The aim of risk reduction activities in prison is to achieve a level-headed approach to the health care matters that concern drug addicted inmates and the health risks of the prison personnel. Therefore the organisation of risk reduction activities must be prepared carefully. One should approach this task via the following steps:
Setting priorities and aims
Defining the target group(s)
Choosing an approach
3.1 Needs assessment / collecting information
The initial point of departure is a needs assessment, which should be based on a general understanding of the aims and target group(s). Therefore, the first step will be to collect information on the following issues:
What are the needs/problems of inmates when it comes to health risks?
What are the needs/problems of prison staff concerning health risks?
What services are available?
How are these services functioning? (quality, accessibility, etc.)
What services are lacking?
This information is necessary in order to verify any prior assumptions. It also provides the basis for establishing priorities regarding the specification of aims and target group(s).
Important steps in this process are:
Collecting and reading written information such as:
Statistical material about the characteristics of the target group(s) (age, gender, ethnic background, health risks faced, awareness, knowledge, etc.).
Studies of drug users in prison.
Reports of prison and community services (number and types of drug users, information on health services avail able, information on health problems, etc.).
Identifying key persons (staff of prison and community services, drug users, etc.) and collecting information from them.
Getting information inside prisons, exploring the situation (when, where and what drugs are used, what healt problems and safety risks are encountered by inmates and prison staff, etc.).
It is worth bearing in mind that all these sources of course have their limitations and biases. Therefore, it is important to check and compare information to get a relatively accurate picture of the situation.
When collecting this information it is helpful to begin by making a rough plan:
What data is relevant? (e.g. how many drug users are HIV-positive, how many inject, how many are homeless, etc.)
Where to find this data? (at which organisations, on the street, etc.)
Who is collecting such information?
3.2 Setting priorities and aims
Based on this initial information, priorities for risk reduction activities should then be formulated. First of all, it has to be clear what one wants to achieve via these activities. Making the goals of such a project clear is important for different reasons, e.g.
To create common ground for the people (both staff and inmates) involved
To explain to the ‘outside’ world what you are aiming at.This is not only important to convince policy makers of the urgency of financial support but also for public relations reasons.
To have a standard by which you can measure the results. This is not only important because one will have to prove the results of one’s work to external agencies, such as policy makers, funding organisations, etc. Similarly, it is important for one’s own organisation to gain a clear insight into the results of any work. This provides a basis from which one can learn from one’s successes and mistakes and subse quently improve one’s approach.
The aims therefore should be smart, i.e.:
Specific, describing as exactly as possible what one wants to reach through the activities. Global aims like reducing risk behaviour within the target population are not enough.
Measurable, allowing a final evaluation to determine whether one has reached the goals that one wanted to reach.
Acceptable, for both inmates and prison management and staff (everyone involved should be fully informed about the aims and content of your work, otherwise it might cause suspicion or be perceived as threatening).
Realistic, meaning that they should be achievable. It is important here to establish priorities (what aims are most important and what is less important), and to get a picture of what could realistically be achieved in the actual situation. It does not make sense, for example, to state that activities are aimed at getting all inmates drug-free.
Time specific, meaning that one should produce a plan identifying how much time it will take to realise these aims.
Risk reduction activities in prison could, for example, aim at:
Improving knowledge of infection risks and safer behaviour among prison staff and inmates (this can be measured by using the information in the following chapter about the con tent of the message).
Increasing general health awareness in the drug-using community (taking care of injuries, nutrition, etc.).
Changing social norms, attitude and behaviour of prison staff and inmates.
3.3 Defining the target group(s)
Selecting the target group(s) is closely linked to setting the aims of the project. The selection of a target group(s) could be made upon
Priorities within a problem area, e.g. based on an epidemic profile
Identifying the limits of the reach of existing prevention programs, and/or
Priorities within a problem area
In the field of risk reduction activities, the target group(s) with a high incidence of health risks - both for prison staff and inmates - will generally take priority. Thus, an epidemic profile can be very useful. In order to establish priorities one has to collect information on the current state of the epidemic (e.g. an estimate on how many drug users are HIV-positive or already have AIDS) and on the expected future development. Different sources can be used to obtain this information, such as:
HIV counselling and testing programs,.
