Health Education for Social Prosperity (Preventing Drug-Use and Drug-Related Harm)1
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HEALTH EDUCATION FOR SOCIAL PROSPERITY (PREVENTING DRUG-USE AND DRUG-RELATED HARM)1 Keywords Reducing drug-related harm and drug use, Increasing capacity of staff to work with inmates at risk of drug use, Reducing vulnerability of inmates at risk of drug use, Improving co-operation between prison service and civil society 1.1 Case study 27: Health Education for Social Prosperity Name of practice: Health Education for Social Prosperity Country: Bulgaria 1.1.1 Main objective and specific aims The main objective of the project is to reduce drug-related harm in prisons and prevent drug use. It has three specific objectives: To build the professional capacity of prison and NGO staff working with inmates who are at risk of drug use; To reduce the vulnerability to health risks of prison inmates using drugs; Improve co-operation between the prison service and civil society in working with inmates at risk of drug use. 1.1.2 Relevance for 3rd EU-Health Programme objectives This programme is relevant to objective one of the 3rd EU Health programme: Promote health, prevent diseases and foster supportive environments for healthy lifestyles taking into account the 'health in all policies' principle, in that it supports prisoners to make their lifestyles healthier. 1.1.3 Target groups The target group of this programme was prisoners. The activities were targeted at three of the most vulnerable groups of prisoners in Bulgaria; drug users, underage inmates and Roma inmates. 1.1.4 Thematic focus of intervention in relation to reducing health inequalities Prison inmates tend to have lower educational status, lack of a supportive social environment, low awareness of health issues. These factors are also associated with low health literacy and increase the likelihood that the individual will take health risks2.The project was designed to redress the lack of knowledge of health risks among prisoners and teach them harm reduction techniques related to drug use. The project also trains prison staff to help bring inmates away from drugs and teaches them harm reduction techniques to share with the prisoners. This works to improve the health of prisoners by helping more of the prison population to avoid or cease using drugs and by improving the prison staff’s overall knowledge of health prison health issues. 1.1.5 Key activities The project took place in three prisons in Bulgaria and consists of two stages: Prison staff and NGO teams participated in four training modules over four days: 1https://ec.europa.eu/health/sites/health/files/social_determinants/docs/2017_vulnerable_casestu dyinventory_en.pdf page 176 2 Здравно обучение за социален просперитет “health Education for Social Prosperity” (2015) Project Summary: English [Online] Available at: http://www.healthyprisons.info/en/ [Accessed 21 Sept. 2016] - Motivational interviewing (a method of counselling to help individuals find motivation to seek treatment); - Treatment and prevention of drug use in prisons; - Brief interventions in cases of drug use or suspected drug use; and - Reduction of the harms of drug use. The trained prison staff and NGO members deliver health training to groups of inmates in their prison. The trainings take place in small groups of around 10 inmates over a period of eight months, with each group receiving at least three sessions. Training workshops with prisoners were centred on harm reduction themes: “Drugs, safer use and overdose”, “TB and sexually transmitted infections” and “HIV and hepatitis”. The prison staff also implement the techniques of brief intervention and motivational interviewing in the daily work with inmates. A brief intervention helps the individual to identify current issues with substance misuse and motivational interviewing is a non-combative counselling technique which seeks to help the individual find motivation to change their behaviour. The intervention was performed in prisons by the trained staff from each locality and they were supported by the expert team made up of representatives of the Bulgarian Initiative for Health Foundation and the Norwegian Tyrili Foundation. This support was provided in the form of follow up visits and remotely via email and phone. 1.1.6 Geographical scope The project takes place in three prisons across Bulgaria: the prison in the town of Pleven, the Prison in the town of Plovdiv and the Correctional Facility in the town of Boychinovtsi. 1.1.7 Intersectoral dimension This programme cuts across two policy areas: health and criminal justice. The harm reduction techniques are specific to the health risks faced by prisoners, especially vulnerable prisoners at risk of using drugs. The programme has a preventative element which is a criminal justice issue as keeping inmates away from drugs or helping them to stop using them means they are more likely to leave prison rehabilitated and not addicted to drugs. 1.1.8 Duration The project was a single intervention which ran for 14 months ending in April 2016. 