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Public Health Strategy for Offenders

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Health Services Vision: Improved offender health that contributes to the safety of Canadians.

Objective of CSC's Public Health Program: To provide public health services to federal offenders in order to prevent and control disease and promote good health within federal institutions.

TABLE OF CONTENTS


THE PURPOSE OF A PUBLIC HEALTH STRATEGY FOR CORRECTIONS

The penitentiary environment inherently presents the potential for the transmission of diseases, given the high number of persons in close confinement and the daily movement of staff, visitors and others from the community in and out of the penitentiary.

The potential for transmission of air-borne, sexually transmitted and blood-borne pathogens is heightened by the generally poorer levels of health among inmates, many of whom also have a history of high-risk behaviours such as injection drug use, sex work, and unprotected sex with high-risk partners, and by the compromised health of those with chronic diseases. For example, in the area of infectious disease, at year-end 2008, 219 inmates or 1.69% of the total inmate population were known to be living with HIV and 3,903 or 30.2% of the total inmate population were known to be Hepatitis C Virus positive.

Over the course of the past 15 years the Correctional Service of Canada (CSC) has progressively implemented public health services in its institutions. Some of these services, such as tuberculosis (TB) prevention and control and immunizations against hepatitis A and B, were established and strengthened as resources were made available to CSC, while other services such as special treatments were introduced in response to the emergence of new public health challenges such as HIV and Hepatitis C. In short, public health services in CSC have grown incrementally as a result of various opportunities and influences. A strategic approach to identifying, aggregating and planning for the public health needs of the inmate population is now timely, given the establishment of a dedicated public health branch in CSC (2007) and the considerable growth in capacity and expertise within CSC that has developed across the past decade. A strategy will provide CSC with a framework to guide the development of public health activities, including the collaboration that will be required with internal partners and external stakeholders. In addition, it will provide a stronger focus for public health activities, along with expressed goals for improving offender health in order to contribute to the safety of Canadians.

This Public Health Strategy for CSC will be implemented across five years, beginning in fiscal year 2010-2011. It will strengthen and build upon current public health activities. As well, it identifies areas for enhancement and expansion of the scope of public health activities if additional resources become available. While the Strategy speaks to high-level goals for seven strategic areas, an action framework has been developed to detail activities within those strategic areas, track progress, report results, and ensure ongoing alignment and congruence with corporate plans and priorities. Annex A outlines how the Strategy links to CSC's strategic priorities.

LEGISLATIVE CONTEXT

Section 86(1) of the Corrections and Conditional Release Act (CCRA) requires that every inmate be provided with essential health care as well as reasonable access to non-essential mental health care that will contribute to successful rehabilitation and reintegration into the community. Section 86 (2) states that the provision of health care under subsection (1) shall conform to professionally accepted standards. In addition, section 70 requires that CSC take all reasonable steps to ensure that the penitentiary environment and the living and working conditions of inmates are safe and healthy.

Section 4 (h) of the CCRA sets out the principle that corrections policies, programs and practices [shall] respect gender, ethnic, cultural and linguistic differences and be responsive to the special needs of womenand Aboriginal peoples, and the needs of other groups of offenders with special requirements. Accordingly, public health activities must be tailored to achieve the most appropriate, meaningful and most likely to succeed approaches for those groups.

This is the legal framework within which CSC provides public health services to offenders.

OBJECTIVE OF PUBLIC HEALTH PROGRAM

The objective of CSC's Public Health Program is to provide public health services to federal offenders in order to prevent and control disease and promote good health within federal institutions.

GUIDING PRINCIPLES

The way forward in implementing the Strategy is illuminated by a set of Guiding Principles for the delivery of public health services in CSC.

  • Offender responsibility: Offenders must be involved both in taking responsibility for behaviours that affect their health and in being proactive in order to safeguard their health.
  • Long-term public health perspective: The provision of public health services to offenders has the potential to lessen the burden of health care on society as a whole. By endeavouring to improve offender health during the period of incarceration, public health services in federal penitentiaries may contribute to the reduction of the downstream costs of health care for the community after offenders are released.
  • Continuous Quality Improvement: CSC is committed to ongoing improvement in the quality and delivery of health services to offenders. Public health services must meet or exceed national accreditation standards.
  • Partnerships: Public health activities will be strengthened through internal and external partnerships.
  • Holistic health approaches: Holistic approaches to meeting the public health needs of offenders will be developed and implemented over time, as resources permit.
  • Emergency response preparedness: Public Health staff will work collaboratively with all sectors to develop contingency plans and protocols for timely, effective and efficient responses to infectious disease outbreaks and other health challenges in CSC institutions.