AIDS service programs
Knowledge, attitudes, beliefs and behaviour surveys
Prison medical services, etc.
The limits of the reach of existing services
In combination with an epidemic profile, data can be collected on which inmates or groups are not successfully being reached by current risk reduction activities. To be more precise, these could be:
Inmates who literally are not reached by risk reduction activities, e.g. because the main part of HIV/AIDS prevention measures are aimed at drug users, or focus more or less exclusively on dependent opiate injectors. Thus, the so-called recreational, non-dependent drug users - people who are using or injecting substances other than opiates and people who are starting or experimenting with injecting or other types of drug use - are more or less systematically neglected. Other groups who sometimes tend to be over looked are women, homosexuals and ethnic minorities.
Inmates who have got information about HIV/AIDS, safer use and safer sex, but don’t appear to have achieved rea sonable results. This might be due to:
Incomplete or inadequate information
An inadequate approach, e.g. getting information during a methadone intake assessment
Factors or problems on the user’s side, such as feelings of distrust, lack of motivation, negative attitude, social norms, lacking resources, etc.
Experiences with risk reduction activities in prison have shown that pragmatic considerations can be very useful in selecting the target group(s). In general one should consider starting by informing prison staff, as their support will be needed to work with drug-using inmates successfully.
3.4 Choosing an approach
In general, among the various risk reduction activities in prison, certain approaches currently dominate. As we stated above, in this chapter we distinguish between three major approaches to risk reduction in prison:
An individual approach (individual counselling)
Agroup oriented approach (training seminars)
Services and supportive measures
The choice of approach depends on a number of different issues, such as:
The target group(s); e.g. if one is focusing on prison staff or on inmates, or trying to get new people involved in risk reduction activities then an individual approach will be pref erable. Alternatively, if targeting people who are not yet involved then a seminar might be an adequate option.
The aims; what is the best way to reach your aims?
For example, if a snowball effect is a key aim then a train ing seminar for drug-using inmates (‘how to pass on the message effectively’, for instance) can be of great value.
The specifics of the situation one is working in; again, pragmatic considerations play a major role here. Which approaches are acceptable for those in the criminal justice system, prison management and staff?
The available human resources; the qualifications of the drug users and/or professionals involved, and the availability of professional support are decisive factors in determining what can be done.
The available resources; this is especially important where there is not enough money to do both outreach work and training seminars. As outreach work by peers generally is seen as less expensive and time-consuming (due to the limited involvement of professionals) than organising train ing seminars, often the decision to use outreach work will be made on this pragmatic consideration.
3.5 Preparing activities
When preparing activities the following things should be considered:
It is of vital importance to obtain permission from the prison
governor and any national or regional criminal justice author ities prior to anything else. These people should be con sulted about the activities planned in plenty of time, inviting them to give their opinions and have input into the plans. Having them involved in the planning of the activities is nec essary to get them both convinced and committed. A useful strategy could be:
To identify the people one would have to address
To send these people information about the extent and range of health problems, on your plans for risk reduction activities and on your organisation, acknowledging in the accompanying letter that you need their support and would like to discuss your plans with them, and finally, informing them that you will call to make an appointment.
To make an appointment for a personal meeting by phone,
Discussing the plans at this meeting, trying to convince them to co-operate.
Organising a seminar or meeting on this issue and inviting prison governors and criminal justice authorities; involving as speakers governmental and inter-governmental officials (e.g. from WHO) might be another initial step.
As already stated, the support and commitment of prison staff is a vital prerequisite. Once again, a seminar can be an appropriate format to give information about the relevance of risk reduction activities for both inmates and prison staff; both to provide information about your plans and as a means of getting people involved in a discussion on how to realise risk reduction in their prison - while taking into account that particular prison’s specific circumstances.
The value of co-operation between prison services and community health (drug) services in the creation of risk-reduction services should be given careful consideration. Using the expertise and support of the latter has proved highly effective in numerous countries. These organisations can contribute to the knowledge and skills of prison staff and inmates, on issues such as infection risks and how to avoid them. It is also efficient to use such services as it avoids the necessity for prison staff to ‘re-invent the wheel’. Finally, such co-operation can also contribute to better coordination between health services, facilitating continuation of treatment when drug users enter prison and referral to community health services when they leave.
