A comparison of drug-related and sexual risk-behaviours in the community and prison for canadian federal inmates (summary)

The authors would like to thank the National Inmate Infectious Diseases and Risk Behaviours Survey Working Group for their guidance and insightful feedback throughout questionnaire design and report development (Jacqueline Arthur, Katherine Dinner, Marie-Line Gilbert, Emily Henry, Gayatri Jayaraman, Rhonda Kropp, Tammy Maheral, Marissa McGuire, Mary Beth Pongrac, Jonathan Smith, Greg Springer, and Jill Tarasuk). The support, cooperation and dedication of the National Senior Project Manager (Heather Lockwood), the Regional Survey Coordinators (Kimberley Andreassen, Michelle Beyko, Teresa Garrahan, David Lewis, and Hélène Racicot) and institutional survey coordinators (Tim Ankers, Cathy Ball, Bob Barkley, Louise Barriage, Gaston Bélanger, Réjean Bérard, Diane Bergeron, Sherry Blakeney, Laura Bodvarsen, Lori Boss-Greenhow, Michèle Boutin, Celeste Bowes-Koep, Randall Breaton, Pam Briar, Marsha Brown, Bev Bruce, Joan Christianson, Pénélope Cossette, Shelley Crawford, Solange Cyr, Johanne Demètre, Micheline Désilets, Penny Drury, Mary Ann Dundas, Annette Dupuis, France Duquet, Claire Erkan, Donna Fillmore, Linda Fumerton, Debbie Fury, Lyne Giroux, Carla Grace, Sue Groody, Derek Hutchings, Kevin Jean, Pat Jones, Virginia Jugo, Wally Klein, Dan Larocque, Luc Lavigne, Sylvain Lefebvre, Gail Lévesque, Cherie Maceachern, Daniel Major, Alison Martin, Penny Martin, Dorothy McGregor, Mark Noon-Ward, Tim O’Hara, Enid Oke, Viateur Perreault, Christian Rivest, Johanne Roy, Eva Sabir, Holly Samuels, Suzanne Scott, Dale Shackleford, Marg Smith, Natalie Soroka, Stéphanie Fournier, Jeff Strange, Paul Taylor, Tana Taylor, Brenda Tilander-Masse, Liza Trohan, Darlene Turk, Mario Veilleux, Vicki Vervynck, Katherine Visser, Lorena Watson, Marilyn Winters, and Carol Young) were integral to survey implementation and data collection. Finally, none of this work would have been possible without the participation of Correctional Service of Canada management, federal penitentiary staff and inmates.

Canadian and European studies involving the adult incarcerated population indicate that the proportion of offenders reporting risk-behaviours (i.e., drug-, sex-, tattooing- and piercing-related) is lower in prison than in the community. Some studies suggest, however, that those who engage in risk-behaviours in prison may be performing them in a riskier fashion. Unfortunately, most studies suggesting riskier behaviour in prison share a common design limitation: the time periods being compared outside and inside prison have not been standardized. Furthermore, none of these studies have specifically examined whether the observed riskier behaviour in prison is a continuation of community behaviour or practiced primarily in prison.

To address these deficiencies in the literature, in 2007 the Correctional Service of Canada (CSC) conducted the National Inmate Infectious Diseases and Risk Behaviours Survey (NIIDRBS), a self-administered paper questionnaire completed by a large sample of Canadian federal inmates. The NIIDRBS captured information on drug- and sex-related risk-behaviours during the last six months in the community prior to the current incarceration, and during the past six months in prison prior to completion of the questionnaire.

Consistent with previously published research, the prevalence and frequency of non-injection drug use and injection drug use declined in prison compared to the community for both men and women. The change in injection equipment sharing practices across environments reflected the decline in injection drug use among women but not men. Specifically, although the proportion of men who reported injecting drugs significantly declined from 22% in the community to 16% in prison, the proportion who passed a needle to someone else after using it (7% vs. 7%), used someone else’s needle after they used it (8% vs. 7%), and shared a needle with someone who was infected or possibly infected (4% vs. 5%) did not significantly decline. These findings indicate that the proportion of male injectors who share injection equipment is greater in prison than in the community. This was not entirely due to the riskiest injectors continuing their risky practices as they move from the community to prison. In fact, among inmates who injected in both the community and prison, 33% used a needle previously used by someone else during the past six months in prison but not during the last six months in the community.

