Collaborative community-prison programs for incarcerated women in BC

Correctional institutions in BC offer a variety of health and education programs for wo­men, including drug and alcohol counseling, Narcotics/Alcoholics Anonymous meetings, and Native liaison services. Incarcerated women also have access to health care professionals, including nurses, doctors, dentists, psychologists, and psychiatrists[1,2] The World Health Organization mandates that incarcerated individuals receive “equivalence of care” and have access to the same health services available to those in the outside community.[3]

In BC six collaborations between community organizations and cor­rection­al facilities and one inmate-developed initiative have facilitated access to health and education programs for incarcerated women. These programs show that incarceration provides op­portunities to engage women in activities with potential long-term healing benefits. 

Screening mammography program
In March 2010 a mammography technician and the assistant deputy warden of a provincial correctional centre for women, who was undergoing routine screening mammography during her lunch break, realized that incarcerated women did not have access to breast cancer screening. Together, they organized a visit from the BC Cancer Agency’s Screening Mammography Program mobile service to the cor­rectional centre, which resulted in 73 women being screened. Of those, 50 women had never previously received screening. 

Prison staff members, who are shift workers, and incarcerated women both benefited from the visit. “The unexpected nuance of success was the jovial atmosphere created and felt by all in the prison. It was equally a mixture of anxiety, fear, and anticipation, especially for the 50 women who had never done this before, and it did not matter whether we were staff or inmate. Women became a group who were taking personal responsibility for their health.”[4] Subsequently, the BC Cancer Agency made arrangements to visit both provincial and federal correctional institutions annually. 

HIV outreach program
By Dulce Feder
Oak Tree Clinic (OTC) is a provincial tertiary referral centre in Vancouver that provides interprofessional HIV/AIDS care to women, children, and families.[5] In November 2008 an OTC outreach program began to provide HIV care onsite at a women’s provincial correctional centre in BC to complement the primary care provided by the prison health care team. The outreach team did this by:

•    Providing HIV care for positive and newly diagnosed women. 
•    Encouraging and supporting prison health care practitioners to offer HIV point-of-care serology testing, counseling, and diagnosis.[6,7]
•    Offering continuity of HIV care and addressing comorbid conditions.
•    Working with incarcerated women and prison staff to develop strategies for improving medication adherence, thereby reducing risks of resistance.
•    Assisting women moving into the community to ensure continuity of HIV care. 
•    Providing HIV education and support to prison staff.
•    Collaborating with prison physicians to manage the complexities of incarcerated women’s conditions.

Today the OTC outreach program continues to provide a unique opportunity to engage and educate incarcerated women and prison staff. Women welcome the program, and OTC anti­cipates that this initiative will translate into improved health outcomes. Al­though the number of persons new­ly diagnosed with HIV in BC has de­clin­ed,[8] the prevalence of HIV continues to increase,[9] and makes this interprofessional on-site program especially important. 

Therapeutic recreation
By Alison Granger-Brown 
Therapeutic recreation (TR) is an in­tervention to increase functioning in any of six domains: social, spiritual, cognitive, emotional, creative, or phys­ical.[10] It is delivered using leisure and recreation programs to teach skills, build learning relationships, and, ultimately, to empower individuals to believe they are capable of and entitled to a healthy life.[11]

The prison environment itself can be a barrier to learning. In addition, information retention can be difficult for many incarcerated women because of damaged working memory from posttraumatic stress disorder, fetal al­cohol spectrum disorder, brain injury, and mental health issues. TR creates opportunities for joy and healing, which are both vital when dealing with addictions and antisocial/unhealthy behaviors. Following a riot at King­ston Penitentiary, an inquiry found that re-evaluation was essential: “such things as access to hobby crafts and sport, freedom to decorate cells… were significant factors in reducing the dehumanizing effects of incarceration.”[12] 

TR in prison can facilitate transformative learning and healing, take individual learning style into account, deliver a program that is fun and creative, and increase motivation for change—something that may be sustained after release from prison. Women in BC’s federal correctional institution are offered TR programs that include cooking lessons; mask making; beading, quilting, and artwork; poetry and journal writing; photography; and dance classes. These activities permit women to acquire skills, explore aspects of themselves and the world, and have fun. Prison staff report that women engaged in TR activities are mentally healthier. In future, rigorous evaluation of the use of TR to deliver health promotion and healing opportunities in the prison setting should be undertaken to quantify the benefits.

Holistic learning and healing for Aboriginal women
By Lara-Lisa Condello 
From May 2007 to May 2010, over 100 women in prison participated in the Building Bridges: Community Reintegration Through Education program, an accredited[13] adult basic education program resulting from a partnership between BC Corrections and BC’s Aboriginal public post-secondary institute, the Nicola Valley Institute of Technology. The program was unique in its reliance on an in­digenous philosophical concept of holism,[14] which honors the inter­relationships between the intellectual, spiritual, emotional, and physical realms of learning.