Providing information about the activities you are planning to these community services can be seen as the first step in developing co-operation with them. At this stage, suggestions about ways of working together can be pro posed. Here again, a seminar involving representatives from prisons and community services can be an appropriate choice for kick-starting a project of this nature, as it facilitates a discussion between prison and community services.
The contribution of community services to risk reduction activities in prison can vary widely. Some organisations can offer professional support, e.g. the development of working methods, training and supervision of the prison staffin volved, etc. With other organisations, regular consultations over issues such as fine tuning the policies and creating a basis for satisfactory referral might be a better approach. These consultations should not be limited to the formal level - informal talks between individual workers can be valuable and effective as well. Through this process, a local network can be developed or maintained.
Clear arrangements between prison administrations and community health services should be made, defining and dividing the tasks between the various organisations and individuals involved. The specific conditions of the prison will have to be accepted, meaning that the structure of decision-making, communication and co-operation in the prison system has to be acknowledged. There might be considerable differences between different countries and regions. Every prison has its own policy, its own population of inmates and its own way of communication and co-oper ation with external drug and AIDS services. Careful prepa ration is necessary to target the specific needs of the inmates, as well as the staff members.
Due to the fact that drug use, sex and tattooing are forbidden in prison, there is a desire for anonymity and a need to protect the privacy of inmates. This canbe a significant obstacle to organising risk reduction activities in prisons. Admitting drug use, or even showing interest in information about safer use might be avoided due to the fear of being treated differently. These fears range from being identified by the guards as an active or current drug user and being the target of intensified checks such as cell searches or searching visitors, intensified urine testing and losing privileges such as home leave, things that are all very impor tant in the everyday life of a prisoner. This is a particular problem for those inmates who so far have been success ful in hiding their drug use. For these inmates, participation in risk reduction seminars would be comparable to a coming out as drug user. Their interests might be different from the interests of those inmates who believe that they have noth ing to lose and whose drug use is common knowledge.
Talking openly about drugs, drug use and risk reduction in prison might also be interpreted by staff members as not taking the problems connected with intravenous drug use seriously. However, this could be used as a starting point for a thorough discussion of the issues.
Another problem, also linked to privacy, might be that inter est in participating in a safer sex training seminar might be interpreted by other (male) inmates as a sign of either having sexual problems, or being a homosexual. The will ing ness to participate in the safer use/safer sex program always reflects the climate of confidence, acceptance and policy in that specific penitentiary system.
It is also worth considering ways to introduce and discuss risk reduction activities in prison with other relevant organi sations and with the general public. This should only be done with the agreement and co-operation of the prison and criminal justice authorities. By other organisations, we mean not only drugs and HIV/AIDS services but also gen eral social and medical services, politicians, policy makers, police and criminal justice officials. This is one basis on which tuning in and co-operation can be realised.
With regard to public relations, one possible strategy could be the following:
Begin by considering if representatives of the most rel evant organisations should be informed, even before the actual start of any activities. Collecting information on the local and regional specifics will provide the infor mation on which organisations should be contacted. Generally, an informal personal conversation is more effective than sending written information. In this first meeting, the aims and the approach of the activities can be explained and discussed. In addition, first plans for attuning the services can be made at this meeting.
Directly before the start of the activities, all relevant organisations could get a letter with ample information on the project, covering its aims, approach, starting date, contact person, etc.
In the starting phase, additional meetings for the teams of these organisations can be organised, in order to inform the workers about your activities in greater detail.
Informing the general public generally means informing the media. As with the drugs and AIDS service organisations, a written general announcement can be sent to the media. In addition, a press conference can also be organised. This shows the press and public alike that one has nothing to hide and satisfies any curiosity about what risk reduction activities in prison might look like. Finally, if one has particu lar media contacts who you know from experience will sym pathise with this sort of initiative, they should be invited for an exclusive interview or story.
In some cases, it might be better not to go public at the very beginning. There might be good reasons for initially establishing the activities and being able to present some results prior to announcing the project. This is especially true when your activities might be expected to meet some resistance.
However, not going public involves the risk of losing control over the information process. A single inaccurate or nega tive article in a newspaper - based on rumour or secondhand information - can cause major problems. Once out there, correcting this false picture is invariably very difficult. Moreover, by not informing the public voluntarily, one can give the impression that one has something to hide. Any discovery by accident may well result in negative publicity.