With respect to sexual behaviour, the proportion of inmates reporting any sex and specific sexual behaviours significantly declined in prison compared to the community except for sex with a partner of the same sex. The proportion of men reporting sex with other males remained stable at about 4% across environments while the proportion of women reporting sex with females significantly increased in prison compared to the community (26% vs. 22%). In regards to unprotected sex, the bulk of men and women who reported unprotected sex with a regular partner in prison had actually engaged in the behaviour in the community (5% and 14%, respectively). Similarly, the majority of males who reported unprotected sex with casual partner(s) in prison also reported the behaviour during the last six months in the community. Among women, however, 70% of those who reported recent unprotected sex with a casual partner in prison did not engage in the activity during their last months in the community. For women, this indicates that unprotected sex with a casual partner is not necessarily the continuation of a recent community behaviour.

Thus, in general, there was a lower prevalence of risk-behaviours as offenders moved from the community to prison, but those who engaged in risk-behaviours in prison were not necessarily continuing recent community behaviour. This general decline in risk-behaviours may be more a consequence of incarceration rather than an independent choice to live a healthier lifestyle.

The major limitations associated with the NIIDRBS, such as measurement error and social desirability bias, are typical of cross-sectional, self-report surveys that attempt to capture information about sensitive or illicit activities over time. Additional limitations included lack of information regarding why behaviours change, and how and why behaviours change upon community reintegration. To address these limitations, future research should be longitudinal in nature, surveying inmates at several points in time throughout incarceration and community reintegration, and should inquire as to why behaviours change. Such information is useful in identifying important modifiable factors which can inform CSC’s health policy and programming decisions.

Health risk-behaviours, such as injection drug use and unprotected sex, occur at a high rate among offenders entering the correctional system (Conklin, Lincoln, & Tuthill, 2000;Hogben, St. Lawrence, & Eldridge, 2001;Long et al., 2001). Such risky behaviour increases the risk of acquiring blood-borne and sexually transmitted infections, as evidenced by the high rate of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections among inmates compared to the general population. For example, studies involving Canadian federal inmates have estimated the overall seroprevalence ^Footnote1 of HIV at 2% and HCV at 26% to 33% (De, Connor, Bouchard, & Sutherland, 2004;Ford et al., 2000). Conversely, the prevalence of HIV is estimated at 0.3% (UNAIDS, 2006) in the Canadian adult population (15-49 years old), and the prevalence of HCV is estimated at 0.8% in the Canadian population as a whole (Zou, Tepper, & Giulivi, 2001).

Canadian and European studies involving the adult incarcerated population indicate that the proportion of offenders reporting risk-behaviours (i.e., drug-, sex-, tattooing-, and piercing-related) is lower in prison than in the community (Bullock, 2003;Calzavara et al., 2003;Calzavara, Myers, Millson, Schlossberg, & Burchell, 1997;Gyarmathy, Neaigus, & Szamado, 2003;Martin et al., 2005;Poulin et al., 2007) (see Appendix A for study details). Some studies suggest, however, that those who engage in risk-behaviours in prison may be performing them in a riskier fashion (Allwright et al., 2000;Calzavara et al., 1997;Poulin et al., 2007;Rotily et al., 2001). For example, in a Republic of Ireland prison sample of men and women who inject drugs, 46% shared needles in the month prior to prison while 71% shared needles inside prison (Allwright et al., 2000).

Unfortunately, most studies suggesting riskier behaviour in prison share a common design limitation: the time periods being compared outside and inside prison have not been standardized. Furthermore, none of these studies have specifically examined whether the observed riskier behaviour in prison is a continuation of community behaviour or practiced primarily in prison.

