Tattooing in Scottish Prisons a Health Care Needs Assessment

Tattooing in Scottish Prisons A health care needs assessment

Dona Milne December 2009

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.

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.

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.

The following activity took place:

- In each establishment interviews were conducted with a Hall Manager, Health Centre Manager, and one each of hepatitis C specialist staff and prison officers

- A one to one interview was completed with a tattooist in each establishment

- One focus group of prisoners who had obtained a tattoo whilst in prison was undertaken in each establishment

- A short survey of prison doctors (25 approx) was completed to identify the frequency of clinical complaints related to tattooing

SPS identified the work as a management-commissioned enquiry rather than a research exercise. However, the Research Access and Ethics Committee of SPS were advised of the work and confirmed that ethics committee approval was not required.

7 3. EPIDEMIOLOGY

Prison population 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 year6.The vast majority of prisoners are young, white males who come from deprived backgrounds, many of whom have not completed secondary education or experienced employment, either themselves or within their families. They are recognised as a population group who lead chaotic lives and regularly engage in risk taking behaviour that may have a negative impact on their health.

An overview of prisoners in Scotland and the state of their health is available in Prison Health in Scotland, A Health Care Needs Assessment6. This needs assessment identifies the need for prison health care to be comparable with that provided in the community “Guiding principles are that health care in prison should be equivalent to that delivered in the community, that prison health is part of public health and that the prison setting is potentially an opportunity for health promotion”. However, it is also recognised that health care is not the top priority of the SPS where security and maintaining order are of prime concern and undoubtedly have an impact on the effectiveness of any health care intervention provided.

The SPS has identified thirteen clinical areas that are of greatest concern to prisoner health and which therefore merit particular action - one of these is blood borne viruses. This has led to the identification of BBV health care standards for SPS which all establishments are expected to deliver.

Hepatitis C infection Within the Scottish population, the total number of people known to be infected with hepatitis C in Scotland at March 2009 was 25,845. This equates to one in 240 people in the Scottish population having been diagnosed hepatitis C antibody-positive. However, the most recent report from Health Protection Scotland7 estimates that “the number of undiagnosed hepatitis C antibody-positive cases in Scotland still exceeds the number of diagnosed cases”. 58% of those diagnosed with hepatitis C are current or former injecting drug users (IDUs); this represents 89% of those with a known risk factor and confirms that the most common source of hepatitis C infection is injecting drug use. Tattoo was indicated as a risk in some of the 6% of reports where “other” source of infection was indicated.

The high level of reported drug use amongst prisoners (67% in the past 12 months) including past or current injecting status (17%) 7 accounts for the increasing level of Hepatitis C within prison settings. The SPS health care needs assessment recognises that the figure for hepatitis C is under reported as the figure published is lower than data held in clinical records.

8 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-IDUs8. Applying these estimates to the annual Scottish prison population gives an estimated number of 9551 prisoners with hepatitis C in a year9. These figures should be treated with caution as they are based upon data from prevalence studies undertaken some time ago. A survey of Hepatitis C prevalence and incidence among prisoners in Scotland will be undertaken as part of the Scottish Governments Hepatitis C Action Plan for Scotland: Phase II (May 2008 – March 2011)10.

More recent data available from SPS provides information on the numbers of prisoners tested for hepatitis C, the numbers testing positive and of those the numbers referred for and subsequently started on treatment. The data shows increased levels of hepatitis C testing over a 4 month period in 2009 (table 1), compared to a nine month period in 2008 (table 2), although this may not be entirely accurate as data for the period 1 April to 31 December 2008 is limited as not all establishments have provided data. It is unlikely that hepatitis C testing did not take place in those establishments during this period and in fact is more likely to reflect under reporting of hepatitis C testing in Scottish prisons. An interesting figure to consider however is the difference in the positivity rate identified from the tests that were undertaken – 68.8% in 2008 compared to 21.2% in 2009. This may be due to increasing awareness amongst prisoners of the risk of hepatitis C infection leading to requests from prisoners that may not have been at risk or poor targeting within the prison setting – it is impossible to explain this until more data is available and further consideration of current testing practices in Scottish prisons.

Table 1: BBV stats: 1st Jan – 31st April 2009 HCV Number tested Number +ve Number referred Number on or outpatient treatment Aberdeen 11 5 15 0 Barlinnie 47 14 14 1 Castle Huntley 40 14 8 2 Cornton Vale - - - - Dumfries 32 3 3 2 Edinburgh 82 26 7 7 Glenochil 20 8 7 6 Greenock 14 2 2 0 Inverness 23 7 9 1 Kilmarnock 124 5 0 6 Noranside 10 6 3 2 Perth 29 15 14 5 Peterhead 4 0 0 1 Polmont 11 1 1 0 Shotts 16 1 1 10 Total 924 407 88 84

Table 2: BBV stats 2008 1st April – 31st December 2008 Number tested Number +ve Number referred Number on for HCV HCV or outpatient treatment Aberdeen - - - - Barlinnie - - - - Castle Huntly 83 104 35 9 Cornton Vale 0 0 0 0 Dumfries 50 5 5 2 Edinburgh 66 81 23 4 Glenochil 48 54 42 9 Greenock 17 3 20 0 Inverness 27 1 7 2 Noranside 28 15 5 2 Perth 102 43 20 6 Peterhead - - - - Polmont 28 3 2 0 Shotts - - - - Total 449 309 159 34

Note: instances where numbers positive exceed those tested is due to testing taking place elsewhere.

A further action in the Scottish Governments Hepatitis C Action Plan for Scotland: Phase II (May 2008 – March 2011) is “Service Level Agreements/Memoranda of Understanding between NHS Boards and the Scottish Prison Service (SPS) to promote the treatment of Hepatitis C infected inmates in prisons will be developed in the context of the SPS Blood Borne Virus (BBV) strategy”. This has provided an impetus to SPS to further work with NHS Boards to increase the capacity of SPS to devise effective patient pathways to increase the number of prisoners identified and referred for treatment for hepatitis C. The above figures suggest that this focus is beginning to pay off with an increase in those testing positive being referred for treatment (95% of those tested positive in 2009 compared to 51% of those tested positive in 2008) and an increase in those being referred commencing treatment (46% of those referred in 2009 compared to 21% of those referred in 2008). Once again, it is important to note the small numbers and differences in time periods for these figures: no firm conclusions can be drawn at this stage.