Public relations on these different levels - can also be very important in the later stages of a project. Consider whether to provide the media and other relevant organisations with information on the project’s activities on a regular basis. This can be done through things like an annual report, but also through other strategies for disseminating news about the project. News, in this context, can mean organising a seminar on the public health implications of infectious diseases in prison, or starting a new activity, having new people appointed, new collaborative working arrangements with other organisations, etc.
Throughout all of this, one should take good care to create and maintain a positive image of the project’s activities. Gaining public acceptance can be an extremely important means of support. To facilitate this, it generally is very effec tive to have good contacts with one or two journalists who sympathise with one’s work. This can be helpful not only during possible conflicts, but can also offer the possibility of press coverage of one’s activities on a regular basis. This sort of press coverage can be helpful in convincing the public of the value of one’s work.
Besides the internal need for evaluation, necessary to be able to adapt and improve the work (see below) there is also a demand to prove to the outside world (politicians, other organisations, etc.) that risk reduction activities are having a very real positive impact on the target groups. When designing evaluation strategies for internal and exter nal purposes, it is useful to seek professional assistence, particularly when the evaluation is for external use. This is especially true if one is aiming at getting statistical informa tion from the evaluation. Undoubtedly, the best option is to employ an experienced researcher to take care of this aspect of the work. However, the available financial and human resources might not allow this. In this case, support could also come from a volunteer expert at a university or from a social science student in his practical training, etc.
One workable and very efficient solution to this problem is to develop and use the evaluation measures and results we describe below, both for internal use and also for exter nal purposes.
3.6 Monitoring and evaluation
At any given time, there is always a need to see what has been accomplished, who has been reached, what the result has been, which step has to be taken next, and if and how the chosen approach can or should be developed or modified, etc. This process requires relevant and accurate information, both for internal and external purposes. Therefore, it is important to collect data and monitor and evaluate risk reduction activities. There are a number of different ways to do this.
First of all, one should consider a process evaluation. This is a detailed description of the development and realisation of the risk reduction activities undertaken. A process evaluation should cover a description of all of the steps that we’ve mentioned above, i.e.
Setting priorities and aims
Defining the target groups
Choosing an approach
Preparation of activities
Realisation of activities
The first five points can be covered by writing a report that describes what has been done, which decisions have been taken and why these decisions have been taken.
To evaluate and monitor the risk activities undertaken, one can use a more standardised form of collecting information (see below).
Always keep in mind that the effect of risk reduction activities in prison might be hard to measure in quantitative terms. Many experts doubt whether a solely quantitative approach to research would make sense when investigating this issue. This is particularly true when considering the effects of peer support by snowballing’ i.e. drug users who are reached by the project and then pass on the information they have learned to their peers), as it is difficult to establish a representative statistical sample that can measure such an effect. When dealing with these effects, more qualitative research (field observation, interviews with drug users, etc.) tends to provide the most useful material, both for evaluation and also for those authorities who are interested in new ways of HIV/AIDS prevention as for drugs services and drug user self-organisations. However, quantitative data tends to be most highly regarded, and is often insisted upon by funding organisations, policy makers, etc.
Evaluating and monitoring individual counselling
To evaluate and monitor the results of individual counselling, registration forms are a useful instrument for getting the necessary information about the reach and results of one’s project.
Important issues to record can be:
Date of counselling session
Is this a new or repeat contact?
Risk assessment, including:
Modes of drug use, levels of sharing drugs and drug use equipment (syringe and needle, spoon, filter, water; frontloading, backloading, etc)
Sexual risks (forms of sexual behaviour, different partners, sex work, etc.)
Who initiated the contact? (staff or inmate)
How has the contact been made? (accidental talk or appointment)
Where was the contact made? (In a cell, at medical ward, in the corridor etc.)
What did the contact consist of?, e.g.
Handing out condoms, syringes and needles, other paraphernalia
What role can the contact play in the development of a network? (‘chain’ referral to other inmates, etc.)
It is evident that, for reasons of privacy, no personal information (name, date of birth, exact address) should be collected, where possible. The inmates who participate in these programs should receive full information on who has access to what information, what will be done with the information, etc.
