PriSUD-Nordic: Intervening substance use disorders in the prison population – A public health opportunity
A short description of the qualitative study:
Harm caused by substance use disorders (SUD), including illicit substances as well as alcohol and other legal substances, is a significant contributor to the burden of disease. Individuals with SUDs have a higher risk of premature death, ranging from a four-fold increased mortality among persons with alcohol use disorder (AUD) (1) to a four to-15-fold increased mortality among persons with opioid use disorder (2). During 2015, 28 million years of healthy life (disability-adjusted life years, DALYs) were lost worldwide as a result of premature death and disability caused by drug use (3), with a heavier burden among socially disadvantaged groups, such as the prison population. People with SUD in prison thus constitutes a group of people that are marginalized both in terms of substance use and in terms of incarceration, and suffer disproportionately from poor physical and mental health, infectious diseases social marginalization and economic disadvantage (4).
A continuing challenge in public health is to provide services to the people who need them the most and who are hardest to reach. Prisons may provide an ideal environment for health interventions: a high proportion of prisoners have untreated SUD, and in prison, they are reachable for a set amount of time. The detection of mental health problems and SUDs, accompanied by adequate treatment and the introduction of harm reduction measures, will significantly improve the overall health status of the communities that the prisoners come from and to which they return. From a public health perspective, time in custody could therefore represent a turning point, as a way of promoting SUD treatment among some highly disadvantaged people. However, the global provision of health services in prison is characterized by large diversity, on a spectrum of no health services offered to universal health coverage, with the Nordic countries being examples of the latter (5, 6). Where high-quality health services are offered to prisoners, prison is one of the few arenas where the health services are sure to get in regular contact with marginalized populations living precariously outside.
Advancing our knowledge of traditionally marginalized and understudied groups such as people with SUD in prison is important to understand social disparities in health. In addition, this is a precondition for planning the most appropriate interventions among people with SUD in prison. Because of the number of people who cycle through prisons each year globally, improving the health of this population is important on human rights, public health, criminal justice, economic grounds and not least for society as a whole (7, 8).
PriSUD-Nordic will be the first longitudinal study to investigate the epidemiology of people with SUD in three Nordic countries. The overall objective of PriSUD-Nordic is to develop new knowledge contributing to better mental and physical health, improved quality of life and better life expectancies among people with SUD in prison. The project aims to investigate the epidemiology of people with SUD in the Nordic prison population during three different periods relating to incarceration: the time prior to imprisonment, the time during imprisonment and post-release.
To reach the ambitious aims of the PriSUD-Nordic study, we will analyze a wide range of existing, high quality Nordic registry data available for research, combined with analysis of qualitative data based on ethnographic fieldwork and semi-structured interviews.
Prisons are situated in complex social, cultural and political contexts, dependent on social, structural and historical factors. This makes a multidisciplinary mixed method approach relevant, as it includes the methodological perspective of both epidemiological, quantitative methods and ethnographic, qualitative methods. Mixed methods enable investigators conceptually and analytically to integrate qualitative research and qualitative data with traditional epidemiological and quantitative methods of research to facilitate translation. Mixed methods help understand, not just whether an intervention works, but how, why, and for whom (9).
When investigating the epidemiology of SUD among people in prison with longitudinal registry data, it is therefore relevant to take the context of the prison into account. Two methodological approaches will be at the centre of the qualitative research; the ethnographic fieldwork and semi structured interviews. The ethnographic fieldwork could focus on the SUD treatment situation and the context surrounding this, with the researcher being present in the context of the SUD treatment. This could be the prison wards, the various treatment facilities inside the prison or outside the prison. In terms of the interviews, it would be relevant to talk to both prisoners, who have been in SUD treatment, prisoners who has not, health care providers, other SUD treatment provider, e.g. therapists or coaches, social workers or other people situated in the prison context, whether they have a direct, in direct or no association to the SUD treatment.
Qualitative methods can provide descriptive analysis for the epidemiological and statistical analysis, helpful when developing hypotheses and research design. Secondly, the qualitative analysis can help to qualify and validate the interpretation of the quantitative results, by developing knowledge of processes, mechanisms and explanatory models behind the results. Thirdly, the qualitative methods can qualify the development and implementation of interventions, guidelines and recommendation of the results from the research project. This can thereby improve the effect of the research and the value of the project to the target populations.
The interviews will be conducted following a semi-structured interview guide, based on a scoping review of the current knowledge within the field. Some of the overall themes in the interview guide could be social relations, support and marginalization, health and addiction, motivation for treatment and more. Focus will be put on identifying challenges to successful treatment, the prison as an arena for treatment interventions and different ways of understanding the treatment institutions in question from different perspectives and at different times of the sanction/treatment – release preparation – post-release process.
The specific scientific aims for the qualitative study are:
Aim QI: Investigate the nature, norms, mechanisms and process of SUD treatment in prisons
Aim QII: Investigate post-release narratives among former prisoners
The project management is held at the Norwegian Centre for Addiction Research (SERAF) at the University of Oslo, and Dr. Anne Bukten is the project leader. Dr. Stavseth will be the project lead analyst and in charge of developing the Nordic syntax for the registry data. Professor Ugelvik will lead and run the qualitative part of the project and supervise the PhD-student. Nicoline Lokdam (PhD, PriSUD-Norway) will contribute with experience in qualitative research in the prison population and Johan Lothe will oversee the user perspective.
User involvement is integrated in both the Steering committee and the research group, represented by clinicians, policy makers and user organizations. The user organization WayBack (10) provides services in-prison and help build pro-social networks post-release in order to prevent relapse into crime and drug use (11). WayBack plays an important role in planning the project, in requirement of participants to interview and in dissemination.
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