The rate of hepatitis C infection in the prison population varies internationally: estimated prevalence in Australian prisoners is thought to be around 34% to 47% amongst male inmates11. In Canada, the prevalence of hepatitis C virus within the prison population is 24.6% compared to 0.6% of the Canadian population 12.

Tattooing prevalence in prison SPS undertakes an annual survey of prisoners in all Scottish prisons. The 2008 survey was the 11th survey undertaken and had a 62% response rate: the results of the survey are used to improve the quality of service delivery across Scottish prisons. Prisoners are asked a range of questions relating to

10 health issues and in 2008 were asked specific questions relating to hepatitis c, body piercings and tattooing13.

The SPS Annual Prisoner Surveys conducted in 2007 and 2008 reported the following tattooing activity amongst prisoners:

55% prisoners reported having a tattoo with 19% reporting receipt of a tattoo in prison (2007)

54% prisoners reported having a tattoo with 18% reporting receipt of a tattoo in prison (2008)

Rates of prisoners reporting receipt of a tattoo in prison varied across Scottish prisons, from a low of 10% in one prison to a high of 28% in another prison. There are no obvious reasons for this variation with high and low rates reported in short and long stay establishments. The only difference is that reported rates were lower in both the women’s prison and that for young offenders. Appendix A illustrates reported practices across each prison.

Similar rates of tattooing activity were reported in a national survey of prisoners in England and Wales in 1994, where 21% of 536 prisoners who reported ever having a tattoo had been tattooed in prison14. Research into prisoner risk taking in Russian prisons found that from a sample of 1,044 prisoners aged 15-30 who completed a survey similar to those above, 26% reported receiving a tattoo whilst in prison15. More recently, a cross-sectional survey conducted in prisons in Australia16 found that of 449 prisoners who had ever had a tattoo 41% had received a tattoo in prison either as an adult or whilst in a detention centre for juveniles.

The main risks to prisoners engaging in tattooing in prison is that of potential blood borne virus transmission and the risk of other infections such as skin infections, allergic reactions, skin disorders and abscesses. The main area of concern for previous studies has been blood borne virus transmission due to the high levels of morbidity attached to hepatitis infection, particularly hepatitis C. Attempts to quantify the potential transmission risk are flawed due to the current lack of SPS HCV test data aligned to self reported tattoo in prison. However, there is a hypothesis amongst BBV staff that due to the fact that there are many hundreds of punctures per tattoo, the transmission risk could be significant and certainly enough to warrant public health intervention.

In addition to being asked to complete a questionnaire, prisoners in the Australian study were asked to provide a finger prick blood sample that was then tested for HCV antibodies. The study considered a range of risk behaviours, including injecting drug use (which is recognised as the most significant risk behaviour for HCV transmission). However, after adjustments authors still identified tattooing in prison as an independent risk factor for HCV16.

Tattooing as an independent risk factor for HCV infection has also been reported by others17,18 although there are limitations to some of these studies.

11 Many are cross sectional in nature and recognise the difficulty in attributing infection to tattooing activity in prison amongst a population with high levels of injecting drug use, either current or historic. There have been occasional case reports of hepatitis C virus infection amongst prisoners where tattooing was identified as a possible route of transmission19,20. The most recent of these recognised that “the possibility of undisclosed injecting drug use cannot be completely discounted as the route of transmission”. 20.

There are real challenges in attributing HCV infection to an activity in prison due to the activities that prisoners engage in (or have engaged in) within the community; the regular “churn” through the prison system; and the fact that hepatitis C infection can be asymptomatic within the first six months making it difficult to identify a point of infection.

12 4. CURRENT TATTOOING PRACTICES IN SCOTTISH PRISONS

A number of studies have considered the risks from tattooing in prison, however, very few have considered how tattooing is carried out in practice. This has led to a range of assumptions being made about prison tattooing practices. When talking about tattooing practices in prison, many assume that the practice is based upon the use of needles and ink to write names and scratch out simple designs. Further assumptions revolve around the use of tattoos to demonstrate that the individual has spent time in prison or has been a member of a particular gang or group within prison. Historically, tattoos were recognised as a way of demonstrating why someone was in prison, with particular designs representing the sentence given, however, this has changed over the years, perhaps as a result of the impact that having a tattoo of this kind has on future employment prospects21.

In order to understand tattooing practices within Scottish prisons, interviews and focus groups were carried out with prisoners in four prisons. The prisons were chosen because they had the highest rates of tattooing activity reported in the prisoner survey of 2008. Two short-stay and two long-stay male prisons were chosen:

Prison Type of establishment Tattooing rate Edinburgh Closed, local, remand and short-stay 22% Inverness Closed, local, remand and short-stay 25% Perth Closed, local, remand, short and long-stay 21% Shotts Closed, national long stay 28%

The rates of tattooing reported in the young offenders and women’s prisons were lower and as there is only one of each, they were not considered as part of this needs assessment. The lack of data from these establishments is a recognised limitation of this needs assessment. Peterhead prison had similarly high rates of reported tattooing activity but was excluded due to its atypical prison population i.e. those that have committed sex offences.

Methods One to one interviews were carried out with prisoners who were identified as “tattooists” and focus groups of three to four participants were carried out with prisoners who had received a tattoo whilst in prison. These took place in each of the prisons identified. The interview schedules for both interviews and focus groups were based upon a number of themes and are provided in Appendix B.

Prisoners were invited to take part in either the interview or focus group by a Hall Manager or a member of the health care team. Prisoners were informed that the person undertaking the needs assessment was from public health within the NHS and that answers given in response to questions would remain confidential. This was stressed again at the start of each interview or focus group, and all interviews and focus groups were conducted without prison staff present to enable prisoners to speak freely.

13 The following discussions took place:

Prison Interviews with Number of prisoners Tattooists receiving a tattoo in prison that attended Focus Groups Edinburgh One Three Inverness One Four Perth One Three Shotts One Three

Reasons for getting a tattoo in prison Focus group participants were asked how many tattoos they had, how many they had obtained in prison and why they decided to get a tattoo in prison. The number of tattoos reported by each prisoner ranged from one to 18, with six prisoners reporting that they got their first tattoo in prison. The prisoner with 18 tattoos received all of his tattoos in prison over a two year period. The main reasons for getting a tattoo whilst in prison were boredom, cheaper than outside prison, others were getting one and that they had seen the work of the tattooist on someone else.