To address these and other deficiencies in the literature, in 2007 the Correctional Service of Canada (CSC) conducted the National Inmate Infectious Diseases and Risk Behaviours Survey (NIIDRBS), a self-administered paper questionnaire completed by a large sample of Canadian federal inmates. The NIIDRBS captured information on drug-related and sexual behaviours during the last six months in the community prior to the current incarceration and during the last six months in prison prior to completion of the questionnaire. To optimize recall accuracy, the community questions were only asked of inmates admitted within the past three years. Thus, the survey allowed for a comparison of risk-behaviours in the community and prison for Canadian federal inmates admitted within the past three years.

This report presents information on the prevalence and frequency of drug-related and sexual behaviours in the community and prison. Further, it examines two particularly risky behaviours, needle-sharing and unprotected sex, in greater detail to determine if they are continued from the community into prison or practiced primarily in prison. Information about how risk-behaviours change between the community and prison can inform CSC’s health policy and programming decisions.

Canadian federal inmate population characteristics were comparable across data sources indicating the whole sample was representative of the population (see Appendix C). Based on the NIIDRBS, the majority of inmates were English speaking (78%, 95% CI: 77, 79), non-Aboriginal people (79%, 95% CI: 77, 80), born in Canada (89%, 95% CI: 88, 91), who had a high school diploma or greater at the time of the survey (54%, 95% CI: 52, 56), and were not in committed relationships (69%, 95% CI: 68, 71). Gender differences existed. On average, males were older (38 vs. 34 years, F(1, 3192) = 106.64, p <0.05), had served a longer duration of their current sentence (4.8 vs. 2.2 years, F(1, 2975) = 274.15, p <0.05), and were less likely to be Aboriginal (21% vs. 36%, χ²(1, n = 3,234) = 94.37, p <0.05) compared to women.

When comparing inmates with and without community data, significant differences existed for sociodemographic, incarceration, and risk-behaviour characteristics (see Table 2). Both men and women with community data were younger, less likely to have a high school diploma, and more likely to have ever used non-injection drugs compared to inmates without community data. Among the men, those with community data were also more likely to be in married or common-law relationships (34% vs. 26%, χ²(1, 2826) = 13.73, p <0.05), more likely to be Aboriginal (22% vs. 18%, χ²(1, 2794) = 4.99, p <0.05), more likely to reside in medium security (62% vs. 57%, χ²(3, 2876) = 11.62, p <0.05), less likely to have ever had sex with male partners (11% vs. 18%, χ²(1, 2721) = 18.52, p <0.05), and less likely to have had any sex recently in prison (14% vs. 20%, χ²(1, 2768) = 11.52, p <0.05) compared to those without community data. Finally, among the women, those with community data were also less likely to be Aboriginal (33% vs. 42%, χ²(1, 329) = 4.48, p <0.05), more likely to have ever engaged in sex-trade work (43% vs. 27%, χ²(1, 324) = 13.51, p <0.05), more likely to have recently used drugs in prison (36% vs. 25%, χ²(1, 328) = 5.70, p <0.05), and less likely to have had recent unprotected sex with a regular partner in prison (18% vs. 25%, χ²(1, 321) = 3.87, p <0.05) compared to those without community data.

Differences in the characteristics of inmates by recency of admission were expected. Inmates who have served 3 years or less of their current sentence will be more reflective of the offender population received by CSC. This population will include offenders serving short to long sentences for offences ranging from the relatively minor to first degree murder. Conversely, the population which has served more than three years will be disproportionately comprised of inmates having committed more serious offences for which they are serving longer sentences.

Since information regarding offence severity and sentence length was not captured by the NIIDRBS, it is not possible to determine if changes in risk-behaviours vary by offence severity or sentence length. Nonetheless, limiting the study population to inmates admitted within the past three years ensured the results reflected the experiences of a more representative offender population as they move from the community to prison.

