Towards a Continuum of Care in the EU Criminal Justice System a Survey of Prisoners’ Needs in Four Countries (Estonia, Hungary, Lithuania, Poland)
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Schriftenreihe „Gesundheitsförderung im Justizvollzug“ – „Health Promotion in Prisons“ Herausgegeben von H. Stöver, J. Jacob „Gesundheitsförderung zielt auf einen Prozess, allen Menschen ein höhe- res Maß an Selbstbestimmung über ihre Gesundheit zu ermöglichen und sie damit zur Stärkung ihrer Gesundheit zu befähigen. Um ein angemesse- nes körperliches und seelisches Wohlbefinden zu erlangen, ihre Wünsche und Hoffnungen wahrnehmen und verwirklichen, sowie ihre Umwelt meis- tern bzw. sie verändern zu können“. Diese Gedanken leiten die Ottawa- Charta zur Gesundheitsförderung ein, die 1986 von einer internationalen Konferenz verabschiedet wurde. Versucht man den Leitgedanken der Ottawa-Charta, die Stärkung der Selbstbestimmung über die Gesundheit, auf den Strafvollzug zu beziehen, stößt man schnell an Grenzen der Über- tragbarkeit: Äußere Beschränkungen, Fremdbestimmungen, eingeschränkte Rechte prägen das Leben und die gesundheitliche Lage der Gefangenen. Mit der Schriftenreihe „Gesundheitsförderung im Justizvollzug“ wollen wir Beiträge veröffentlichen, die innovative gesundheitspolitische Anregun- gen für den Justizvollzug geben und gesundheitsfördernde Praxisformen des Vollzugsalltags vorstellen. Außerhalb des Vollzugs bewährte Präventionsangebote und Versorgungs- strukturen werden auf ihre Relevanz zur Verbesserung der gesundheitli- chen Situation Inhaftierter hin überprüft und auf die Bedingungen des Jus- tizvollzugs bezogen. Letztendlich kann nur eine größere Transparenz und Durchlässigkeit des Systems „Justizvollzug“ dazu beitragen, individuelle gesundheitsorientierte Potentiale Gefangener anzuregen und zu fördern. Die HerausgeberInnen Heino Stöver / Katja Thane Towards a Continuum of Care in the EU Criminal Justice System A survey of prisoners’ needs in four countries (Estonia, Hungary, Lithuania, Poland) Volume 20 BIS-Verlag der Carl von Ossietzky Universität Oldenburg Oldenburg, 2011 Verlag / Druck / Vertrieb BIS-Verlag der Carl von Ossietzky Universität Oldenburg Postfach 2541 26015 Oldenburg E-Mail: [email protected] Internet: www.bis-verlag.de ISBN 978-3-8142-2233-2 Contents Acknowledgements 9 List of Figures 10 List of Tables 12 List of Abbreviations 14 Executive Summary 15 1 Introduction 23 2 Methodology 25 2.1 Study Site Selection 25 2.2 General methodological approach 26 2.3 Project management 27 2.4 Details of institutions visited and participants interviewed 29 2.4.1 Field visits 29 2.4.2 Inmates’ survey 30 2.5 Procedures and ethical issues 33 2.6 Methodological issues arising from the fieldwork 34 2.7 Definition of key terms 34 3 General problems in prison health care delivery – results of the literature review 37 3.1 Structures and problems of organisation of health care: Prison as a high risk environment 37 3.1.1 Overcrowding and over-representation of risk groups 37 3.1.2 The principle of equivalence for health care in prisons 37 3.2 High risk behaviour in prisons 39 3.2.1 Nature and prevalence of drug use and related risks 39 3.2.2 Unprotected sex 43 3.2.3 Tattooing and body piercing 45 3.2.4 Drug use and prevalence of BBVs in prisons 46 3.2.5 Transition from custodial settings into the community 49 3.2.6 Consequences of drug use for the prison system 50 3.3 Prevention, treatment, and education programmes for prisoners 51 3.3.1 Testing of and counselling on infectious diseases 54 3.3.2 Hepatitis A+B vaccination 55 3.3.3 Treatment for infectious diseases 56 3.3.4 Information, education and communication on drug use and infectious diseases for prisoners and prison staff 57 3.3.5 Drug testing 58 3.3.6 Prison based drug demand reduction programmes 60 3.3.7 Throughcare 62 3.3.8 Conclusion 65 3.4 Harm reduction 66 3.4.1 Needle exchange programmes 67 3.4.2 Opioid Substitution Treatment (OST) 69 3.4.3 Provision of bleach and disinfectants 73 3.4.4 Provision of condoms, dental dams, and water-based lubricants 73 3.4.5 Training and engaging prison staff in implementing harm reduction services 74 3.4.6 Conclusion 76 3.5 Involvement and support of NGOs 76 3.6 International Guidelines on prison health, human rights etc. 77 4 Profiles and problems of health care delivery in the prisons and NGOs visited – trends and responses to drug use in prisons in the sample countries 83 4.1 Estonia 83 4.1.1 General information on the prison system 83 4.1.2 Results from field visits 90 4.1.3 Results from inmates’ survey Estonia 101 4.1.1 Results from the presentation of the results in Estonia 115 4.1.2 Conclusions 119 4.2 Hungary 121 4.2.1 General information on the prison system 121 4.2.2 Results from field visits 134 4.2.3 Results from inmates’ Survey 146 4.2.4 Results from the presentation of the results in Hungary 156 4.2.5 Conclusions 158 4.3 Lithuania 160 4.3.1 