Prisoners were asked if they had paid for the tattoo. If the tattoo was done by a friend it was usually for free, however, there was a charge if it was done by another prisoner. Where payment was made it was usually in the form of tobacco, although some did involve small amounts of cash payments.

Tattooing Equipment Tattoos were done by another prisoner or by a friend or cell mate. A number of the other prisoners providing tattoos were either professional tattooists or recognised as being artistic and able to produce high quality work of a similar standard to that provided outside of prison. In the main, those tattoos produced by friends were done with needles and ink or some form of equipment that was more primitive than a tattoo gun (an example of this was a toothbrush handle with a staple melted into the end) and as a result the tattoos were of a poorer quality.

A range of tattooing methods are used in prison, however, descriptions from prisoners suggest a fairly standard range of equipment is used, with similar descriptions from all interviews and focus groups. In the main, home-made tattoo guns are made by the prisoner providing the tattooing services. Equipment often involves the use of pen barrels, guitar strings, toothbrush handles, string and glue and some kind of motor from a shaver, electric toothbrush or Playstation control to create the effect of a tattoo gun.

Figure 1 in Appendix C shows an illustration of the components of a prison tattoo gun as drawn by one of the prisoners interviewed. The photograph below shows an actual tattoo gun confiscated from one of the prisons. There is a great deal of creativity involved in producing the tattooing equipment, with components readily available within prison although not intended for this

14 purpose – a great deal of trial and error is needed before an effective tattoo gun is created. Prisoners spoke of the need to be able to dismantle a tattoo gun between uses so that it could not be identified easily and therefore would be less likely to be confiscated.

Photo of prison made tattoo gun

Those prisoners that identified themselves as tattooists further refined the equipment they used to recreate effects provided by a professional tattoo gun. For example, two prisoners spoke of the battery voltage required to create a particular movement of the gun if an effect such as shading was desired. These prisoners also identified the need to replace the guitar strings regularly (effectively replacing the needle) and the need to ensure that the ink wasn’t shared or re-used in order to prevent infection and cross-contamination. These were experienced prison tattooists as they reported completing in excess of 200 tattoos each whilst in prison.

Four of the thirteen prisoners who took part in the focus groups stated that they had used a needle and Indian ink to do their own tattoos in the past.

Sharing and Cleaning Equipment Where prisoners reported the use of a needle and ink to do the tattoo, they generally reported using a new needle each time or limited cleaning with a flame or boiling water. Where improvised tattoo guns were used, prisoners spoke of the needle (guitar string), barrel (pen) and ink being new but other parts being re-used, however, most admitted that they couldn’t be sure that the tattoo gun hadn’t been used on someone else previously.

Most reported that ink was decanted into a toothpaste tube lid before being used to avoid any risks from the use of shared ink. In one establishment, prisoners reported being given their tattoo gun to keep after their tattoo was completed for them to use again and to avoid infection from others. In this case the tattooist was a professional tattooist out of prison and understood the need to sterilise equipment – he was very concerned about getting a bad reputation that would be bad for business once he was released.

15 Attempts were made to clean equipment using a range of materials such as sterilising tablets and boiling water – a limited number reported using the cleaning fluids used for cleaning the prison, such as “Response”, which is used for cleaning blood spills. Experienced tattooists reported going to great lengths to avoid contamination and had a good understanding of infection control procedures, referring to “the need to avoid dirty needles, contaminating ink, dirty hands in Vaseline” and the importance of wearing gloves, cleaning work surfaces and taking care of tattoos to avoid infection. One even mentioned the importance of testing the ink on the skin first for any allergic reactions.

Perceived risks from tattooing in prison Prisoners were asked to identify the potential risks from tattooing in prison. All prisoners identified either hepatitis C or HIV as potential risks. In addition, 3 identified blood poisoning from the ink, 3 identified skin infections and 1 suggested septicaemia. When asked about any problems following a tattoo, 1 had an ingrown hair and another reported becoming unwell with swollen glands and septicaemia, leading to 13 days in hospital with a collapsed lung. Half of the prisoners reported that subsequent tests for blood borne viruses were negative. It is not known if the remaining half had ever been tested or tested positive as this information was not shared.

Prisoners that provided tattoos were able to identify a wide range of risks from tattooing in prisons. Three out of the four reported methods adopted to reduce risks, however the remaining tattooist said that if other prisoners were willing to take the risk they would provide the tattoo. It was clear from the interview with this prisoner that they had limited experience of tattooing and a lack of understanding of the potential risks.

Previous studies have identified tattooing as a significant risk for BBV transmission, however, many have been unable to rule out the possibility that prisoners had not also previously injected drugs. Two of the 13 focus group participants reported previous injecting drug use, although stated that they wouldn’t share needles whilst in prison due to the BBV transmission risk. All other focus group members declared that they had never injected drugs either in prison or in the community setting. When discussed further it was clear that the perception of risk from sharing needles for drug use was significantly higher than that from tattooing. There is a perception that injecting into the blood stream is riskier than tattooing, which is perceived as only breaking the surface of the skin.

Although this is a limited sample, it is clear from the focus group and interview results that tattooing activity is fairly routine practice within some Scottish prisons – this is supported by the results of the prisoner survey which has a good return rate over a number of years and which therefore presents a consistent picture of prisoner reported behaviour.

The quality of the tattoos provided is significantly higher than that expected and achievable from the use of needles and ink by amateur tattooists or prisoners tattooing themselves. Prisoners reported tattooing activity increasing

16 when particular individuals were in prison and spoke of “everyone in the hall” getting a tattoo within a few months of someone arriving in prison. This finding was corroborated by prison officers during their interviews.

Clear attempts are made to clean equipment especially by individuals that describe themselves as tattooists and who have a vested interest in maintaining a reputation for their work outwith prison. The lack of available cleaning products were identified as a barrier to cleaning equipment fully, however, there is also a lack of perceived risk from tattooing: although prisoners report an understanding of the risks from tattooing, this is not reflected in their behaviour as they continue to have tattoos in prison and report continued sharing of equipment.

17 5. STAKEHOLDER VIEWS

A range of methods was adopted to seek the view of stakeholders:

A survey was sent to all prison doctors seeking a response of one per establishment Interviews were undertaken in each of the four establishments with one each of the following: hall manager, prison officer, health centre manager and BBV Nurse

The results in this section focus on the knowledge of staff in relation to tattooing activity, risks and associated health care needs as a result of tattooing activity in prison. Stakeholder views on possible responses and interventions to reduce the risks from tattooing are included in section 6.