The collaborative community-based[15] pedagogy was designed to accommodate the participants’ “poor self-concept, low achievement levels, [and] learning disabilities,”[16] and the impacts of the residential school system and other colonial projects on their ability to learn.[17] Elders from the Nicola Valley Institute and professional Aboriginal women supported the participants’ learning and healing journeys, and served as models for the acceptance of diverse histories and the resiliency and relevancy of language, culture, and spirituality in learning. 

Teaching methods used were based on competency measures “rather than on comparison with other students,”[16] including learning circles that “symbolize[d] wholeness, completeness, and ultimately wellness”[14] between oneself and one’s family, community, band, and nation. The program offer­ed Aboriginal women a culturally relevant learning process, and to non-Aboriginal women, a deeper under­standing of Aboriginal peoples of Canada, their cultural vibrancy, and their di­versity. Women shared their passions through artistic, oral, and written presentations. 

The following sample presentation titles show how the participants addressed issues of health, culture, spirituality, healing, addiction, and identity: Road to Re­covery for Schizophrenia; My Story and My Addiction; Growing Towards a Happy Balance; The Medicine Wheel and Me; Healing with Laughter; Steps to Recovery: My Life and How I Got the Tools to Change; The Sweatlodge and the Sioux; The Potlatch and My People. The learners discussed person­al journeys toward social, economic, political, cultural, and spiritual well-being.[18] At the end of the program they discussed creating a circle of support to facilitate continued education in the community. 

By combining this kind of cost-effective16 learning and healing with better access to basic social services such as health care, housing, and income assistance, we can in­crease the employability of women leaving prison and make it more likely that they will not return to prison.

Prison health education for UBC medical students and residents 
In 2006 the Collaborating Centre for Prison Health and Education (CCPHE) was created within the Department of Family Practice at the University of British Columbia to facilitate collaborative opportunities for education, service, and advocacy. As well as being a way to enhance the well-being of individuals in custody, CCPHE op­portunities offer medical students and residents exposure to the diverse and complex medical needs found in prisons, including communicable disease, problematic substance use, and mental illness (unpublished paper by Buxton JA, Smith MJ, Rothson D, et al. Medical students and residents go to prison). 

Initially, fourth-year medical student and family practice residents participated in pilot electives. In 2009/10, second-year medical students developed and presented 36 health education seminars to over 600 inmates at three correctional centres. The students reported it was very re­warding to work with inmates, who they des­cribed as a “grateful patient population.” 

Students found some incarcerated individuals had highly so­phisticated knowledge about drug use but misunderstood disease transmission. As one student stated, “A balance of cultural/personal respect and clarification of current medical knowledge was required.” In addition to benefiting from the information sessions, inmates said they felt proud to be part of the development of medical student skill and knowledge. They stated they were more likely to ask questions and disclose information to students than to more senior educators who can be perceived as “part of the system.” 

Working in correctional settings was found to provide students and residents with an opportunity to understand the consequences of social determinants of health and health care inequities, and to confront their own preconceived ideas about marginalized populations. 

Nutrition and exercise program developed by incarcerated women
Prison programs incorporating a wellness model, including exercise and lifestyle changes,[19-23] have been introduced into prisons by corrections staff and outside agencies in many jurisdictions. In an initiative involving incarcerated women themselves in program design, implementation, and evaluation, a 6-week nutrition and fitness pilot program was offered inside a BC correctional centre (unpublished paper by Adamson S, Korchinski M, Granger-Brown A, et al. Incarcerated women develop a nutrition and fitness program: Participatory research). 

The inmates who developed the program described it at an introductory seminar and invited their fellow inmates to participate. Participants were given the Canada Food Guide and a personalized food chart that enabled them to monitor their eating behavior for 6 weeks. A presentation about nutrition was offer­ed to inmates every Saturday morning (available at www.womenin2healing.org/research-projects/nutrition-exercise). Participants were also given an exercise program card to help track progress made in improving their cardiovascular health, strength, and flexibility. Group circuit classes were of­fered twice a day. 

The inmate re­search team designed pre- and post-program evaluation methods, which relied on responses to a self-administered questionnaire and body measurements. The numerous women who attended the circuit classes only as “drop-ins” were not included in the evaluation of the program. Results from the pre- and post-program evaluation complet­ed by 16 women indicate that their weight, body mass index, waist-to-hip ratio, and chest measurements de­creas­ed by the end of the program, while energy, sleep, and stress levels improved. Responses to open-ended questions show that “having fun” was a recurrent theme: 

“ I felt very good afterwards and it was fun.” 
“ I didn’t feel as depressed as I did before—exercise makes me feel better in my mind.”
“ Because it was organized and led by another woman in prison… she understands us… not someone coming in from the outside saying, you must do this because it is healthy for you.”

Interdisciplinary prison contract staff observed increased interest in and use of the gym equipment during the 6-week pilot program. The success of the program suggests it is feasible for incarcerated women to develop and lead a prison fitness program, and that this can result in improved fitness levels and other health benefits. 