1.1.9 Lead organisation The project was led by Initiative for Health3 – a Bulgarian NGO foundation which promotes harm reduction approaches for drug users in Bulgaria and prevention of HIV among intravenous drug users. 1.1.10 Partners Initiative for Health was supported by the Norwegian organisation Tyrili4 who were represented on the expert team that provided training to the prison staff and NGOs. Tyril has extensive experience of working with drug users in closed communities. The project worked with prison staff and local NGOS in each of three localities. 1.1.11 Main sources of funding The project was mostly funded by the Norwegian Financial Mechanism 2009-2014. It was a project in the “Correctional services including non-custodial sanctions” programme 3 Initiative for health (2016) "Инициатива за здраве" намалява рисковете за здравето на най- уязвимите членове на обществот [Online] Available at: http://www.initiativeforhealth.org/ [Accessed 21 Sept. 2016] 4 Tyrilistiftelsen –mulighetenes sted (2016) Detter er Tyrili [Online] Available at: http://www.tyrili.no/ [Accessed 21 Sept. 2016] under the Justice and Home Affairs priority sector. The total costs of the project was € 97,166 and Norway grants provided €74,332, with the remainder co-funded by other sources. 1.1.12 Evidence base for implementation The lead organisation, Initiative for Health, began conducting health training for inmates in prisons in Sofia, Bulgaria in 2005. These sessions focused on reducing the risks of drug use and how to take more care of the prisoner’s general health. This strand of activity grew over five years and is to be one of the major activities of the organisation. In the years between 2005 and 2010 they trained around 400 prisoners. The Health Education for Prosperity project was designed to replicate Initiative for Health’s action in Sofia across the country. The interest from other prisons came as a result of the positive reputation of the Sofia project5. Roma prisoners were particularly targeted for the intervention as the Initiative for Health outreach work in Sofia found that 70% of drug users were Roma6. 1.1.13 Evaluation: Has the practice been evaluated? The project was evaluated in 2016 using Kirkpatrick's Four-Level Training Evaluation Model. The evaluation looked at the training of the prison staff, and the prison staff’s application of what they learnt in the trainings. 1.1.14 Effectiveness: evidence of outputs, outcomes, results and cost-effectiveness7 The staff training was attended by 27 members of the penitentiary system and 9 experts from NGOs. Over a period of eight months the professionals conducted 35 educational groups with prison inmates: 15 groups in Pleven, 15 groups in Plovdiv and 5 groups in Boychinovtsi. The groups each did three sessions covering: “Drugs, safer use and overdose”, “TB and sexually transmitted infections” and “HIV and hepatitis”. The overall number of educated inmates was 352. Generally, the evaluation of the project was positive, finding that the trainings were a successful way to transfer knowledge to prison staff. It also showed some early findings of changes in attitudes of inmates and some evidence of behaviour change. Additionally, the project had a positive effect on establishing a stronger relationship between NGOs and prison staff. 1.1.15 Effectiveness of training on prison inmates8 The evaluation of the effectiveness of the training for prison inmates is based on entry and outcome information level tests and in-depth interviews with inmates and staff which assessed the usefulness of the information provided in the trainings. Interviews were conducted with prisoners to evaluate the trainings; 14 in Pleven, 14 in Plovdiv and 5 in Boychinovtsi. A professional was also interviewed from each location. Positive results were found in each location during the inmate interviews. In Pleven respondents reported that they were previously unaware of the risk of contracting a blood disease via tattooing but were now going to end this practice as a result of the training. In Plovdiv six of the 14 respondents stated that the training changed their attitudes and five had discussed the training with others. One inmate had even organised his own hepatitis C training, demonstrating the capacity for knowledge to spread through the prison. 5 Здравно обучение за социален просперитет “health Education for Social Prosperity” (2015) 6 EEA Grants (2015) Health Education for Social Prosperity http://eeagrants.org/project- portal/project/BG15-0016 7 All data from Rusev, A., Genchev, E., Nesheva, E., Rainov, I. and Georgieva, Y. (2016). Evaluation report on the results of the project “Health Education for Social Prosperity”. [pdf] Iniitative for Health. Available at: http://www.initiativeforhealth.org/wp- content/uploads/2016/04/Evaluation-report-en.pdf [Accessed 21 Sep. 2016] 8 All data from Rusev, A., Genchev, E., Nesheva, E., Rainov, I. and Georgieva, Y. (2016) In Boychinovtsi juvenile prison the piece of information which stuck with the inmates the most was the need to use condoms during sex with many saying they had never used a condom before.