Abstract

The author applied innovative Health Care Change Management strategies in Irish Prisons to transform the community health culture from a reactive to preventive culture using the WHO (2007) Whole Prison approach to health.

Following the evaluation of a successful Action Research project in one prison, the model was introduced in all fourteen prisons in the Irish state over four years in which the programme received the best Public Health Award by the WHO in 2011. The success of the programme raised international interest and the project was scaled up and introduced to Australian, Norwegian, French and Colombian Prisons.

In 2022, Ireland became the Global Hub for Community-Based Health in Detention through an MoU between the Irish Red Cross,  the Person Service, the International Committee of the Red Cross ICRC) and the International Federation of the Red Cross/Red Crescent Societies (IFRC) in Geneva.

This paper describes the harnessing of complex systems theory and its sub-sets of Complex Adaptive Systems and Chaos theory as a basis for practical second-order organisational change to effect preventive Detention health through a WHO (2007) Whole Prison Approach to health. This used peer inmate Red Cross volunteers to assist healthcare in raising community health wellbeing linked to formal health systems.

The project emerged from the author’s previous doctoral research into Nursing management learning using chaos theory applied to nursing management and learning, aimed at creating enhanced capacity for innovative change in the health and systems in detention contexts.

The theoretical underpinnings of the Community-Based Health in Detention approach described in this paper, acknowledges that in reality, there are ‘only relationships’ (Bateson 1985) and that systems are divided into other systems which interact together.

The training and subsequent peer education, linked to prison healthcare systems in all prisons, ensured that proactive preventive healthcare messages were established as the extended ‘arm’ of nurses into the local prison community.

University-sponsored Evaluations (UWO 2015; IRC 2018; UWO 2023) identified significant impact in health, safety and wellbeing outcomes. Violence reduction in cutting weapon injuries were reduced from 97% of all attacks to 6% over a six month period leading to safer prisons and reduction in hospital transfers.

Inmate peer awareness campaigns and advocacy for mass testing for Hepatitis C led to 80% attendance rate and the diagnosis of 17 new cases of HCV (Crowley et al  2017; 2018). A cost effectiveness study by the University of Bath (UK) showed societal savings of 7 million Euros (Ward et al (2020). Mass voluntary HIV testing in three prisons resulted in attendance rates 40%. 52% and 60% as a result of inmate peer education and advocacy (Bannon et al 2016).

Mental Health wellbeing was identified as the most pressing health problem in Irish Prisons. Projects by peer educators lead by the nurse and psychologist in each prison enabled greater access to local peer messaging and signposting to professional care. A study using the Warwick-Edinburgh Mental Health Wellbeing scale, demonstrated statistically significant)cant improvements in mental health wellbeing amongst Red Cross inmate peer educators engaging in volunteering activity (IPS 2019).

Qualitative studies (IRC 2013; UWO 2015; UWO 2023) showed improvement in personal development, locus of control, confidence and behaviour change. A ten-year longitudinal mixed methods study using psychometric measures at time 1 and 2, along with qualitative interviews, is in progress with University College Cork. (2023-2033).

The pre-existence of inmate volunteer peer educators in all prisons prior to the COVID-19 pandemic were a centrally important healthcare asset in local infection control measures during the pandemic. Their activities contributed significantly to the Irish Prison Service’s preparedness and response (UWO 2022), resulting in only one death during the pandemic period UWO 2022); (IPS 2023).

This Project has changed the culture of Community-Based Health in Irish Prisons and in those jurisdictions into which it has been implemented. Its successful replication in other jurisdictions has demonstrated a scalable, innovative public health initiative that has a Global potential for change in Detention Community Health care.