Survey of prison doctors There are 25 doctors across Scotland contracted to provide medical input into prison health care services. A survey was sent to each of the doctors by email from the contract administrator – they were asked to complete the survey and return it to SPS electronically or by post. The survey is in Appendix D.

Six out of 14 establishments returned a survey completed by a prison doctor. Only one of the six establishments that returned a questionnaire reported awareness of a health need as a result of tattooing in prison. All other questions received a nil response except for the final two which asked if they, as prison doctors had provided prisoners with information on risks from tattooing and on general risks of BBV infection. Three out of 6 doctors reported providing information about tattooing whereas all reported providing information on the risks of BBV infection generally.

This result was not unexpected as the majority of prison health care is part of a nurse led service, it was therefore expected that doctor involvement in this area would be low.

Interviews with prison officer staff Interviews were undertaken with a Hall Manager and a prison officer in each of the establishments. In order to reduce the time away from prison duties, a joint interview took place. There was a high level of awareness of tattooing within establishments, although one establishment thought that the survey response rate for their establishment was much higher than expected.

Prison officer staff had a high knowledge of the tattooing equipment being used, with 7 out of the 8 interviewees able to describe the components of a prison tattoo gun. All prison officers were aware of tattoo guns having been confiscated previously and all advised that when cells were being searched prisoners would hand over the guns before they were found to avoid any needle stick injuries to prison staff. Interestingly, prison officers stated that whilst they were often given a “tip-off” when needles (for drug use) were in circulation, this was not the case for tattooing equipment. This could be linked to the prisoner perception of risk, where prisoners identified sharing of

18 injecting equipment as being riskier than having a tattoo in prison and acting accordingly to reduce the circulation of needles.

There was a general view that tattooing activity was higher amongst long term prisoners and this was supported by the level of confiscated equipment reported from the long stay establishments. It is also supported by the significantly higher reported rate of tattooing activity from Shotts Prison which, as a national long stay prison, has a higher number of long stay prisoners than HMP Perth, the other establishment housing long stay prisoners that took part in this work.

There was a unanimous view that equipment was being shared and that tattooing activity was higher when particular individuals were in the prison – it was felt that the amount of time taken to acquire the components of the tattoo gun would not enable a new one to be made for each tattoo that was done in prison. Prison officers had a good understanding of the potential risks from tattooing but felt that there were a high number of prisoners who already had hepatitis C and did not see tattooing as something to be concerned about.

Prison officers were able to identify when tattooing activity was high within their establishment and 6 out of 8 prison officers reported speaking to prisoners about the risks of tattooing and in some cases making a referral to medical staff if a prisoner was subsequently worried about BBV infection. Prison officers in one establishment were aware of a prisoner having medical needs as a result of tattooing, and this was the fairly serious case reported by the prisoner groups. Others were unaware and felt that this would not usually come their way. In general, providing information about health related risks was seen as the responsibility of health care staff either at prison induction sessions or through one-to-one consultations.

Interviews with prison health care staff Interviews were completed with a health centre manager and a BBV/addictions nurse in three of the establishments – one of the nursing staff was off sick on the day of the interview, therefore on this occasion only the health centre manager was interviewed. Six out of the seven health care staff interviewed were aware of tattooing in their establishment, however, unlike prison officers they had limited awareness of the equipment being used. On the other hand, health care staff could identify prisoners who had presented with a medical need, with two nurses each reporting up to 3 prisoners coming forward for BBV testing following receipt of a prison tattoo in the last 12 months. Two of the health centre managers each identified a possible case of BBV transmission as a result of tattooing activity, however, similar to published case notes, they could not rule out previous injecting drug use as a risk factor.

In terms of providing information to prisoners on the risks of tattooing in prison and the risks of BBV infection more generally, all confirmed that prisoners had received a significant amount of information on BBV risks either as part of induction, through an individual health screen or via health promotion events. However, only two establishments identified specific interventions that had

19 taken place regarding tattooing risks: one had displayed posters in the health centre waiting area and another had put information on the back of menus and canteen sheets, the latter being produced by the health care staff. Similar to prison officers, nursing staff were all able to identify conversations that had taken place with prisoners informally about tattooing risks.

20 6. INTERVENTIONS TO REDUCE RISKS – Stakeholder views

Prisoners and prison staff were asked to identify how SPS could reduce the risks of infection from tattooing in prisons. A range of interventions were suggested which are summarised below:

Intervention Prisoners Prison Prison Total officers medical staff

Numbers of each 17 8 7 32 survey group Confiscate gun 4 5 9 components Increase 1 1 2 punishment/better security Educational 9 7 7 23 materials such as leaflets and posters Addictions services 8 2 5 15 provide cleaning materials and equipment Provide training on 1 1 2 health and safety Discussion 7 1 8 groups/induction Local education 2 1 3 project Increase staff 2 2 knowledge Provide a prison 12 5 6 23 tattoo service

Prisoner views Of the 17 prisoners that took part in interviews or focus groups, more than half identified the benefits of making cleaning and educational material more freely available as a way of reducing risks. Many felt that it would be impossible to stop tattooing activity entirely but that the best way to do this would be to remove access to electronic equipment that contained small motor parts. In terms of educational materials there was a strong view expressed that these should contain pictures and show examples of bad tattoos (design and infections) as a way of reducing the desire for prison tattoos.

A high number of prisoners wanted to see a tattooing service being available to prisoners for a fixed fee, although some recognised that for those that couldn’t pay, unofficial tattooing may continue, therefore the cost had to be realistic. However, this was viewed by all as an unrealistic request that would

21 never be allowed by SPS. There was a perception that prison officers would feel threatened and therefore stop the service from being introduced and that the public would respond badly to prisoners receiving “privileges”. Within this context, the need for relevant and realistic educational materials was identified as a priority.

The importance of these materials being realistic was stressed by many of the prisoners that knew the prisoner that had experienced hospitalisation as a result of a tattoo. There was a suggestion that this real story could be used to provide more information on risks to other prisoners.

