SPECIAL FEATURES: METHODS

Challenges and Strategies forResearch in PrisonsZoltan L. Apa, B.A.,1 RuoYu Bai, B.S., B.A., M.P.H.,1 Dhritiman V. Mukherejee, M.S., Ph.D.,1,2,4

Carolyn T. A. Herzig, M.S.,1,2 Carl Koenigsmann, M.D.,3 Franklin D. Lowy, M.D.,4 andElaine L. Larson, R.N., Ph.D., F.A.A.N., C.I.C.1,21School of Nursing, Columbia University, New York, New York; 2Department of Epidemiology, Mailman School of Public Health, ColumbiaUniversity, New York, New York; 3New York State Department of Corrections, Albany, New York; and 4Division of Infectious Diseases,Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York

Correspondence to:

Zoltan Ludovic Apa, School of Nursing, Columbia University, 617 W 168 St. Room: 331, New York, NY 10032. E-mail: za2149@columbia.edu

ABSTRACT In this article, we discuss some of the challenges encountered while conducting researchin two maximum security prisons and approaches we found helpful to facilitate the research processthrough the development of collaborative relationships, the establishment of prison contacts, and theimplementation of rigorous research methods. As a result of our experiences, we have been successfulat maintaining a high rate of inmate participation (>80%) and a well-functioning multidisciplinary team.The approaches described may be useful to other investigators planning to conduct research ina challenging setting such as prisons.

Key words: prison collaboration, prison network, recruitment methods.

Over 9.8 million people are incarcerated throughoutthe world, with the United States having the highestincarceration rate at 756 per 100,000 of the nationalpopulation (Walmsley, 2009). Although a decline inthe growth rate of the overall prison population hasbeen seen in recent years, the number of adultsunder correctional supervision increased about four-fold between 1980 and 2009, from 1,840,400 to7,225,800 (Walmsley, 2009). Inmates are a vulnera-ble population at high risk for violence, substanceabuse, mental illness, and infectious diseases. As aresult, correctional facilities are an important site forpublic health research. There is a growing body of lit-erature regarding prison inmates, and a few publica-tions have provided guidance regarding thechallenges and strategies for public health researchconducted within these facilities (Byrne, 2005; Fox,Zambrana & Lane, 2011; Innes & Everett, 2008; Pat-enaude, 2004; Quina et al., 2007; Wakai, Shelton,Trestman & Kesten, 2009). This article adds to theexisting literature by addressing research challengesand approaches using our study (Risk Factors for

Spread of Staphylococcus aureus in Prisons,5R01AI82536) in two New York State maximumsecurity prisons as a framework. Aims of this articleare to propose methods to (a) develop a collaborativeresearch relationship between an academic institu-tion and a department of corrections, (b) establishprison contacts, and (c) maintain rigorous researchmethods in the context of sustaining security andconfidentiality (Table 1). Although the collaborativeand methodological procedures described belowwere tailored to our research goals, they can serve asa general guideline for investigators seeking to con-duct research within the maximum security prisonenvironment.

Develop a Collaborative ResearchRelationship

Know the systemBy nature of its mission, The Department ofCorrections must maintain a controlled, secure

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setting (Wakai et al., 2009). As part of the NationalInstitute of Justice’s appraisal action aimed atdeveloping more effective decision tools, however,efforts are being made to develop cooperative rela-tionships with research institutions (Welsh & Zajac,2004). Hence, correctional facilities administratorshave become more receptive to collaborations withuniversities and other research-based organizationsin recent years (Welsh & Zajac, 2004). To facilitatesuccessful research within correctional facilities,researchers need to acquire a basic knowledge ofthe administrative system within the Department ofCorrections, and the various stakeholders and deci-sion makers, to identify appropriate research part-ners and to get a realistic sense of what types ofresearch methods and approaches are possible andacceptable in the context of a setting in whichsafety and security are primary (Fox et al., 2011;Greifinger, 2007; Vanderhoff, Jeglic & Donovick,2011; Welsh & Zajac, 2004).

