Correctional Authority - implementation
Approval by the correctional authorities is critical in implementing the local and system changes needed to support scale-up of testing and treatment.
Although a dedicated correctional officer(s) to facilitate escort of prisoners to the clinic and to potentially act as a champion of scale-up is recommended, the practical issues associated with this appointment include:
- shortages in the correctional staff roster, such that recruitment must be undertaken to fill the role
- unpredictable incidents and operational priorities that result in the rostered officer being reassigned to other duties and not back-filled
- reluctance of some officers to be posted to this role (reflecting concerns regarding the perception of other officers against such a proactive role supporting the health care of prisoners)
Some of the challenges during implementation may be overcome by ensuring flexibility in the staffing model (e.g. use of casual staff), and targeted educational efforts to facilitate engagement of supportive officer(s). Informal and formal positive recognition of dedicated officers, for example in staff communications, awards or performance and promotion systems, may strengthen the perception of organisational support and foster engagement by correctional officers.
Recruiting to the dedicated officer role
Difficulty with attracting dedicated officers to the ‘escort officer’ position was faced during the SToP-C program. This was due to philosophical objections to hepatitis C testing and treatment of prisoners, the potential backlash faced from other staff, and adverse implications for career progression, such as the inability in the role to earn penalty rates available for other evening or weekend shifts.
Education regarding the goals of treatment scale-up and the potential benefits of harm minimisation reduced philosophical concerns among correctional officers. Local processes and potential contacts for the dedicated officer were outlined prior to appointment into the role. Wherever possible, officers selected for this dedicated position were recruited from within the prison, so that the designated officer already had well-established trusted relations with other officers and prisoners.
We need to identify champions at the correctional-officer level who will support the implementation of hepatitis c treatment in prisons […] How can we develop correctional officer champions to support a hep-c-free prison?”
Negotiating the appropriate allocation of resources is pivotal to the success of implementation.
Staffing costs of dedicated correctional officer(s) are a significant budget item. As movements of prisoners within a correctional centre generally require an escort, and the scale-up plan involves an increased number of prisoner movements, provision of a dedicated officer to facilitate prisoner transport to and from the clinic enables a significantly higher rate of scale-up compared with reliance on officers already working in the prison.
Other expenses which need to be costed by the correctional authority include: the opportunity cost of using prison space or rooms for the scale up of hepatitis care, and any modifications to these rooms (if needed); staff education and training costs; rewards or recognition programs for staff contributing to the hepatitis service; and costs of preparing and extracting the data needed for the evaluation of the scale-up. A regular review of the budget is recommended to assist in making adjustments to meet performance targets.
Data collection and information
Provision of data on prisoner population sizes, intake of new prisoners, and inter-prison transfers and releases is needed to monitor and evaluate the effectiveness of scale-up. Approval by the central correctional data unit (if applicable) or prison governor for access to regular data reports should be negotiated by the scale-up team. The data specifications and processes for obtaining these data should be approved by the data custodian and documented.
The use of electronic devices such as tablet computers can facilitate efficient data collection for treatment scale-up.
The use of electronic devices such as tablet computers can facilitate efficient data collection for treatment scale-up. Appropriate permissions for use of such devices should be in place prior to implementation, noting that there may be variations in policies governing use of electronic devices between individual centres. Security-driven barriers regarding the transport and safe storage of equipment, such as electronic devices including clinical equipment such as fibro-elastography machines, as well as needles/syringes for venepuncture may be encountered especially if facilities other than the health clinic are used during scale-up. Standardised procedures for the use and storage of equipment across multiple centres may be difficult, requiring individualised arrangements at each centre.
Permission to use electronic data capture
Permission of the correctional authority to use and store electronic devices for SToP-C data collection was needed given strict rules to avoid theft or misuse of electronic devices by prisoners. There were no standardised procedures or rules across all prisons.
High level permission from the correctional authority was secured and documented in a letter signed by the organisational head. Negotiations relating to the conditions of use and storage then had to be undertaken with each prison governor. The ultimate approval often required all networking and camera capabilities to be disabled, and documentation of the serial number of each item to be maintained at entry into each prison.
Rules relating to equipment handling, storage location and access varied across prisons, and it was important that staff involved in data collection were aware of, and followed, these rules. Maintaining documentation of all approvals and processes is recommended given the turnover of prison management staff.
Access to data
Testing and treatment scale-up requires regularly updated data regarding the number of individuals incarcerated within each centre (e.g. weekly or monthly) and movements between centres, as well as to/from the community. Requesting site specific data from local centre management (e.g. general managers and managers of security) in the selected SToP-C prisons was unsuccessful.