To avoid or minimize the problems with sorting data where there are several different forms on the same person, a list of those people who have been contacted that is separate from the registration forms can be made. On this list, each person will correspond to a certain code (a number, nickname, whatever). On the registration form only the code is filled in. However, the latter should only be done if one can guarantee that this list, linking the code to an actual person, is absolutely secure and no negative ramifications for the individual are likely to result from their participation.
One problem tends to be that collecting all of the data of potential interest is just too much work. If filling in the form takes more than five minutes, then it might not work. Though having someone to remind the counsellors to fill in the forms can be helpful, it still is important to develop a form which can be easily and quickly filled in. One good suggestion here is to split the registration form into two, with one part focusing on general information about the contacts made, followed by a second part that concentrates on one specific issue.
The first part has to be filled in for all contacts, comprising the first five points listed above plus the section on ‘what did the contact mean’. This approach allows the collection of good, albeit primarily quantitative, information on the reach of a project.
The second part of the registration form can then be on different specific issues, for example, on modes of drug use and how they change, on (changes in) sexual behaviour, etc. After having monitored one issue in this manner for a period, (say two or three months) one can then change to another issue. Using this process of registration at least some indicators, albeit qualitative, can be discovered on certain issues. This two-part design of the registration form, then, results in relatively short forms that are easy for workers to complete.
We have suggested that it may be useful to seek some professional support for the design of the registration form, the evaluation, etc. This support can come from a sympathetic or interested expert from a local university, who may have a social science student seeking practical research experience, etc.
Having somebody from outside the prison system (i.e. somebody from a university or a community health service) doing the actual evaluation, particularly the interviewing, might also help to gain trust and therefore more truthful answers from the inmates. In addition, it might be worthwhile to consider using inmates themselves as evaluation interviewers. An approach that mixes a number of these strategies could also be considered, as it is one way to reduce possible biases by making them visible.
This sort of data collection has a severe limitation, insofar as it is restricted to the active period of the project. It does not tell you anything about the effect of your interventions. In case of a project of short duration (some months) this is a significant disadvantage. It is impossible to assess the longer term effects of one’s work on issues like changes in attitude and behaviour of the target group. In such a case a combination of an evaluation during the course of the project and a small outcome evaluation (e.g. some interviews with people from the target group) following the project is advisable.
An additional evaluative instrument could be focus groups, i.e. meetings of a selected group of participants (such as prison staff or inmates) to discuss with them their impression of the results of the risk reduction measures, and any necessary adaptations they may consider desirable or feasible in the light of their additional experience in this area.
The collection of additional data on issues like the prevalence of health problems of the inmates can provide us with some indications of the impact the project is having. For instance, the reduction in the number of abscesses, number of new infections (number of people who prove positive in a test on HIV, Hep C, etc. while having been tested negative before), etc. can serve as an indicator - although not as a proof - that people are less frequently engaged in risk behaviour.
Evaluating / monitoring training seminars
An evaluation of a training seminar can provide relevant information for the organisation responsible for the seminar, for the trainers and the participants. The responsible organisation and the trainers can learn about the following:
Has the content been relevant for the participants? What issues do participants regard as a priority for future training, seminars, etc.
Were the format and didactics adequately chosen to pass on the content effectively? (Was it a well matched mix of presentations, discussions and exercises? Were there enough breaks, etc.?)
Has the seminar been well organised? (Adequate accom modation, etc)
Has the seminar been well performed? (Clear, understandable presentations, friendly, open attitude of presenters, trainers, etc.)
What are the participant’s further training needs?
For the participants, an evaluation can help them to reflect on their level of knowledge, skills, etc. and on further training needs.
An evaluation of a training seminar can cover a number of different elements. It can be:
A reaction evaluation, eliciting information about the general response of the participants to the seminar. Did they enjoy the seminar? Did they like the atmosphere in the group? Did they like the presentation style?
This will tell you something about the choice of the trainers, the choice of composition of didactic tools, the balance of the program, the logical composition of contents, the choice of the target group, the composition of the group, etc.
A learning evaluation eliciting information about the extent to which the participants learned what they were intended to learn. This type of evaluation covers skills, insight in problems and attitude in addition to knowledge.