The involvement of key correctional officials,such as the Chief Medical Officer and the correc-tional facility Superintendent and Facility HealthServices Director, is crucial for conducting public

health research. As the Department of Correctionsis a top down/hierarchical institution, all approvalsmust be granted first by the head of the appropriatedepartments. To properly set the stage for success-ful research, it is extremely important to identify asenior prison administrator as co-investigator. Theclose collaboration and support of the Chief Medi-cal Officer of the New York State Department ofCorrections as a collaborator on our study wasessential to its successful implementation.

Obtain appropriate permissionsThis study’s initial challenge was to obtain the nec-essary approvals from both the Columbia UniversityInstitutional Review Board (IRB) and the CentralOffice of the NYS Department of Corrections. Forstudies involving inmates, IRBs are required tohave a prisoner advocate who reviews the protocol.In addition, certification from the Office of HumanResearch Protections (OHRP) Division of Policy andAssurance is necessary (http://www.hhs.gov/ohrp/policy/populations/prisoncertlet.html). Because proto-cols must be reviewed and approved by both theDepartment of Corrections and the IRB, there may

TABLE 1. Essential Components and Approaches for Conducting Research with a Department of Corrections

Essential Component Steps to Be Taken Suggested Approaches

Develop a collaborativeresearch relationship

Know the system Review Department of Corrections rules and regulations;Establish early contact with decision makers at the stateand prison levels

Obtain appropriatepermissions

Obtain approval from Institutional Review Board and fromDepartment of Corrections;Obtain OHRP Certification Letter

Emphasize mutual goals Identify a senior corrections administrator ascollaborator/co-investigator;Discuss research interests and aims with facilitysuperintendents for feedback and modification;Clarify benefits to each facility

Establish the prisoncontacts

Work with administrativepersonnel, health care staff,security personnel, andinmates

Identify key personnel;Establish and maintain a professional relationship;Emphasize their importance in carrying out the study;Keep them fully informed throughout the study

Maintain rigorousresearch methods

Accommodate to variations inprison cultures

Learn how each facility is set up; Know and follow therules;Identify strategies to cope with differences betweenfacilities;Manage time to accommodate different recruitment andinterview requirements

Data collection, maintaininmate’s privacy

Maintain security and confidentiality during interviewsand data collection;Obtain Certificate of Confidentiality

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be considerable negotiations to request changesand clarifications. It may be difficult to determinewhether it is more efficient to submit for approvalsimultaneously or serially as IRB approval andapproval from the Department of Corrections aregenerally contingent upon each other. The appro-priate staff at the Department of Corrections can behelpful in providing guidance throughout thereview process, but researchers should not underes-timate the amount of time required to review pro-tocols that involve vulnerable populations such asprisoners (Fox et al., 2011).

Emphasize mutual goalsEven with approval from top administrators,however, difficulties in the day-to-day operationalaspects of the project may be encountered at loweradministrative levels and among staff in direct con-tact with inmates. Hence, other correctional staffmust also be well informed and involved in ongoingplanning and discussions (Appelbaum, 2008; Grei-finger, 2007). To facilitate the development ofmutually agreed-upon goals, meetings to discussresearch interests and aims with facility superinten-dents, for feedback and modifications, are essential.Clarifying benefits of the research with the superin-tendents can deepen their involvement asstakeholders throughout the project (Trulsona,Marquartb & Mullingsb, 2004). Properly alignednegotiations best succeed at the intersection ofcommon interests.

We used a variety of mechanisms to enhancemutual goals. For example, we formed an AdvisoryCouncil, which included prison leaders who met ona regular basis. In addition, these prisons also hadInmate Liaison Committees (ILCs) with whom wemeet to keep inmates updated and to obtain theirfeedback. Furthermore, we identified a “point per-son” within each prison to facilitate communica-tion. Depending on the nature of the study, theposition of this person may vary; in our case, the“point person” was a member of the health carestaff who advised us as we navigated the system.We also met with correctional officers (COs) todescribe the study and respond to any concerns,published an article in the state prison newsletter,and planned co-authorship opportunities withprison staff. Early in the project, at the requestfrom one of the prison superintendents, we pro-duced a video describing the study to inmates and

correctional staff in which inmates were offered theopportunity to volunteer as “actors” in the video.