The overall prevalence of non-injection drug use declined in prison compared to the community for both men (33% vs. 57%, M_CS = -23%, t (1369) = 16.53, p <0.05) and women (27% vs. 60%, M_CS = -32%, t(224) = 16.37, p <0.05) (see Table 3). The proportion who reported using at least once per week was also lower in prison compared to the community for both men (10% vs. 47%, M_CS = -35%, t(1325) = 25.00, p <0.05) and women (4% vs. 52%, M_CS = -46%, t(214) = 24.86, p <0.05). Although the top three most frequently used drugs (cannabis, cocaine, and opiates) were consistent across gender and environment, their relative ranking was not. Most notably, the proportion who reported cocaine as one of their most frequently used drugs declined substantially in prison compared to the community for both men (3% vs. 34%, M_CS = -31%, t(1259) = -21.62, p <0.05) and women (6% vs. 46%, M_CS = -38%, t(198) = -18.72, p <0.05). The decline in opiate use, however, was less substantial for both men (7% vs. 9%, M_CS = -2%, t(1259) = -1.51, p >0.05) and women (7% vs. 9%, M_CS = -4%, t(198) = -3.61, p <0.05).

The overall prevalence of injecting drugs declined in prison compared to the community for both men (16% vs. 22%, M_CS = -6%, t (1400) = 5.2, p <0.05) and women (15% vs. 29%, M_CS= -15%, t(240) = 8.48, p <0.05) (see Table 4). Similarly, the proportion injecting at least once per week and binge-injecting significantly declined in prison compared to the community. Although the two most frequently injected drugs (cocaine and opiates) were consistent across gender and environment, their relative ranking was not. Most notably, the proportion reporting cocaine as one of their most frequently injected drugs declined in prison compared to the community for both men (3% vs. 15%, M_CS = -13%, t(1262) = -11.58, p <0.05) and women.

The change in injection equipment sharing practices across environments mirrored the decline in injection drug use among women but not among men (see Table 5). Specifically, the proportion of women passing or receiving a needle or works, or sharing a needle or works with an infected or potentially infected person consistently decreased in prison compared to the community. As an example, the proportion of women who injected with someone else’s used needle was three times greater in the community compared to prison (15% vs. 5%, M_CS = -10%, t(230) = -7.68, p <0.05). Conversely, men did not show consistent declines in their sharing practices in prison compared to the community. For instance, the proportion of men who injected with someone else’s used needle was about the same in the community and prison (8% vs. 7%, M_CS = 0%, t(1365) = 0.37, p >0.05).

The drug-injecting risk-profiles of both men and women indicated that those inmates who recently injected in prison did not necessarily inject during their last six months in the community (see Table 6). Approximately 7% (95% CI: 6, 8) of inmates reported recently injecting drugs in prison but not during their last months in the community. This means that close to half of inmates [7% / (7% + 9%) = 44%] who recently injected in prison did not inject during their last months in the community. Conversely, about 13% (95% CI: 12, 15) of men and 20% (95% CI: 18, 23) of women reported they had not recently injected in prison despite injecting during their last months in the community.

Inmates who reported injecting during the last six months in the community and prison were explored in more detail with respect to their tendency to use a needle after someone else had used it (see Table 7). Approximately 32% (95% CI: 23, 40) of these inmates reported this behaviour in both the community and prison. A similar proportion (33%, 95% CI: 24, 42), however, reported this behaviour recently in prison but not during their last six months in the community. Thus, among inmates who reported injecting in both the community and prison, approximately 50% [33%/(33% + 32%)] of the sharing in prison appeared to be specific to the prison environment.

The proportion of inmates reporting any sex (oral, vaginal, or anal) substantially declined in prison compared to the community for men (14% vs. 83%, M_CS = -70%, t(1354) = -55.61, p <0.05) and women (30% vs. 84%, M_CS = -54%, t(231) = -29.08, p <0.05) (see Table 8). Similarly, the proportion reporting specific sexual behaviours declined in prison compared to the community except for sex with a partner of the same sex. The proportion of men reporting sex with males did not significantly differ across environments (4% vs. 4%, M_CS = -1%, t(1058) = -1.24, p >0.05) while the proportion of women reporting sex with females increased in prison compared to the community (26% vs. 22%, M_CS = +5%, t(197) = 3.12, p <0.05).