Again, this will tell you something about the choice of the trainers, the choice of didactic tools, the balance of the program, logical composition of contents, the choice of the target group, the composition of the group, etc. It can also provide insights about the earning aims, about the question of whether participants could elate to the subject and about their needs for further training.
A performance evaluation, eliciting information about whether the trainers performed well. Were they well prepared? Did they present well? (Understandable and well structured.) Did they behave well? (Friendly attitude, etc.).
An outcome evaluation, eliciting information about whether the training seminar has had or will have an impact on risk reduction. This type of evaluation will tell you something about the adequacy of the learning aims, and the choice of the target group, but also about the question of whether the participants could relate to the subject, about possible barriers to realising risk reduction (E.g. people know and want to change behaviour but don’t have the necessary means to do so), and again, about potential needs for further training.
A training seminar can best be evaluated by an evaluation form. As annex 4 we have included examples of an evaluation form for use by trainers and participants, both staff and inmates.
However, instead of using forms, one could also opt for a discussion at the end of a course, which would be structured by a series of questions taken from the evaluation forms. This could be achieved in a focus group like set-up, discussing issues such as further training needs.
Another option might be an exam format, using a quiz format similar to those we offer in earlier sections. One can also use observation. A good format here can be a role play or demonstration where participants are requested to show what they learned (see exercises under 8 in this chapter). This is especially usefull in skills training. Finally, for the long-term effects of a training seminar, assignments can be used, requesting participants to work on certain issues after the seminar. In a follow-up meeting the results of the assignments can be discussed. This format has been used successfully in the aforementioned program ‘Everything under control’(see chapter 1).
Evaluating and monitoring services: supportive measures
By services here, we mean things like condom or bleach distribution. Supportive measures could be producing and distributing a newspaper or magazine or leaflets for inmates. Both - services and supportive measures - will be discussed later on in this chapter.
Both services and supportive measures can, in general, be evaluated in a quantitative way. One can count how many people have requested bleach or condoms or how many condoms or bleach tubes have been taken from an anonymous distribution service. The same measures apply to leaflets and newspapers or magazines.
In addition to this quantitative data, you can also choose additional ‘qualitative’ information. This can be done through individual talks or through group meetings. Individually, this can be an element of a counselling session or through an evaluation interview using a questionnaire. Questions about the use of services and suppor- tive measures can also be answered anonymously, e.g. by depositing short questionnaires at an anonymous distribution service. This latter, of course, might suffer from a serious bias as you cannot check if people are serious when giving the answers. Furthermore, only some people will fill in the questionnaire and this selection will be far from a representative sample.
Evaluation is not a static thing which can be done once, e.g. after a training seminar or at the end of a risk reduction project, and then forgotten. It is much more effective to use evaluation at a certain stage, e.g. after a seminar as an element in an ongoing monitoring process. Another option is to have evaluations on a regular basis, e.g. every three months.
Each evaluation step can provide relevant information that necessitates the adaptation of the program of risk reduction activities. This will lead to a process of ongoing evaluation identifying what is going on and resulting in a monitoring cycle that will allow you to adapt risk reduction activities to the actual needs and problems as and when they are discovered and identified.
decisions about the kinds of interventions that should be implemented
implementation of interventions
evaluation of interventions
modification of interventions or development of new ones
This monitoring process can focus on all the organisational elements mentioned above, on:
Needs assessment - have the needs changed?For example through a change in the inmate population (target group) or through the outbreak of a new epidemic( an outbreak of TB might lead to the urgent need for a general TB test andsubsequent prevention measures). Additional questions might be: Is the picture one has of the situation concern ing health risks still accurate?Is he definition of the prob lem still accurate?
Priorities and aims - do the priorities and aims have to change? For example through the results of earlier riskre duction activities (e.g. the introduction of condom distribution may make other needs a priority). Besides a check on whether the aims and priorities are still up-to-date, a reg ular check might be considered if the aims could or should be more specific, better measurable, acceptable enough for the target group(s), still realistic and adequately speci fied in time (smart, see 3.2 above)
Target group(s) - have they changed? (Through the growing influx of a particular ethnic group with specific risk patterns of drug use).
Approach and activities - does the approach have to be adapted to a new target group? (Counselling about sex risks will have to take into account the cultural, religious background of inmates) or would other activities be more appropriate? (Individual counselling instead of group meetings to discuss delicate issues).