Prison officer views There is a general view amongst the prison officers interviewed that stopping tattooing in prisons will be very difficult. The officers expressed clear views that it should not be encouraged and should be punished if discovered. However, most recognised and suggested the benefits (unprompted) of having some kind of educational/health promotion intervention mostly in the form of posters with pictures (recognising some of the low literacy levels amongst prisoners) and as part of prisoner induction sessions which are a well established part of admission procedures. The provision of cleaning materials was felt to be a difficult area to justify, although there was recognition that tattooing was not an illegal activity unlike injecting drug use and therefore could potentially be treated differently.

Five out of 8 prison officers recognised the potential benefits of having a professional tattoo service available that could be run either by prisoners or someone from outside who provided a service which prisoners could pay for. Whilst many agreed that in principle this would be a good idea, there was a general feeling amongst prison officers that this would not be acceptable to prison staff as it allowed needles into prison and there could be a possibility that these were used against staff. In addition, there was a view that it would be “seen as an unnecessary privilege similar to that of providing condoms in prisons”. A further cautionary note was expressed regarding the possibility of prisoners getting into debt or potential bullying due to their inability to afford an official tattoo service – similar to concerns expressed by one of the prisoner focus groups.

Health care staff views Health care staff felt strongly that prisoners should be made more aware of the risks from tattooing in prison and that they should also have access to equipment and materials to enable them to put that knowledge into practice – to manage the reduction of risks themselves. There was no mention of increasing punishment; instead healthcare staff suggested a more pragmatic approach should be adopted.

There was a view that there was a lack of specific health promotion material available on tattooing risks in prison, although one establishment had located some recent materials produced by the British Liver Trust. There was a request to work with prisoners to produce information that was relevant to them that would then be used by SPS staff across all establishments.

Whilst it would appear that prison health care staff and prison officers had similar views in terms of the use of educational materials and the provision of a tattooing service, the feedback from health care staff was not an in principle view like that of the prisoners officers but rather a strongly expressed view that this would be an appropriate way to reduce risk. Some health care staff identified the possibilities of prisoners being trained in matters such as health and safety and tattooing practices which could then contribute to prisoners’ job prospects upon leaving prison. Benefits were seen as two-fold: reducing risk and providing training.

There was a call from some health care staff for a change in organisational culture, a call for a “time for common sense” not just in relation to tattooing but also in relation to other harm reduction approaches such as provision of condoms and needle exchange. There was a view expressed by four members of staff that some prejudices and stigma amongst prison staff (including health care staff) were holding back prison health care and preventing them from having a real impact on public health.

23 7. INTERVENTIONS TO REDUCE RISKS – Research findings

There have been a number of peer reviewed prevalence studies regarding blood borne virus infection and risks of infection (including tattooing activity) within prisons. Some of these studies have recommended interventions to reduce the risks from tattooing. However, the number of studies from the published and grey literature regarding the implementation and evaluation of effective interventions to reduce risks from tattooing is limited.

The literature was reviewed to identify previous studies and their conclusions. Peer reviewed and non-peer reviewed papers were considered, including any guidelines provided to prison and public health authorities. A summary is provided below:

Author/Year Title Paper type Content Conclusions Country Awofeso21, Jaggers in the PHD study Review of Multi-faceted 2002 pokey: Australian arguments approach of Australia understanding Health from public interventions tattooing in Review health and needed that prisons and prison takes account reacting authorities, of all rationally to it includes stakeholders. prisoners Limited public views health benefit of tattoo parlour in prison Elliot22, Deadly Research Commentary Denying 2007 disregard: Comment on prevalence prisoners Canada government Canadian studies and access to refusal to Medical evidence tattooing implement Association based equipment evidence-based Journal measures to (amongst measures to prevent HIV other harm prevent HIV and and hepatitis reduction hepatitis C virus C in prisons measures) infections in infringes their prisons human rights Levy et al23, Prisons, Viewpoint – Review of Recommends 2007 hepatitis C and Medical current professional Australia harm Journal of practices tattooing minimisation Australia relating to parlour in harm prison reduction as a strategy to reduce hepatitis C in Australian prisons

24 Kondro24, Prison tattoo Editorial - Review of Prison tattoo 2007 program wasn’t Canadian Canadian project should Canada given enough Medical government have been time Association decision to given more Journal cancel prison time to show tattoo parlour it’s worth, pilot quotes Chief Public Health Officer of Canada Dept of Prevention of Guidelines Implementati Professional Health and Hepatitis C in on of tattooist visits Ageing – Custodial established to be trialled; Australia25 Facilities hepatitis C Services to (accessed prevention develop local 25.04.2009) programmes protocols to reduce the risk of infection from tattooing Ministerial Hepatitis C Evidence Explanation The need for committee prevention, base to of the a standard on AIDS, treatment and support the evidence approach Sexual Care: above base for the across prison Health and Guidelines for guidelines above settings; a Hepatitis11, Australian guidelines collaborative July 2008 Custodial and Settings comprehensiv Evidence base e approach is for the required guidelines Correctional Evaluation Evaluation Presents Recommends Service report: Report findings of the continuation Canada26, Correctional targeted of the 2009 Service evaluation of education Canada’s Safer the Safer component of Tattooing Tattooing the initiative; Practices Pilot Practices integration Initiative Pilot Initiative with other that involved findings to education for provide a cost prisoners and effective harm the provision reduction of tattoo strategy; if rooms within tattoo rooms 6 prisons as are continued part of a pilot a number of project modifications are recommended

25 Harm reduction approaches Much of the literature recognises that public health professionals advocate the use of harm reduction approaches and the equal provision of health care and health promotion activities for the prison population in line with what could be expected within the community27. There is an acknowledgement that this often results in a tension between public health professionals and prison officers who have been identified as reluctant to pursue the provision of harm reduction approaches that include the availability of needles within the prison environment. There is a view amongst some public health professionals16 that risks from the legal provision of needles within prisons (for the purposes of needle exchange or safer tattooing) are much less than the current illegal use of needles which present risks from the regular sharing of a limited supply and the possibility of needle stick injuries when searching for prohibited equipment.

Those who undertook surveys and prevalence studies within prisons all identified a range of possible interventions that could lead to reduced risk from tattooing in prison. Whilst several mention the option of providing a professional tattoo parlour within the prison, many recognise the barriers to providing this type of facility within the secure environment, not just from prison officers, but also from prisoners who recognise that there may be barriers to making use of this facility such as the issue of affordability and the desire to rebel against the prison system through participation in contraband activity 16 28.

