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Tattooing in Scottish Prisons a Health Care Needs Assessment

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Tattooing in Scottish Prisons a Health Care Needs Assessment Tattooing in Scottish Prisons A health care needs assessment Dona Milne December 2009 1 TABLE OF CONTENTS Executive Summary 3 1. Introduction 5 2. Methodology 6 3. Epidemiology 8 4. Current tattooing practices in Scottish prisons 11 5. Stakeholder views 16 6. Interventions to reduce risks – stakeholder views 18 7. Interventions to reduce risks – research findings 22 8. Conclusions 26 9. Recommendations 28 10. References 29 11. Appendices 31 Prisoner Survey Results to tattoo questions Appendix A Interview questions for tattooists Appendix B Focus Group questions for prisoners who got a tattoo Appendix B Illustration of how to make a prison tattoo gun Appendix C Survey for completion by prison doctors Appendix D 2 EXECUTIVE SUMMARY There are approximately 8,000 prisoners in Scottish prisons on any given day, with in excess of 26,000 individual prisoners admitted to the prison system in the course of a year. Prisoners are often admitted more than once a year either on remand or short term sentences, leading to a total of 43,000 admissions per year. In the past prisons have been contributing sources of hepatitis C reports: 6% of all reports since 1998 giving a total of cases diagnosed in prisons as 1663. Studies in Scottish prisons suggest an overall prevalence of hepatitis C of between 16-20%, 45-54% in prisoners who have been or currently are IDUs and approximately 4% in prisoners who are non-IDUs. Tattooing within the prison environment whilst not illegal is unregulated. Studies have considered the degree of tattooing activity in prisons and attempted to quantify the potential risks to prisoners and others. There is a risk of blood borne virus (BBV) transmission as a result of tattooing in prisons. Tattooing has been identified as an independent risk factor for hepatitis C. The Scottish Prisons Service (SPS) “requires to assess the nature, extent and risks related to tattooing in prison and to assess the need for public health intervention”. Prisoners reported a high level of tattooing activity undertaken with home made tattoo guns made from a range of components available in the prison setting. Prisoners also reported attempts at cleaning equipment and avoiding infection through changing equipment and not sharing ink. There was a good level of understanding of the risks of blood borne virus infection and how this could be prevented, although this knowledge was not always applied in practice. Prison staff had a good understanding of the tattooing activity taking place and recognised that this was unlikely to be stopped easily. Staff identified a range of possible interventions that could be deployed by SPS to reduce the risks to prisoners from tattooing. One of the barriers identified by staff was the prevailing culture within prisons particularly the attitude of prison officers to the availability of any kind of needle within the prison environment. This is a challenge that SPS will need to overcome if it truly intends to adopt tried and tested harm reduction approaches that could have an impact on public health within and outwith the prison environment. There are a number of studies that have identified tattooing as an independent risk factor for BBV infection. There are a small number of studies that identify possible interventions to reduce risks from tattooing and only one intervention that was fully evaluated to assess its impact on illicit tattooing activity. Collectively, these studies call on the prison authorities to adopt a harm reduction approach and increase prisoner education on tattooing risks; make cleaning materials freely available; and where possible consider implementing a tattoo parlour in the prison environment. 3 The needs assessment led to the following recommendations: i) The Scottish Prison Service should review existing health promotion materials on tattooing in prisons used in other countries for use in Scottish prisons. This review should take place with Scottish prisoners to ensure the relevance of the final materials that should be made available to all establishments in Scotland. ii) Information on the risks from tattooing in prisons should become a feature of staff training and prison induction sessions alongside information on blood borne virus risks. iii) The prisoner survey should be amended to seek information on when the prisoner obtained a tattoo within prison, in particular to identify those who have received a tattoo in the last year to better assess current tattooing activity within prisons. iv) Sterilisation materials or facilities should be made available to prisoners providing tattoos to other prisoners, either through health care or addictions staff. v) The Scottish Prison Service health care standard on blood borne virus prevention, care and treatment should be updated to reflect the inclusion of the above approaches within prison health care services. Furthermore, SPS should consider the piloting of a tattoo studio within one of its long stay prisons. This could provide the impetus for a wider organisational change in culture towards harm reduction approaches and enable the introduction of tried and tested community based harm reduction methods into the prison environment in the future. 4 1. INTRODUCTION Tattooing has become common practice amongst large sections of the UK population as part of an international revival1. Recent changes in legislation2 in Scotland have sought to ensure that any potential risks to the public from tattooing activity are minimised through improvements in licensing requirements for those providing such services. Tattooing within the prison environment whilst not illegal is unregulated. There has been a limited number of studies in recent times that have considered the degree of tattooing activity in prisons and attempted to quantify the potential risks to prisoners and others. There is a risk of blood borne virus (BBV) transmission as a result of tattooing in prisons, although limited evidence that this has actually occurred in practice3. The Scottish Prisons Service (SPS) “requires to assess the nature, extent and risks related to tattooing in prison and to assess the need for public health intervention”4. The aim of this work is to undertake a health care needs assessment to assess the need for a public health intervention to reduce the risk of BBV infection through tattooing in prison. This needs assessment has the following objectives: To describe the current population in Scottish prisons and the disease burden related to blood borne viruses To identify current tattooing practices and associated risks/potential risks To elicit stakeholders views: prisoners, staff and management To consider evidence of effective interventions to reduce risks related to tattooing in prison To recommend potential interventions to reduce risks associated with tattooing which could be delivered within the prison environment, taking into account feasibility and cost 5 2. METHODOLOGY Health care needs can be assessed using a range of approaches, however, it is generally accepted that a comprehensive approach would include the following methods5 Epidemiological – combining epidemiological approaches (health status assessments) with assessment of effectiveness of potential interventions Comparative – comparing different population groups receipt (and use) of different services Corporate – seeking the views and wishes of service users, stakeholders, service providers Epidemiological A range of data sources was used to provide information on the size and state of health of the prison population, rates of reported tattooing activity and estimated prevalence of blood borne virus infection. This included surveillance reports on blood borne virus infection in Scotland; results from the Scottish Prison Service Annual Prisoner Survey; and a recent health care needs assessment of prison health in Scotland. A number of peer reviewed prevalence studies relating to BBV infection in prisons were identified through a literature search to provide information on potential risk from tattooing. Published clinical case reports were also considered. Comparative This was more difficult as the needs assessment was related to a specific population group, however, consideration was given to the services provided (both in terms of tattooing services provided by prisoners and health care provided by staff) and used by prisoners across four different establishments within the SPS estate. Email enquiries were made to the two main prison networks seeking details of any interventions/services within prisons related to tattooing – none were reported. Furthermore, a search of the published and grey literature was conducted to identify provision and uptake of services and interventions within prisons nationally and internationally to assess options for future service provision. Corporate Local information was gathered from a range of sources. Following identification of Scottish prisons where incidence of tattooing is reported to be high a purposive sample was selected to reflect the different type of 6 establishments in Scotland. A letter was sent to the Governor of each of these establishments to explain the purpose of the needs assessment and to seek their co-operation in identification of a Hall Manager to support contact with staff and prisoners (both those who have received a tattoo and those providing tattoos). In order to gain a better understanding of the equipment being used, the Governor was asked to send to SPS any tattooing equipment confiscated during the following three month period.
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