The majority of men (65%, 95% CI: 62, 68) and women (56%, 95% CI: 52, 60) did not have unprotected sex with a regular partner recently in prison despite engaging in the behaviour during their last six months in the community (see Table 9). Small proportions of men (0.4%, 95% CI: 0, 1) and women (4%, 95% CI: 2, 5) reported engaging in the behaviour recently in prison, but not in their last months in the community. Rather, the bulk of men and women who recently had unprotected sex with a regular partner in prison also engaged in the behaviour during their last months in the community (5% and 14%, respectively).

The majority of inmates (66%, 95% CI: 64, 69) did not have unprotected sex with a casual partner during either of the community or prison six-month time periods (see Table 10). In addition, substantial proportions of men (32%, 95% CI: 29, 35) and women (24%, 95% CI: 21, 27) did not recently engage in the behaviour in prison but did during their last months in the community. Approximately 7% (95% CI: 5, 9) of women, however, reported unprotected sex with a casual partner recently in prison, but not during their last months in the community. This means that 70% [7% / (7% + 3%)] of women who recently reported unprotected sex with a casual partner in prison did not engage in the behaviour during their last months in the community.

Consistent with previously published research, the prevalence and frequency of non-injection and injection drug use declined in prison compared to the community (see Tables 3 and 4). According to a study involving drug using male inmates in England, the main reasons reported for decreased drug use in prison were relative lack of availability (61%), desire to discontinue drug use (14%), inability to afford drugs (13%), and concerns about punishment (6%) (Bullock, 2003).

Inmates who did inject during the past six months in prison were not necessarily continuing a recent community behaviour (see Table 6). More specifically, approximately 7% of inmates reported recently injecting drugs in prison but not during their last months in the community. This group accounts for about 44% of inmates who recently injected in prison.

In the transition from the community to prison, women demonstrated a decline in needle-sharing behaviours that was proportional to their decline in injection drug use. Among men, however, needle-sharing behaviours did not significantly decline in prison compared to the community. Specifically, although the proportion of men injecting drugs declined from 22% in the community to 16% in prison (see Table 4), the proportions who passed a needle to someone else after using it, used someone else’s needle after they used it, and shared a needle with someone who was infected or possibly infected did not decline in prison compared to the community (see Table 5). This indicates that the proportion of male injectors who share injection equipment is greater in prison than in the community.

An elevated rate of injection equipment sharing among men who inject drugs in prison compared to the community has been previously documented. In a study involving Quebec provincial prison inmates, 63% of men ever injecting in prison shared needles compared to 53% of men ever injecting in the community;for women the estimates were 50% and 56%, respectively (Poulin et al., 2007). In a predominantly male prison population of ever injectors in the Republic of Ireland, approximately 46% reported sharing needles in the month prior to imprisonment compared to 71% in prison (Allwright et al., 2000). Finally, among European male inmates who injected during their last four weeks in the community, 46% injected with a used needle compared to 50% to 76% of ever prison injectors (Rotily et al., 2001). Although these studies suggest elevated rates of sharing among men who inject drugs in prison compared to the community, the findings are weakened by an inconsistent time frame across environments. Because the NIIDRBS standardized the time frame, it provides more definitive evidence of an increased rate of sharing among male inmates who inject drugs in prison compared to the community.

The sharing of injection equipment in prison is not entirely due to the riskiest injectors continuing their risky practices as they move from the community to prison. In fact, among inmates who injected in both the community and prison, 33% used a needle previously used by someone else during the past six months in prison but not during the last six months in the community (see Table 7). This suggests that needle-sharing in prison may reflect the reduced availability of needles. Further research is necessary, however, to validate and explain the gender differences observed.