These data were ultimately provided by the centralised data management unit for the corrective service as a whole, after provision of one-off funding from the SToP-C project to cover the costs incurred in setting up automated regular reports from the correctional database.
Use of facilities other than the health clinic
There were inconsistencies in the approvals provided by individual prisons authorities on the constraints in the storage and use of venepuncture equipment. Some centres required dedicated safe and restricted use of equipment only in health care clinics, and others allowed venepuncture in non-traditional areas within the prison such as in work locations (which facilitated testing of large numbers of prisoners during work).
A flexible approach to testing and treatment targets, resourcing, and timelines was applied, as a uniform strategy across all correctional centres was not feasible. Meetings with prisoner governors were important to negotiate alternative arrangements, for example after-hours visits for prisoners on day-work release. Support of senior correctional authority personnel was critical in negotiating approvals with individual prison governors. Maintaining records and documentation of approvals was important for continuity of practice when prison management changed.
Communication and education
Efficient movement of prisoners is a critical element of successful scale-up. Slow responses to movement requests are common, sometimes attributable to adversarial attitudes from both prisoners and correctional officers. Support for the testing and treatment scale-up from senior correctional staff and good communication between health and correctional staff are both key to resolving this barrier. Support of correctional staff is encouraged by both hepatitis C education and project-specific updates.
Targeted prison-focused hepatitis C education for correctional officers and for prisoners is a key element underpinning efficient scale-up (see Health services – implementation, Communication and Education). For correctional staff, this may include brief information as part of orientation and on training days, potentially with video resources and print material displayed in staff common rooms. This promotional material should emphasise the direct benefit to staff in terms of reduced occupational risk exposure resulting from reductions in the prevalence of hepatitis C in the prisoner population and hence reduced risk from needlestick injuries. Please refer to the Resources page for examples of education and training materials.
The education should also emphasise the wider community benefit of prison-based scale-up of DAA treatment in reducing the prevalence of hepatitis C infection in the community. In combination, these messages should seek to resolve negative attitudes. Regular communications with correctional authorities by the project team should be followed by endorsement and dissemination of progress toward targets to all correctional staff in internal communications, such as newsletters via email, or conveyed during staff meetings including publicising staff champions.
Navigating opposition in prison
The main concerns identified amongst correctional staff during the SToP-C program related to the notion of preferential treatment of prisoners (above community members), the significant cost implications (to Australian taxpayers who subsidise treatment of prisoners), as well as initial fears of the potential mood-altering effects of DAA treatments. These perceptions led to resistance from correctional officers against the project.
These concerns were successfully resolved by education sessions for correctional officers. The key points covered in these education sessions included: the fact that treatment of prisoners was not preferential, (as there was broad access to DAA therapy in the Australian community); that DAA treatments had been shown to be cost-effective in reducing the future morbidity and mortality due to hepatitis C (largely via avoiding end-stage liver disease and its complications); and the benefits of reduced occupational risk via needlestick or other blood-to-blood contact. Finally, the lack of mood-altering effects associated with DAAs was emphasized, as well as the potential benefits of improved prisoner health, which may in turn result in a positive impact on behaviour.
“The SToP-C officer was the one who explained it in pretty easy to understand terms about what the goal of the program was.”
Corrective Services Officer
Prisoners often fear repercussions from corrective services, as a result of participating in testing and treatment for hepatitis C and indirect disclosure of their hepatitis C infection status and hence likely injecting drug use. This may be a significant barrier to prisoners presenting for screening and treatment. The location of the health clinic and consultation office should ensure privacy is maintained and attendance is not highly visible.
“We’ve broadcast it to staff and we’ve had staff presentations at staff meetings and even at our morning parade at 8 o’clock. I’ve told them about the results of this project and said, “This is what we’ve done, you know, the benefit to you is it’s less inmates in here that have got hepatitis C, less likelihood of you getting it, you know”. So it’s what we’re doing to help and making the staff aware, “You need to promote this”. You need to support it because it wasn’t being strongly supported by the whole of the staff in the centre.”
Cultural and ethnic minorities in the prison setting may be strongly influenced by their peers either in favour of treatment or against it. These groups may be engaged by ensuring key influencers from the group come forward for testing and treatment and then potentially act as champions to encourage others. Movement of prisoners within these ethnic or other groups, should ensure privacy is maintained and potential adverse incidents against individuals or groups are monitored by correctional staff.
“Say if they’re in the bikie crew [gang member]... no way they’ll come in [for testing]... because if it gets around that he’s got hep C it will be an embarrassment and he’s not going to buy drugs... They care about what people think, they care about their persona or whatever you want to call it...”