More pragmatically, there has been a call for increased education for prisoners regarding the risks from tattooing in prisons and the need for increased harm reduction and infection control measures to be introduced 14 15 16 20. As Bird28 suggests “the use of sterilisation tablets should be promoted, and the booking of sterile equipment be considered with appropriate safeguards for staff and prisoners”. Unfortunately, the literature search did not find any studies where the provision of cleaning materials for tattoo equipment had been tried and tested in the prison environment.

Tattoo rooms There has been one published evaluation report from a study that involved the provision of tattoo rooms within the prison environment26. Unfortunately, the pilot was limited to a 12 month implementation period as it was stopped by the Canadian Government24. This pilot was the only structured intervention and evaluation identified within the literature and involved two components:

Operational component – providing tattoo rooms in 6 Canadian prisons. Training was provided to inmates who then provided tattoos to other inmates within a controlled environment. Quality control, safety and security were key components of the service. Prisoners were charged for the service. Education component – provided educational materials during prison induction that informed inmates of the risks from unsafe tattooing practices.

26 The approach to the evaluation was thorough, making good use of qualitative and quantitative methods including pre and post questionnaires with prisoners who took part in the education component. A further 234 interviews were conducted with a range of stakeholders including; health and prison officer staff; inmates who received a tattoo; and those who participated in providing the tattooing service.

Within the limitations of a pilot study of such a short duration the authors identified a number of findings relating to both components of the pilot, in particular identifying that “a significant element contributing to the reduction in risk of infection among inmates, staff and the community was the education of inmates regarding safer tattooing practices”. The authors collected information on the rates of confiscated tattooing equipment during the pilot in both the pilot and non pilot sites and whilst some pilot sites showed a reduction in rates of confiscated equipment, others did not. The authors identify a number of factors but suggest that further evaluation is needed to establish any attribution. However, on a more positive note, staff members reported significant reductions in perception of risk from tattooing equipment and needle stick injuries from before the pilot compared to during the pilot. Bearing in mind the views of prison officers and their reluctance to provide needles of any kind in prison this type of provision could support a change in perception of risk that could lead to an increase in harm reduction activities within the prison setting in the future.

The findings resulted in the authors making three recommendations: the continuation of the educational component; the integration of the findings with results from other studies to ensure a cost-effective harm reduction strategy; and that if the tattoo rooms were to continue a number of modifications should be made to their provision to improve effectiveness.

The total cost of the pilot was identified as $960,000 Canadian dollars. After removing start up costs implementation costs for the 12 month pilot period were in the region of $600,000, this provided 1,043 tattoo sessions at a cost of $578 per session. 324 inmates received a tattoo as part of the initiative and 60 inmates were on a waiting list for the service at the point when it was stopped. The authors have made some attempts at estimating cost-effectiveness using the cost of providing a tattoo session against the cost of providing treatment for HCV. They conclude that “the ratio of HCV treatment costs to the cost of tattoo session is 38:1”. Whilst this figure may well be acceptable for the delivery of a proven harm reduction approach such as provision of clean needles to reduce HCV amongst injecting drug users it is unlikely to be viewed as an acceptable cost to reduce HCV from tattooing when this is still perceived by many as a hypothetical risk. Unfortunately, the cost of providing the education component is not identified within the overall costs.

27 8. CONCLUSIONS

Tattooing in prison has been identified as an independent risk factor for blood borne virus transmission amongst prisoners; the issue for the Scottish Prison Service is what can it realistically do to reduce this risk?

There are a number of possible approaches:

Prevent tattooing in prisons The prevalence of tattooing activity in prisons is high, equipment is relatively easy to come by and although most prison officers and a small number of prisoners interviewed suggested confiscation of materials all acknowledged that this would be impossible to achieve.

Educate prisoners on the risk of tattooing in prison Prisoners providing tattoos reported high levels of awareness of BBV risk and infection control. The prisoners that had received a tattoo had high levels of BBV awareness but didn’t fully appreciate the possible risks from tattooing in prison. Therefore, there is a need to make explicit reference to possible risks from tattooing and to ensure that awareness and education levels are such that they lead to a change in practice.

This approach was supported by the majority of prisoners, prison officers and health care staff interviewed either through the provision of posters or through group discussions. The education and health promotion activity regarding tattooing is almost non-existent in Scottish prisons and is an area that could easily be improved upon. Some additional components within staff training and a small outlay for material development and printing is possible with little extra cost.

Results from the Canadian Safer Tattooing Pilot Initiative suggest that providing educational input upon admission can increase prisoner knowledge and awareness of risks, however, the pilot does not provide full assessment of behaviour change as a result of the educational component – the results must continue to be treated with caution and not seen as the only solution.

The importance of working with prisoners to produce materials that are realistic has been identified within the literature and by the prisoners that took part in the interviews for this study. There is limited health promotion material specifically about tattooing for prisoners, however, both the British Liver Trust in the UK and PASAN in Canada have made attempts at the production of such material. There is no need to reinvent the wheel; however, such materials should be reviewed by Scottish prisoners before they are considered for use or adaptation for Scottish prisons.

Provide access to cleaning materials and tattoo equipment Prisoners and health care staff identified the provision of sterile equipment or a sterilisation facility as a positive option, however, this was not supported in the main by prison officers. This was due to a concern that it would lead to needles being freely available within the prison and that cleaning equipment

28 provided for tattoo equipment could also be used for cleaning needles that had been brought into the prison environment illegally. This is not actually the case as the sterilising techniques used for tattooing equipment would destroy injecting equipment. There is merit in working with prisoners and prison officers to consider an approach that could enable a supervised sterilisation facility purely for tattooing equipment. This would require a change in the current prison culture, not just from prison officers but also from prisoners who may prefer the illicit nature of the current operation.

Provide a tattoo service in prison Surprisingly, there was support for this type of service from prisoners, prison officers and health staff – although for prison officers it was given in principle and both staff and prisoners had concerns about the cost of the service. Many studies have called for the provision of tattoo rooms in prisons – tattooing is not illegal in the community where through legislation the risks from tattooing have been removed, therefore why should it not be provided (at a cost) to those in prison? The answer lies in the culture associated with the prison environment – it is ultimately a place where security and maintenance of order are paramount.