The most frequently used drugs differed across environments (see Tables 3 and 4). Specifically, the proportion of inmates reporting cocaine as one of their most frequently used non-injection or injection drugs dramatically declined in prison compared to the community. Because declines in cannabis and opiate use in prison were smaller, they became the most frequently used drugs in prison. Similarly, Bullock (2003) and Calzavara et al. (1997, 2003) found there was a greater tendency to use depressants (opiates, cannabis, and tranquilizers) rather than stimulants in prison. The most frequently cited reasons for using depressants were relaxation and relief of boredom (Bullock, 2003;Calzavara et al., 1997). Bullock (2003) hypothesized that the use of depressants are more suited to the prison environment than stimulants because the heightened mental awareness associated with stimulants may be exacerbated by the physical confinement of imprisonment resulting in increased paranoia, anxiety, and related mental stresses. Further, the potential for stimulants to induce insomnia is also likely to be a deterrent. According to Calzavara et al. (2003), possible explanations for opiates being the most commonly injected drug in prison include: the nature of addiction to opiates;a preference for the high from opiates, a sedative and pain-killer with an effect that lasts hours, rather than cocaine, a stimulant with an effect that lasts minutes;and, that opiates may be more accessible in correctional facilities.

With respect to sexual behaviour, the proportion of inmates reporting any sex and specific sexual behaviours significantly declined in prison compared to the community except for sex with a partner of the same sex (see Table 8). The proportion of men reporting sex with other males remained stable at about 4% across environments while the proportion of women reporting sex with females significantly increased in prison compared to the community (26% vs. 22%). These findings are consistent with previous research examining the sexual behaviours of a small sample (n = 39) of Canadian federal inmates during their last 12 months in the community and past 12 months in prison (Calzavara et al., 1997). This study found that the proportion reporting sexual activity with a partner of the same sex increased in prison compared to the community for both men (15% vs. 10%) and women (37% vs. 21%).

In regards to unprotected sex with a regular partner, small proportions of men and women reported recently engaging in the behaviour in prison but not during their last months in the community. Rather, the bulk of men and women who reported this behaviour recently in prison had actually engaged in the behaviour during their last months in the community (5% and 14%, respectively) (see Table 9).

The pattern for unprotected sex with casual partners was similar to that for regular partners for men but not for women. Only 3% of women reported engaging in unprotected sex with a casual partner in both the community and prison time periods. A greater proportion (7%) reported engaging in the behaviour recently in prison but not during their last six months in the community (see Table 10). This indicates that for women, unprotected sex with a casual partner is not necessarily the continuation of a recent community behaviour.

Although encouraging declines in the prevalence and frequency of risk-behaviours are observed in federal penitentiaries, some men and women are at risk for blood-borne and sexually transmitted infections because of injection drug-use and unprotected sex while in prison. The occurrence of risk-behaviours in federal penitentiaries reinforces the importance of presently available health promotion, treatment, and harm-reduction programs. Specifically, CSC provides health education classes;voluntary testing and treatment for infectious diseases;vaccines for hepatitis A and B;substance abuse treatment programs that are tailored to an inmate’s level of addiction, gender and ethnicity;dedicated living arrangements in some institutions to assist inmates in achieving a drug-free life style;opiate substitution therapy for opiate addicted inmates;bleach to disinfect injecting equipment;and, condoms, dental dams, and lubricant for safer sex.

The major limitations associated with the NIIDRBS, such as measurement error and social desirability bias, are typical of cross-sectional, self-report surveys that attempt to capture information about sensitive or illicit activities over time. In particular, if inmates underreported their risky behaviours while in prison, the study findings would overstate the decline in risk-behaviours as offenders move from the community to prison.

Additional limitations included lack of standardization of the duration of incarceration at time of survey completion and not exploring why behaviours change. Although all inmates were admitted within the past three years, there was still some variability in the amounts of time they had served prior to survey completion. It is conceivable that inmates’ behaviours during their first six months of incarceration may be different than their behaviours during subsequent six month periods. Consequently, estimates of prison behaviours presented in this report represent an average for the past six months among inmates admitted within the past 3 years.

To address identified limitations, future research should be longitudinal in nature, surveying inmates at several standardized points in time throughout incarceration and community reintegration, and should inquire as to why behaviours change. Such information is useful in identifying important modifiable factors which can inform CSC’s health policy and programming decisions.

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Appendix B: Sexual and Drug-Related Behaviours Captured by the NIIDRBS