Infant and mother health initiative
By Amy Salmon and Jeanine Thompson
From 2005 to 2007 a partnership be­tween BC Corrections, the Ministry of Children and Family Development (MCFD), and BC Women’s Hospital’s Fir Square Combined Care Unit led to an infant and mother health initiative at the major BC provincial correctional centre for women. 

The program allowed women who gave birth while incarcerated to return to the correctional centre with their infants in their care. 

Thirteen babies were born to incarcerated mothers during the program, nine of whom returned to the correctional centre with their mothers and stayed there until their mother’s release. Fifteen months was the longest stay of any infant in the correctional centre (unpublished paper by Salmon A, Thompson J, Murphy K, et al. Incarcerating mothers: The effect on women’s health). Mothers participating in the infant and mother health initiative described the experience of bonding with their babies as a turning point in their lives, and reported that the supervised environment of a prison-based program assisted them in acces­sing support in a timely fashion:

“ If I ever need anything I would just let one of them know. Health care was right next to me, so if I had a problem… The nurses would come in and when I was having complications, when I was pregnant, they would come in and check on me.”

Women also identified their fellow inmates as sources of mothering support, providing them with practical assistance, encouragement, and emotional respite: 

“ We were all mentoring the young one who had never had a child before and she was scared. And didn’t know what life was going to look like, what she would do with her life… and so we worked as a team, all of us. Okay if you need a shower, we’ll watch your baby.”

Eight of the nine babies were breastfed for the entire duration of their mothers’ incarceration—a significant fact given that only 53.9% of Canadian babies in the general population are receiving breast milk at 6 months.[24] Mothers who were separated from their children while incarcerated also reported that they were positively affected by the correctional centre infant and mother health initiative:

“ We were a family unit, the four of us and the two kids . . . It was very cool, so therapeutic for me to sit, you have a lot of time to sit and talk with the moms and, like, all of us were very intimate. We all talked about our shame and our guilt, how we could have done things differently.”
“ It was really therapeutic for the three of us, particularly the three of us who had lost children, to be with each other and to be able to support each other in the grief, in that joy.”

Twelve months after the mothers were released, seven babies continued to live with their mothers, one baby was in the care of the father, and one was in the care of the MCFD. At the time of writing, only two of the mothers who participated in the infant and mother health initiative have returned to prison. 

In April 2008 the infant and mother health initiative was discontinued; subsequently, all infants born to mothers at provincial correctional facilities in BC were either placed with a relative or entered foster care under the guardianship of the MCFD. A BC Corrections spokesperson stated, “Our staff are not trained to supervise infants and they’re not [trained] in infant first aid or anything… if something went wrong and we didn’t respond appropriately, we just couldn’t risk putting an infant in that situation.”[25] 

Infant safety has not been reported as an issue in numerous countries where prison infant and mother health initiatives are well established. On 10 November 2008, five women filed a claim with the BC Supreme Court maintaining that they have the constitutional right to keep their children with them while incarcerated in pro­vincial correctional centres (File Number 087858). The court decision is pending.

Summary
The collaborative prison-community programs described here have all provided women with different health and social benefits. Government and community organizations can provide incarcerated women with equivalent programs to those offered in community.  Women in prison enthusiastically participated in a nutrition and exercise program that was developed by a peer inmate. They also participated in health education seminars that were offered by second-year medical students.

Acknowledgments
We are grateful to the women in prison who initiated, participated in, and evaluated the nutrition and exercise program, as well as to the women who shared their stories for the infant and mother health initiative article. We acknowledge funding provided by the UBC Teaching and Learning Enhancement Fund, UBC Department of Family Practice, and the Vancouver Foundation.

Competing interests
None declared.

AUTHORSHIP NOTE: Except where noted, this article was written by guest editors Drs Elwood Martin, Buxton, Hislop, and Ms Smith. Ms Granger-Brown is a recreation therapist for the Regional Treatment Centre, Correctional Service of Canada. Dr Buxton is an associate professor at the School of Population and Public Health, University of British Columbia (UBC). Ms Condello is a criminology instructor at the Nicola Valley Institute of Technology, Vancouver Campus. Ms Feder is a nurse clinician of Oak Tree Clinic, BC Women's Hospital. Dr Hislop is a clinical professor with the School of Population and Public Health at UBC and a retired epidemiologist at Cancer Control Research, BC Cancer Agency. Dr Elwood Martin is a clinical professor at the UBC Department of Family Practice and director of the Collaborating Centre for Prison Health and Education at UBC. Dr Salmon is a clinical assistant professor, School of Population and Public Health, UBC, and the executive director of Sheway, a pregnancy outreach program located in the Downtown Eastside of Vancouver. Ms Smith is the former coordinator of the Collaborating Centre for Prison Health and Education. Dr Thompson is a family physician practising in British Columbia.