General information on the prison system 160 4.3.2 Results from field visits in Lithuania 168 4.3.3 Results from inmates’ survey Lithuania 179 4.3.4 Results from the presentation of the results in Lithuania 194 4.3.5 Conclusions 195 4.4 Poland 198 4.4.1 General information on the prison system 198 4.4.2 Results from field visits 206 4.4.3 Results from inmates’ survey 221 4.4.4 Conclusions 237 4.5 Summary of the quantitative results from all four countries 238 4.6 Identifying common and structural problems 243 4.6.1 General resistance to harm reduction services for drug users 243 4.6.2 “Prison health care is of better quality than public health care” 245 4.6.3 Denial of a drug problem, denial of an opiate-related problem 246 4.6.4 Lack of understanding of the nature and dynamics of drug dependence 247 4.6.5 The myth of ‘control’ of the spread of infectious diseases 248 4.6.6 Stigma 248 4.6.7 “Harm reduction is not implemented in prisons in most European countries, so why should we do it here?” 249 4.6.8 Overcrowding and lack of resources 250 4.6.9 Involvement of NGOs 251 4.6.10 Problems of health care in detail 251 5 Barriers to improvement of health care in prisons and requirements to ensure sustainability 259 5.1 Overcoming institutional challenges 259 5.2 Overcoming abstinence orientation as pre-dominant response 260 5.3 Information, education and communication 262 5.4 Adjustments in regulations and legislation 264 5.5 Reduction of prison populations and prison reform 265 5.6 Commitment and political and management leadership 265 5.7 Overcoming resistance from prisoners and prison staff 266 5.8 Human rights legislation and international guidelines 268 5.9 The need for protocols, standards of care and guidelines 271 5.10 Continuity of treatment 271 5.11 Opioid Substitution treatment (OST) in prisons 274 5.12 Needle exchange programmes in prisons 275 6 Conclusions 277 References 285 Authors 313 Acknowledgements The completion of this study would not have been possible without the sup- port and assistance of a wide range of individuals. We would like to thank the Director Generals of the Prison Service in the four European countries for having authorised the research and for having provided logistic support: Estonia: Priit Kama Lithuania: Saulius Vitkunas Poland: Jacek Włodarski Hungary: Dr. Antal Kokenyesi We would also like to thank all the prison staff in the sample prisons, who agreed to be interviewed and who provided such a depth of information, and to all the prisoners who participated in the focus groups and in the survey. Our partners in the four countries did a great job in facilitating the research, translating the questionnaire and all the interviews, and commenting on the research process. Thank you very much: Estonia: Anna Markina, University of Tartu, Ms. Maret Miljan, Ms. Kristel Jürgens, both Prison Administration Lithuania: Janina Kulsiene, Prevencijoscentras – Prevention Centre, Ms Birute Semenaite, Mr. Vladas Kasperunas, both Prison Administration Poland: Prof. Dr. Krzysztof Krajewski, Alicja Papierz, Maria Stozek, Jagiellonian University Krakow Hungary: Meszaros Mercedesz, Valto-Sav – Changing Lanes, Gergely Fliegauf, Police College Hungary, Prison Department Thanks also to Cinzia Brentari and Alex Stevens for their help and support. List of Figures Fig. 1 Imprisonment rate Estonia 84 Fig. 2 Length of current prison sentence, Estonia 102 Fig. 3 Suffering from prison situation, Estonia 104 Fig. 4 Rating of own health status, Estonia 104 Fig. 5 HIV and Hepatitis, Estonia 105 Fig. 6 Own substance use, Estonia 108 Fig. 7 Acquisition of drugs in prison, Estonia 109 Fig. 8 Estimations on violence occurring in prison, Estonia 110 Fig. 9 Risk behaviour, Estonia 111 Fig. 10 Service availability, Estonia 112 Fig. 11 Service use in prison, Estonia 113 Fig. 12 Assessment of quality of treatment, Estonia 115 Fig. 13 Imprisonment rate per 100,00 inhabitants, Hungary 121 Fig. 14 Positive screening for TB in prisons, Hungary 127 Fig. 15 Length of current prison sentence, Hungary 147 Fig. 16 Suffering in prison situation, Hungary 149 Fig. 17 Rating of own health status, Hungary 149 Fig. 18 Drug use prevalence inside and outside prison, Hungary 152 Fig. 19 Acquisition of drugs in prison, Hungary 153 Fig. 20 Estimation on violence, Hungary 154 Fig. 21 Risk behaviour, Hungary 154 Fig. 22 Assessment of the quality of health care, Hungary 156 Fig. 23 Incarceration rate Lithuania (per 100,000 inhabitants) 160 Fig. 24 Length of current prison sentence, Lithuania 181 Fig. 25 Suffering from prison situation, Lithuania 183 Fig. 26 Rating of own health status, Lithuania 183 Fig. 27 Infectious diseases, Lithuania 184 Fig. 28 Substance use, Lithuania 186 Fig. 29 Acquisition of drugs in prison, Lithuania 187 Fig. 30 Syringe or equipment sharing, Lithuania 188 Fig. 31 Own risk behaviour, Lithuania 190 Fig. 32 Availability of help services in prison, Lithuania 191 Fig.