This diagram depicts the framework for the Public Health Strategy.  The 7 strategic areas of the Public Health Strategy are anchored in the centre by the Health Services Vision and the objectives of the Public Health Program. The key target audience for the Strategy is depicted on the outside frame with the guiding principles for public health services supporting the entire framework.


THE PUBLIC HEALTH STRATEGY FRAMEWORK

Seven strategic areas along with corresponding goals provide the framework for the Strategy and its implementation through annual work plans.

Strategic Area #1: Infectious disease prevention, control and management

The goal is to ensure consistency and sustainability in infectious disease prevention, control and management, and to consider enhancements if more resources become available.

Management measures include community standard treatments for infectious diseases such as HIV, Hepatitis B/C, sexually transmitted infections, influenza A and Tuberculosis. CSC currently offers a range of prevention, control and management measures including: screening and testing at reception; immunizations; counselling and education on infectious diseases and how to prevent their acquisition and/or transmission; discreet access to harm reduction devices and information (bleach, condoms, dental dams, instructions on cleaning syringes and tattooing materials); discharge planning to ensure continuity of care upon return to the community; and planning for outbreaks of disease such as Influenza A.

The national office will continue to ensure that the necessary infectious diseases screening and testing, care, treatment and support guidelines and protocols are in place to guide public health staff at the regional and institutional levels.

A key initiative within Strategic Area #1 is the ongoing implementation of the enhanced harm reduction strategy (2007) which is based on recommendations made by the Health Care Advisory Committee to CSC. The findings of the analysis of the National Inmate Infectious Diseases and Risk Behaviours Survey of 2007 also provide a reference for the reinforcement of public health activities.

With respect to discharge planning, more information sharing between Health Services staff and parole officers would expedite the transition from institutional to community health care upon the offender's release. This is particularly important for offenders with complex infectious disease treatment needs and other complicated physical health problems. Dialogue needs to take place at various levels of the organization in order to implement an appropriate process to share information that addresses issues regarding privacy and sharing of medical information with persons outside the circle of care.

The recent experience in dealing with H1N1 has underscored the need for CSC to remain "on top" of the evolving policy for pandemic influenza planning and response. Public health has been working in partnership with stakeholders within and outside CSC, has formed specialized working groups, and has developed tools, procedures and guidelines to enhance pandemic response.

The development of protocols to delineate the roles and responsibilities of branches and sectors within CSC and external partners such as PHAC in dealing with both enteric and respiratory issues is essential. Collaborative work with internal and external partners will be required to produce comprehensive protocol documents.

Strategic Area #2: Health promotion and health education

The goal is to ensure dissemination of health promotion materials to all offenders; and to broaden their content to include healthy lifestyle behaviours, risk factors for chronic diseases, and health needs specific to certain groups.

Public health program managers are leading on the development of material and information reflecting best practice in health promotion, and regional health promotion nurse positions have been established to oversee and facilitate institutional program delivery. The content of current health promotion materials is being expanded to include healthy lifestyle choices and prevention of chronic diseases such as Type 2 diabetes, heart disease and obesity. In addition, health promotion materials are being developed for specific groups or situations, e.g. offenders with mental health needs; private family visits that include children.

Offenders generally rely on health care staff to direct their health-related behaviours and maintain their health. A key element of this strategic direction is the encouragement of offenders to take responsibility for adopting healthy behaviours and to support their efforts through health education programs.

A mid- to long-term enhancement in this strategic area would be to develop broader and more holistic health education programs in such areas as chronic disease prevention and include a greater focus on wellness. Its implementation would require the participation of other sectors and significant additional resources.

Strategic Area #3: Surveillance and knowledge sharing

CSC currently has an effective infectious diseases web-based surveillance system which enables us to understand the prevalence of specific diseases in the offender population and leads to the identification of groups at risk as well as to emerging areas of risk such as local outbreaks.