The SPS has recognised for some time the potential benefit of the introduction of needle exchange services into Scottish prisons to reduce the transmission of blood borne viruses – this has not yet been possible as a pilot project, or as part of the prison health care provision, despite the initiative being part of Government policy, due to opposition from the Prison Officers Association (Scotland) – a staff union. However, drug use is viewed differently to tattooing within the community and the prison environment is no different. Prison officers voiced strong opinions against drug taking but recognised that lots of people had a tattoo and that it was not an illegal activity – many had tattoos themselves. Although further thought would need to be given to the practicalities and cost implications, there would be merit in SPS considering a pilot tattooing initiative in one of its establishments.

A multi-faceted approach It is unlikely that any one approach will achieve the goal of reducing risks from tattooing in prisons – a combined approach may have the best chance of success, particularly if it is based upon the views expressed by staff and prisoners in Scotland and is supported by the literature. A pragmatic response to the prison environment is also required. Therefore, an approach that provides prisoners with the information they need to identify and consider risk (such as the educational input suggested) alongside the means (such as sterilising facilities) to reduce those risks if they continue to engage in the risk behaviour would be advisable.

29 9. RECOMMENDATIONS

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. In addition, the forthcoming Behavioural and HCV Prevalence and Incidence Studies should assess HCV incidence in association with tattooing in the prison setting.

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 update 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. The pilot should operate for at least two years to provide adequate time for evaluation of the intervention in recognition of the time required to make a service of this kind fully operational. This would provide a challenge to SPS and would require a change in attitude amongst prison staff. However, 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.

30 10. REFERENCES

1. Chalmers, C (2009), Charting the existence and approaches to management of the tattooing and body piercing industry – a historical overview. Journal of Infection Prevention; Vol.10 No.3

2. The Civic Government (Scotland) Act 1982 (Licensing of skin piercing and tattooing) Order 2006 – Local Authority Implementation Guide, HPS and REHIS 2007.

3. Goldberg D, Anderson E (2004), Hepatitis C: who is at risk and how do we identify them? Journal of Viral Hepatitis; 11, (Suppl.1), 12-18.

4. Fraser, A (Scottish Prisons Service) personal communication.

5. University of Birmingham. Health Care Needs Assessment (HCNA), (accessed 25.04.2009).

6. Graham, L (2007), Prison Health in Scotland A Health Care Needs Assessment. Scottish Prisons Service.

7. HPS Weekly Report, 2009, Vol 43 No 28. Health Protection Scotland.

8. Hutchinson, S et al., (2006). Hepatitis C Virus Infection in Scotland: Epidemiological Review and Public Health Challenges. Scottish Medical Journal, Vol 51, pp8-15

9. Milne D. Detection of Hepatitis C in Scottish Prisons. June 2006 (unpublished)

10. Hepatitis C Action Plan for Scotland: Phase II (May 2008 – March 2011) First Year Annual Report. Scottish Government, 2009.

11. Hepatitis C Prevention, Treatment and Care: Guidelines for Australian Custodial Settings, Evidence Base for the Guidelines. July 2008. Ministerial Advisory Committee on AIDS, Sexual Health and Hepatitis, Hepatitis C Subcommittee.

12. Evaluation Framework Correctional Service of Canada Safer Tattooing Practices Pilot Initiative, July 2005.

13. Prisoner Survey 2008, 11th Survey Bulletin, Scottish Prison Service October 2008.

14. Strang J, Heuston J, Whiteley C et al (2000). Is prison tattooing a risk behaviour for HIV and other viruses? Results from a national survey of prisoners in England and Wales. Criminal Behaviour and Mental Health: CBMH; 10, 1.

31 15. Frost L, Tchertkov V, (2002), Prisoner Risk Taking in the Russian Federation. AIDS Education and Prevention; 14, Supplement B, 7-23.

16. Hellard ME, Aitken CK, Hocking JS, (2007), Tattooing in prisons-Not such a pretty picture. American Journal Infection Control; 35:477-80.

17. Butler T, Kariminia A, Levy M et al (2004), Prisoners are at risk for hepatitis C transmission. European Journal of Epidemiology; 19; 1119- 1122.

18. Long J, Allwright S, Barry J et al (2001), Prevalence of antibodies to Hepatitis B, hepatitis C, and HIV and risk factors in entrants to Irish prisons: a national cross sectional survey. British Medical Journal; 323, 7323.

19. Thompson, S.C, Hernberger, F., Wale, E., Crofts, N. (1996) Hepatitis C transmission through tattooing: a case report. Australia and new Zealand Journal of Public Health; 20(3):317-318

20. Post JJ, Dolan KA, Whybin LR et al (2001). Acute hepatitis C virus infection in an Australian prison inmate: tattooing as a possible transmission route. Medical Journal of Australia; 174: 183-184.

21. Awofeso N, (2002), Jaggers in the pokey: understanding tattooing in prisons and reacting rationally to it. Australian Health Review; Vol 25 No2.

22. Elliott R, (2007), Deadly disregard: government refusal to implement evidence-based measures to prevent HIV and hepatitis C virus infections in prisons. Canadian Medical Association Journal; 177, 3.

23. Levy MH, Treloar C, McDonald RM, Booker N, (2007), Prisons, hepatitis C and harm minimisation. Medical Journal of Australia; 186, 12.

24. Kondro, W, (2007), Prison tattoo program wasn’t given enough time. Canadian medical Association Journal; 176(3); 307.

25. Prevention of Hepatitis C in Custodial Facilities. Dept of Health and Ageing – Australia (accessed 25.04.2009).

26. Evaluation report: Correctional Service Canada’s Safer Tattooing Practices Pilot Initiative. January 2009. Correctional Service Canada.

27. Hard Time: Promoting HIV and Hepatitis C Prevention programming for Prisoners in Canada. Canadian HIV/AIDS Legal Network, Prisoners’ HIV/AIDS Support Action Network (PASAN), 2007.

32 28. Bird S, (2001), Commentary: efficient research gives direction on prisoners’ and the wider public health –except in England and Wales. British Medical Journal; 323, 7323.

