RISK REDUCTION STRATEGIES IN PRISONS - WHY AND HOW?

It is evident that strategies have to be developed for the prison setting, to address problems such as the use of injectable drugs, unprotected sexual contacts and tattooing with non-sterile equipment, lack of knowledge about transmission of viral hepatitis, HIV/
AIDS and the dynamics of addiction.

The limited possibilities in prison call for creativity and unconventional solutions. ‘Second best’ or ‘better-than nothing’-strategies which are effectively pragmatic solutions to these problems have to be considered. Sometimes, prison-based rules and traditions can be followed. We know for instance, that, if it comes to injecting drugs without having a syringe available for all those involved in the act, in some prisons the inmates will stick to the rule that HIVpositive inmates inject last. Another example is that a used syringe is cleaned by simply drawing up several times with cold water because of a lack of effective means of either thermal or chemical disinfecting. To reduce health risks, inmates tend to develop their own forms of risk assessment, sometimes based on far from scientifically proven facts. For example, fatal errors can occur when inmates select their needle sharing partners by looking into their eyes in order to try and see whether the partner is hepatitis positive or not. Trust plays an important role among inmates and their culture and hierarchy. These onsets of risk reduction may serve as a starting point for risk reduction activities, such as discussing drug use, prison conditions and the spread of viral infections. Risk reduction should integrate the existing knowledge and practices of the target groups: drug users will often already know more than any trainer from outside, and staff have already developed their strategies for tackling intoxicated prisoners. This starting point should form the basis for further discussions.

When developing information material on risk reduction in prisons one has to keep in mind the specifics of the prison situation. Medical staff require different information than guards (prison officers). Inmates have their own specific background, subculture and language. Prevention material designed for target groups in the community cannot simply be transferred to the prison setting. The relevant target groups require prison-adopted versions. This makes it necessary to get input from each of the different groups concerned. This information can be collected through interviews or focus-group discussions. Initial drafts and design need to be tested and approved. The WHO states that: “it is important to recognise that any prison environment is greatly influenced by both prison staff and prisoners. Both groups should therefore actively participate in developing and applying effective preventive measures, in disseminating relevant information...” (WHO 1993)

Developing a network of key persons can be a helpful strategy. This can serve as a valuable background support. Key persons should be selected on the basis of their role in their specific networks (e.g. services for drug-using inmates). It is their task to provide crucial information about the situation in their working area (specific needs, where to organise activities, identifying partner organisations to collaborate with, pointing out other key persons, etc.), in the process of developing and realising modules of any risk reduction approach in prisons.

In many European countries community drug teams, AIDS projects or other health services are included in the care of drug-using inmates. Some prisons even have their own advisory board on drug issues. Sometimes, social and health workers from the community are involved in health promotion and risk reduction activities in prisons. In contrast to prison staff, these workers are more widely accepted and trusted by prisoners as they are not part of the prison system. In some countries, these ‘outsiders’ even have a duty to maintain confidentiality and have the right to refuse to give evidence. Moreover, they generally have a lot of valuable expertise, e.g. about the content of and requirements for the various services offered. They can provide this information on services in and outside prison to inmates. They also can contribute to the process of motivating drug-using inmates to overcome their drug use, e.g. through enrolling in prison or community therapy programs. However, they also can play an important role in delivering a prevention and risk reduction message. Including staff from community services facilitates the development of a chain of treatment, linking prevention and treatment in the community to prevention and treatment in prisons. Thus using such people generally contributes to continuity of health care, avoiding inefficient interruptions in services provided. It underlines the link between prison and community and promotes the advantages and need for prisons to be oriented towards the community.

To sum up, it can be said that when developing risk reduction measures in a prison, the chosen strategies should focus on the specific needs and beliefs, on the myths and the living and working conditions of the target groups. Strategies successfully applied outside cannot necessarily be applied inside without adaptations.

In the following we distinguish between three major approaches to risk reduction in prison:
an individual approach, aiming at personal behaviour change of inmates, i.e. individual counselling (see 6)
a group-oriented approach aiming at personal behaviour change, acquiring knowledge and skills and changing attitudes - both for inmates and prison staff, mainly via training seminars (7 and 8)
services and supportive measures; By services, we mean distributing condoms, bleach or even syringes (9). Supportive measures could be producing and distributing a newspaper, magazine or leaflets for inmates (10).

However, before being able to raise the issue of safer behaviour, first one has to reach, get in contact with drug users in prison. This sounds easier than it often is. Therefore we will deal with this issue separately (5). One basic problem in reaching drug users in prison is the fact that in one way or another they have to ‘out’ themselves as former or current drug user in an institution that generally imposes severe sanctions on this behaviour (in the form of loss of privileges, etc.).

All three approaches will be dealt with in detail below.