The goal is to inform the development of evidence-based measures in the prevention, control and management of infectious diseases and other risks to offender health, through enhanced, co-ordinated surveillance efforts and knowledge sharing

In order to monitor public health issues within the overall offender population, the focus and scope of surveillance activities should be broad and data collection, analysis and evaluation inclusive of all offender groups including women, Aboriginal peoples, ageing offenders and offenders with chronic and other diseases. Information should also be gathered about co-morbidities within the offender population. An expanded surveillance system, which would require additional resources, would assist health professionals to understand the diverse health characteristics of the offender population and to target appropriate interventions.

The Policy Sector conducts research on an ongoing basis in the area of offender demographics. This work could be linked directly to public health activities in order to target relevant issues that need to be explored. In addition, knowledge sharing is imperative within CSC to ensure that the analytical work in epidemiology and research is disseminated throughout various levels of the organisation and to other governmental partners and stakeholders.

Strategic Area #4: Aboriginal and women offender health

The goal is to ensure sustained emphasis on addressing the public health issues affecting Aboriginal and women offenders.

Two separate strategies have been developed to address the needs of Aboriginal and women offenders, many of whom, having been disadvantaged according to the social determinants of health, are at increased risk of compromised health.

While there is a need for more complete information about the health profile of Aboriginal offenders, what is clearly known is that programming that includes traditional culture, spiritual practices and ceremonies appears to be effective. In response, the Public Health Branch has developed, in partnership with the Aboriginal Initiatives Directorate, an Aboriginal Health Strategy (2009-2012) to take into account the health needs of Aboriginal offenders and culturally-appropriate-specific approaches to meeting these needs. The Aboriginal Health Strategy is intended to address Aboriginal health from a holistic perspective, taking into consideration the physical, mental, emotional and spiritual aspects of the offender, and thereby incorporating a range of areas within Health Services (e.g. infectious diseases, mental health, and clinical issues).

Given the high prevalence of infectious diseases among federal women offenders, and recognizing the importance of women-centered programming, the Public Health Branch has developed the Infectious Disease Strategy for Women Offenders (2008-2013) to provide a framework for infectious disease prevention, care, treatment and support for women offenders. In the short term, the Public Health Branch is working with other CSC sectors to support and enhance the delivery of health information currently being offered in the context of women's programming.

In the longer term, the development of a more holistic approach to women's health needs will take significant time to research, formulate/develop and implement. This process will be guided by a multi-sector working group established within CSC.

Strategic Area #5: Healthy Environments

The goal is to ensure that public health activities contribute to and support healthy environments.

In the future, the Public Health Program could play an advisory role in areas related to infrastructure, water and air quality, cleanliness, physical activities and nutrition for inmates. In terms of environmental health, this area falls under the purview of Technical Services and is not currently part of public health activities within CSC. However,in the related area of cleaning of facilities, the Public Health Program is working in partnership with Technical Services in the development of cleaning and disinfection guidelines for CSC's Health Centres.

Strategic Area #6: Public Health competencies

The goal is to ensure that staff has the requisite public health skills and knowledge.

The Public Health Agency of Canada has identified 36 core competencies (essential knowledge, skills and attitudes) necessary for the practice of public health which can be used as a baseline for CSC public health staff.

Health Services has highly skilled health professionals who work to deliver optimal public health results for offenders and the communities to which they return. Ongoing learning opportunities for existing and new staff are important to ensure that they have the right mix of competencies to deliver on the Strategy.

Strategic Area #7: Visibility and accountability

The three goals are (1) to secure collaboration from internal and external partners and stakeholders; (2) to broadly communicate the Strategy and the results of its implementation; and (3) to have in place updated performance measurement indicators and an evaluation framework

It is essential that all branches of Health Services - clinical, mental health, public health, and policy, planning and quality improvement -- work in collaboration. Reinforcing the close relationship with our colleagues in clinical services and mental health services will help weave health promotion and health education into their activities. Quality improvement and accreditation partners will assist in ensuring that the quality of public health services meets or exceeds national accreditation standards. This collaboration must take place at all levels of CSC: national, regional, and institutional.