33 Appendix A

ELEVENTH ANNUAL PRISONER SURVEY 2008 - Hepatitis C comparisons %

Aberdee Barlinni Cornto Edinburg Glenochi Greenoc Invernes Kilmarnoc Open Peterhea Polmon Shott Overal Dumfries Perth ESTABLISHMENTS n e n Vale h l k s k Estate d t s l

HEPATITIS C Do you have any 22 23 16 21 18 66 21 19 22 14 27 17 20 20 23 body piercing/s? (n=29) (n=26) (n=24) (n=18) If YES, did you get any piercing/s in n=1 4 8 n=2 6 6 n=0 n=2 1 0 5 n=4 8 8 6 PRISON? Do you have any 47 52 62 48 59 61 51 52 66 57 59 48 34 65 54 tattoos? If YES, did you get any tattoos in 21 10 16 17 22 19 19 25 14 11 21 24 16 28 18 PRISON? Do you know what 82 79 81 81 86 84 83 86 85 91 83 88 85 86 84 Hepatitis C is? Do you think you could be Hepatitis C 22 17 12 14 14 18 13 7 18 4 18 4 3 9 13 positive? During your time in PRISON have you been given any 44 36 48 60 52 60 64 64 41 67 56 71 59 58 51 information about Hepatitis C?

34 Appendix B Tattooing in prisons – interview questions for tattooists The SPS prisoner survey identified the following rates of tattooing in Scottish establishments:

55% prisoners reported having a tattoo with 19% reporting receipt of a tattoo in prison (2007) 54% prisoners reported having a tattoo with 18% reporting receipt of a tattoo in prison (2008)

As a result SPS have commissioned a needs assessment to assess the need for a public health intervention to reduce the risk of BBV infection through tattooing in prison. This is a short 15 minute interview and any answers given will remain confidential to the interviewer and interviewee. Results from all interviews will be collated and form part of a report to SPS to inform future interventions.

1. I understand that you provide a tattooing service within this prison. Can you tell me what you provide?

2. Can you describe the equipment that you use to do the tattoos? (ask them to draw the equipment if that is easy to do) Is the equipment shared amongst prisoners? Including ink?

3. Is the equipment cleaned in any way? What with?

4. Have you had any training outwith prison related to tattooing? If so, what kind of training?

5. Is there a cost for this service?

6. What would you see as the main risks associated with tattooing in prisons?

7. Are you aware of any prisoners having any medical needs as a result of tattooing? (if yes, ask what kind of medical attention was needed).

8. Are you aware of any injuries to other inmates where tattooing equipment has been used? (if so, please describe)

9. Are you aware of any needle stick type injuries to prison staff caused by tattooing equipment? (if so, please describe)

10. Have you ever been given information on risks of: Tattooing in prisons? BBV infection?

11. What do you think SPS could do to reduce risks of infection from tattooing in prisons?

12. Any questions or suggestions?

Tattooing in prisons – focus group questions

The SPS prisoner survey identified the following rates of tattooing in Scottish establishments:

55% prisoners reported having a tattoo with 19% reporting receipt of a tattoo in prison (2007) 54% prisoners reported having a tattoo with 18% reporting receipt of a tattoo in prison (2008)

This clearly identifies a significant level of tattooing practice within Scottish establishments. As a result SPS have commissioned a needs assessment to assess the need for a public health intervention to reduce the risk of BBV infection through tattooing in prison.

This focus group will take no more than 45 minutes and any answers given will remain confidential. Results from all focus groups and interviews will be collated and form part of a report to SPS to inform future interventions.

1. How many tattoos do you have?

2. How many did you get in prison?

3. Did you get your first tattoo in prison?

4. Why did you get a tattoo in prison?

5. Who did the tattoo for you?

6. Did you pay them for the tattoo?

7. What equipment is used to do the tattoo? (ask them to draw it)

8. Is the equipment (including ink) shared with others?

9. Is the equipment cleaned at all? If yes, what with?

10. Do you think there are any risks from getting a tattoo in prison? What are they?

11. Have you ever injected drugs?

12. Have any of you ever had any problems/infections following a tattoo?

13. Have any of you had any information on risks about tattooing and/or BBV infection whilst in prison?

14. What do you think could be offered in prison to reduce the risks from tattooing in prison?

36 Appendix C

37 Appendix D

Tattooing in prisons Survey for completion by prison doctors

38 This survey is part of 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 will be achieved through a systematic assessment of interventions to reduce risks associated with tattooing amongst prisoners in Scotland with the following objectives:

To describe the current population in Scottish prisons and disease burden related to Blood Borne Viruses

To identify current tattooing practices and associated risks/potential risks

To consider evidence of effective interventions to reduce risks related to tattooing in prison

To elicit stakeholders views: prisoners, staff and management

To recommend potential interventions to reduce risks associated with tattooing which could be delivered within the prison environment, taking into account feasibility and cost

The SPS prisoner survey identified the following rates of tattooing in Scottish establishments:

55% prisoners reported having a tattoo with 19% reporting receipt of a tattoo in prison (2007) 54% prisoners reported having a tattoo with 18% reporting receipt of a tattoo in prison (2008)

This clearly identifies a significant level of tattooing practice within Scottish establishments. We are interested in any experiences you have, as prison doctors, in dealing with medical needs arising as a result of prisoners receiving a tattoo whilst in prison. In addition to this survey of prison doctors, interviews will take place with other prison staff (health care and prison officers), tattooists and prisoners who receive a tattoo.

The information you provide in this survey will be kept strictly confidential. Your name will not be linked to any reports that result from the survey and information that identifies you will not be used.

Could you please complete and return the survey within 14 days using the envelope provided. We estimate it will take 10-15 minutes of your time to fill it in. If you require further information please contact me at [email protected]

Thank you for your help.

Dona Milne, Specialist in Public Health (on behalf of SPS)

39 1. Name of establishment:

2. Are you aware of any reports from prisoners of medical need as a result of tattooing in your establishment?

3. If yes, please complete the following information.

How many prisoners have presented in the past 12 months? (Approximate numbers are acceptable if records not easily available)

If any have presented with the following conditions, please provide detail where possible:

Skin infections?

Allergic reactions?

Skin disorders e.g. granulomas, scarring

Abscesses?

Any other conditions presented?

40 4. Are you aware of any possible BBV infection as a result of tattooing in prison? (if so, please describe)

5. Are you aware of any injuries to other inmates where tattooing equipment has been used? (if so, please describe)

6. Are you aware of any needle stick type injuries to prison staff caused by tattooing equipment? (if so, please describe)

7. Have you (as a prison doctor) provided information to prisoners on the risk of:

a) Tattooing in prisons?

b) BBV infection?

If you provide information, please include a sample copy when returning this survey in the envelope provided. Please remember this survey is about the role of prisons doctors, not other healthcare staff. Thank you for your help.