Balancing expectation and reality: intervention fidelity, trauma, and women with histories of incarceration

New research in BMC Women's Health highlights the importance of fidelity on health interventions and the difficulties in achieving this in prison settings and with vulnerable groups such as women who have history of incarceration. Here, the authors of the paper share some of these difficulties, the specific skills required of health educators in these settings and their involvement in the SHE project.

The research concept of fidelity  is a critical component for any health intervention holding itself to a high standard. In terms of the scientific method, this means we want to ensure that when we deliver any kind of intervention, that we replicate it as close to the same way each time, with each group, with minimal variation. Yet, this assumption of fidelity also means an assumption of a certain kind of audience that receives interventions – one that is predictable. An audience without trauma.

With the Sexual Health Empowerment (SHE) project, we worked directly with close to 200 women with histories of incarceration to deliver a cervical health promotion intervention.  The SHE team has had years of experience working with women both in and outside of jails. Critical for our work is the constant awareness of the trauma the women we serve bring into the room. From sexual and domestic violence to drug addiction and homelessness, women with histories of incarceration are statistically more likely than most populations to have histories of extensive trauma.

One study suggests as many as 86 percent of women in prison have been sexually assaulted. Three quarters of women who have been incarcerated have also been abused by an intimate partner. This doesn’t even take into account the trauma and abuse that can occur once women actually enter incarceration.

For this reason, health educators delivering interventions with women in the criminal justice system must be able to address the unique dynamics of any group and the individuals in these groups, responding in real time to any needs that arise during intervention delivery.

For example, our staff were all trained in emotional grounding techniques that help women move from a state of heightened high emotion to one of calmness.  We employed these techniques regularly during intervention delivery, when conversations got heated, when participants got upset, or when we all needed comfort.  We were prepared to answer any manner of questions and we were lucky to have clinicians (nursing students and faculty) present during the intervention sessions to answer questions about complicated, real-time health needs. In SHE, we worked from a manualized intervention, yet had to be flexible in order to address the women’s needs and questions.

The health educators delivering the intervention always had to keep the sessions moving, … building rapport, and delivering intervention content.

We did this in the highly structured and simultaneously chaotic environment of a county jail. In our article on intervention fidelity in jails, we highlight both the nature of women’s questions and the jail itself as challenges to fidelity.

We were obligated to work with the rules of the jail facility as a condition of being granted access. Such access necessitated flexibility on our parts, working with correctional officers present in the room during private discussions about health, or stopping the intervention if events like lockdowns at the jail precluded our ability to continue. We also had to work around the loss of participants to events within the criminal justice process such as court hearings and disciplinary procedures, or in some cases real-time medical care.

On some days there was a constant movement of people in and out of the session, as we described in our fidelity fieldnotes:

 “At different points during the session, a male guard, a woman who looked like an administrator type, and two nurses entered. Our women were also up and moving around throughout the session—heating coffee in the microwave, getting water—all while our facilitator was talking. One woman disappeared during a bathroom break. We don’t know where she went or why she didn’t return. Two other women went to the desk and visited with the nurses in the middle of the session: one of them had her blood pressure checked. The other seemed to be having something on her foot examined.”

The health educators delivering the intervention always had to keep the sessions moving, while sensing the feelings of participants and others in the room, protecting confidentiality, building rapport, and delivering intervention content.

Jails, like many community settings, are imperfect environments for fidelity in intervention delivery.  Yet the women who move through jails have extremely high health needs, and therefore bear the burden of significant physical and mental health disparities, making intervention delivery in these settings and for these populations highly necessary.  But delivery of interventions must be considered in the context of everyday realities and therefore realistic expectations for fidelity must be set.

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