleeping patterns. Additionally, the majority of participants noted higher levels of motivation and the ability to set goals towards obtaining an improved quality of life. The authors also conclude that the study highlights inconsistencies drawn from previous studies in this area and recommend that further qualitative studies be conducted to explore the use of buprenorphine.
As noted above, a conference was convened in October 2011, in Abano Terme, Italy, as part of the dissemination activities for the throughcare project funded by the Directorate General Justice of the European Commission. As well as throughcare, the conference addressed other issues including prisoners with problematic drug and/or alcohol use, communicable diseases, chronic disease and mental illness. However, the focus of the event was throughcare and we are delighted that Lars Møller, Alex Gatherer, Brenda van den Bergh and Andrew Fraser agreed to share their reflections with us.
Staff and early detection: some afterthoughts on the Throughcare Conference: Abano Terme, September 2011
Alex Gatherer, Brenda van den Bergh, Lars Møller and Andrew Fraser
In these days of gloomy global economics and related public health concerns, it is a privilege to attend an international conference in comfortable and sunny surroundings. Yet with privilege surely also comes responsibility, a duty to make sure that what is learned is passed on into action or further development. All attendees carried home their own “main points” and “what we should do more about” issues. It would be good if these could be shared so that all can benefit where relevant. As an example, several of the attendees have developed a toolkit entitled Throughcare Services for Prisoners with Problematic Drug Abuse, funded by the Directorate General Justice of the European Commission. This toolkit is available to all at: www.throughcare.eu/downloads.html.
Of the many important issues that were covered in the Abano Terme conference, two seemed to come up often, directly or by inference, throughout the meeting. Both have been rather neglected so far in developing strategies in prison health. First, the crucial and only partially covered role of prison security staff in throughcare; the second was the importance of early detection and the need for this to be comprehensive. There is of course considerable interaction between these two issues.
It is understandable that the majority of those at a conference with this theme were health professionals. Yet it was clear that prison health teams cannot, on their own, produce the caring services that are so necessary in present day prisons. They are dependent on the other staff that have day-to-day contact with prisoners and who therefore set the ethos and create the environment in which effective prison health care can take place. We were reminded several times that prisons are typically planned, built and managed with security and safety priorities in mind, not of health and wellbeing. In an important address, a prison governor described his position as similar to that of a mayor of a small town, responsible for everything done in the prison and with all staff necessarily accountable to him. In such an organisation, information had to be shared. This can pose an ethical dilemma for health care staff. Prison officer staff are appointed and trained to facilitate the good running of the prison with security and safety of primary importance.
Yet it is fair to assume that nearly every prisoner has special needs, personal and health related problems and usually more than one. Meeting many of those needs usually requires trained professional staff. In fact, health care is becoming more and more complex as technology improves rapidly and expectations rise just as quickly. We have already reached the position in which training in health literacy is not enough on its own, as understanding of what health care is trying to do is also vital. At the WHO network meeting in The Netherlands in 2004, when mental health care and promotion in prisons were considered, it was made abundantly clear that many of the staff recruited through Europe simply did not have the educational background on the unique quality of prisons to understand what was required of them. It is therefore important for prison health advocates to consider what can be done to improve the attractiveness of working in prisons with a salary, conditions of employment and public respect equal to those for similar staff in other public service jobs. It is not known if that stage has been reached in any country worldwide. What is known is that many countries have difficulty in recruiting and retaining suitable staff in the prison health service.
In addition to wide variations between countries in job specifications and pre-entry educational achievements, there are considerable differences in what is provided for initial training of new staff. This can range from a few weeks training to a two-year course. It is unlikely that health information features much in any initial training, and so to get the health literacy and the levels of understanding required, post-entry training is likely to be necessary. We heard from one country about the impressive learning materials prepared for training staff for their role in TB control in prisons. If that level of training is necessary for each of the main health problems in prisons, then considerable development work is necessary for other prevalent conditions.
It may be thought that prison health should concentrate on the provision of the health services needed to meet assessed health needs and that the issues raised above are outside the remit of prison health. But the advent of HIV a few decades ago, the prevalence of drug resistant tuberculosis, addictions and the widespread mental health problems in every prison show clearly that all staff must be aware of treatment approaches and the value of understanding and caring attitudes.
It would appear that quite a radical shift towards the professionalisation of prison staff, with definite requirements in terms of educational level and with much more attention to both initial and subsequent training is the only reasonable way forward. For this to occur, we first need a major shift in public awareness of and attitudes to a public service of such importance in all societies.
The other issue that was made clear in Lord Bradley’s excellent presentation is the importance of early detection. He argued convincingly, from both the economic and health viewpoints, that the earlier the detection the better and less expensive the outcome. Diversion to him was much more than making sure that prisons do not have the impossible task of coping with prisoners whose mental ill health require specialist care in specialist facilities. The challenge is to detect all special needs as early in the criminal justice experience as possible, if indeed not before entry into the criminal justice system. In discussion, he agreed that he envisaged that early detection of mental ill health would evolve into comprehensive assessment of all special needs, including early identification of non-communicable diseases and disabilities, as well as communicable diseases and addictions
This wide approach made real sense and fitted into the theme of throughcare very well. Unfortunately, we do not seem to have agreement as to the best screening tool for mental illness, let alone the tools for the comprehensive approach that is surely necessary. We wonder if any country has yet moved in the direction outlined above. We heard from Scotland about their use of AUDIT for alcohol problems. Their approach needs to be considered for wide application. We must try to collect the information about screening tools in use throughout Europe and prepare guidance for dissemination where consensus is available.
But who will apply the screening tools and initially interpret the results? Much of the screening must be done by the health care team but the AUDIT approach for alcohol has been tested with non-health care prison staff using the tool. In view of the pressing health problems the health team have to cope with, the more screening which can be done by other staff the better.
It therefore appears that for both of these major themes which emerged in the conference, the role of prison staff is becoming ever more crucial. So much so that those concerned with the development of good prison health services must surely consider what they can do, if anything, to improve the global position.
We suggest the following for consideration:
establish consensus that the above are important issues for prison health;
do what we can to find out just what the practices are throughout Europe and elsewhere to find out if there are countries with experiences from which we can learn;
do what we can to collaborate with organisations which are involved in public and political educational and advocacy activities;
look into health literacy training in any country and develop guidance for all countries; and
finally, collect information about tools for early detection of all conditions currently in use and develop from them so that guidance can be prepared and issued.
In the meantime, we must finish the work on Stewardship of Prison Health and try for consensus on a conclusion that where the services are not provided under the Ministry of Health, there must be close involvement and indeed some shared responsibility between that Ministry with whichever Ministry provides prison health services. The importance of good collaboration between services in prisons with community services came out loud and clear in many of the presentations and workshops. One measure of success would be Paul Hayton’s “inconceivable” test in that we should reach the position where it would be “inconceivable” for community health and other services not to automatically include prison services in their plans and strategies to improve health and care for prisoners.
It may well be that others will have very different action plans following the conference. We hope they will keep us all informed about these perhaps through the Journal pages. In the concluding session, we were reminded that throughcare called for a renewed emphasis on working together. It was important to make sure that research findings were influencing practice. While concentrating on the delivery of health care to all prisoners indeed to all in places of detention according to their human rights and health needs, we can no longer just think of prisons. We need to detect special needs as early as possible and we need new ways for currently very separate services to work well together.
A concluding thought amongst the afterthoughts was that there is still much that has to be done!
Morag MacDonald, Robert Greifinger, David Kane