Second, it is imperative that public health activities have strong horizontal linkages, where appropriate, to other sectors of CSC such as Policy, Security, Corporate Services, Human Resources, Correctional Operations and Programs, Aboriginal Initiatives and the Women's Sector. These linkages must be both strategic and practical, i.e. serve to improve the effectiveness of public health services in the institutions.

The Public Health Branch at National Headquarters has existing external partnerships with federal departments such as the Public Health Agency of Canada (PHAC), Health Canada (particularly the First Nations and Inuit Health Branch), and Public Safety Canada. A Memorandum of Agreement with PHAC for the provision of expert advice and technical support with respect to the prevention, control and management of infectious diseases has been in place since 2003. This MOU will be replaced in 2010 by an Interdepartmental Letter of Agreement that enables the expansion of collaborative activities of mutual interest, reflecting CSC's increasing public health competence and capacity.

In addition, the Public Health Branch liaises on a regular basis with the Federal/Provincial/ Territorial Working Group on Health, the Health Care Advisory Committee, the Federal Health Care Partnership and numerous non-governmental organisations that have an interest in public health issues affecting offenders.

With the introduction and implementation of the Public Health Strategy, we will continue to rely on the support and advice of our external partners and to share best practices. There may also be opportunities to work together on horizontal government health issues and to participate in joint funding ventures that are of mutual benefit. Such partnerships will be encouraged at the regional and local levels with public health authorities and community-based service organizations, for example.

In addition, it will be important to determine the overall effectiveness of the Public Health Program through an evaluation. A Performance Measurement Strategy (PMS) will be developed and will include the following: (1) a program profile (2) expected results along with a logic model and accountabilities and (3) monitoring and evaluation information that provides on-going performance measurement as well as an evaluation strategy.

Performance information will ensure that there is accountability for results and that senior management of CSC is aware of them. The evaluation of the Public Health Program is targeted for 2014.

CONCLUSION

It is intended that the Public Health Strategy for CSC will have a positive impact on the public health program. It is expected to contribute to more effective and efficient public health services and, in the long term, to the reduction of health costs for offenders, healthier communities, and better public safety. It is a collaborative approach to providing public health services to offenders from the date of admission to penitentiary through to their release to the community that will draw upon the expertise of a national network of internal and external partners and stakeholders.

ANNEX A Link to CSC's Strategic Priorities

The Public Health Strategy has linkages to the five CSC strategic priorities in the following manner:

(1) Safe Transition of Eligible Offenders into the Community: The core public health activities that are maintained in the Strategy attempt to maximize offenders' health which in turn contributes to their successful reintegration and the health of communities. The focus on health promotion/education activities assists offenders in becoming more aware of the factors that affect their health and encourages them to adopt healthy lifestyles. In addition, the new focus on individual responsibility for health will empower offenders to be proactive to safeguard their health for the benefit of themselves and their families.

(2) Safety and Security for Staff and Offenders in our Institutions: The Public Health Strategy reinforces the requirement for screening, prevention control (including vaccinations) and treatment of infectious diseases which will have the ultimate outcome of reducing the transmission of these diseases amongst the offender population. The development of department-wide protocols assists in stabilizing the institutional environments in cases of outbreak of communicable and non-communicable diseases.

(3) Enhanced Capacities to Provide Effective Interventions for First Nations, Métis and Inuit Offenders: The Public Health Strategy recognises the necessity to work on issues affecting Aboriginal offenders, and an Aboriginal Health Framework has been developed in consultation with the Aboriginal Initiative Directorate.

(4) Improved Capacities to Address Mental Health of Offenders: There is an indirect link to this strategic objective in the Public Health Strategy as health promotion material will be adapted to offenders with mental health disorders. The Public Health Branch will work closely with the community and institutional mental health specialists to ensure that this information meets these offenders' needs and is accessible to them.

(5) Strengthening Management Practices: The Public Health Strategy will improve internal communications with respect to public health activities through the strengthening of internal linkages among CSC staff. It will also strengthen human resource management by identifying the appropriate mix of competencies and assisting staff in re-orienting their tasks to deliver on public health outcomes. As well, the collection of performance information supports accountability and reporting on the delivery of outcomes. The Public Health Branch will develop and implement a performance measurement framework and an evaluation approach based on the Strategy.