Establish the Prison Contacts

Prisons are unique, restricted, and, at times, unpre-dictable environments that operate as secure set-tings where each group has a well-defined, discreterole. To successfully carry out our prison research,we built collegial relationships within the prisonsystem to establish a positive rapport with four dis-tinct groups of personnel: administrative staff,health care staff, security staff, and inmates.

Administrative staffOnce appropriate approvals and clearances areobtained, a researcher’s interactions with theadministrative staff are likely to be minimal.However, the researcher must maintain a positiverelationship by keeping administrators wellinformed of the status of the project. Administra-tors need to hear directly from the researcher ofprogress, as well as any problems encountered, sothat they are fully involved and understand anyuntoward or unexpected events that occur.

Health care staffHealth care staff, including physicians, nurses, andphysician assistants, provide needed health careservices for the inmate population. Studies thatinvestigate different elements of inmates’ healthrequire that researchers establish professional rela-tionships with these key medical providers, whocan help to facilitate the study.

Security staffThe prison security staff comprised largely COswhose role is to ensure security among the prisonpopulation and to help coordinate inmate activities.Thus, researchers will frequently interact with COs.In terms of security logistics, COs are empoweredto delay or suspend inmates’ activities. Muchdepends on level of security-minimum, medium,and maximum. All visitors to the prison, includingresearchers, must be screened to enter. The steps inthis process include having an appointment(i.e., being expected), carrying proper identification,and electronic or manual scanning. Depending onthe prison security level, approved visitors might bestamped before entering the facility. For additional

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security in some prisons, visitors may be requiredto carry personal alarm pagers within the prisongrounds. Electronic devices, such as computers andcell phones, are not allowed within the maximumsecurity prisons; thus, all data collection must be inpaper form in such security level prisons.

The research team is usually escorted by a COto the data collection site(s). Developing a positiverelationship with COs is important not only toensure that research steps are completed effectivelybut also for the researchers’ safety. In addition, apositive relationship can help reduce concerns orsuspicions that COs may have about the nature ofthe research being conducted and whether they willbe expected to contribute or participate in any way.Responding to issues raised by COs and workingwith them to allay any concerns will prevent delaysand greatly facilitate navigating the prison system.COs may be reluctant to express concerns, so it isessential that the research team members are sensi-tive and attuned to potential issues that may arise.During the course of our study, we found that effi-cient movement within the prison was greatly influ-enced by the security personnel; thus, beingcourteous and respectful to COs encouraged themto help us surmount encountered obstacles. Thisincluded making sure that inmates were present forinterviews and obtaining as well as equipping theinterview rooms.

InmatesThe inmates are the largest group in prisonsettings. In our study, meeting with the ILCs todiscuss our study aims and solicit their suggestionsfor ways to approach recruitment and data collec-tion was the most effective means to communicatewith the inmates. Through working with such rep-resentative bodies, relationships can be developedbased on openness and mutual respect to maximizeunderstanding and support for the study.

Maintain Rigorous ResearchMethods

Accommodate variations in prison culturesAlthough the overall goals of prisons may be simi-lar, each prison has established its own culture andsystem. We recruited inmates from a women’s anda men’s maximum security prison in NYS, and the

major challenge was learning their respective sys-tems and finding the best ways to accommodateand plan for variations in access to inmates anddata sources. For example, like most correctionalfacilities, both sites operated around a scheduledinmate routine. In one facility, the research teamwas allowed to interact with inmates only in themedical unit and only during their free time. In theother facility, we were allowed to directly recruitinmates from different sites during their assignedprograms. Similarly, we were allowed to walk unes-corted within one facility but were escorted by buswithin the other facility, which required consider-ably more time. Such differences require carefulplanning and time management to account formandated variations in prison systems and theirindividual requirements.

There were logistical advantages and disadvan-tages within each system. Although having to waitfor a bus at one site prolonged our time, this pro-cess allowed the researchers to approach inmatesdirectly and talk with them about the study. In con-trast, the other facility’s system called out inmatesto the medical unit which limited the number ofinterviews/participants due to issues such asinmates not receiving the call, deciding not to showup, or simply refusing to participate because theymay not have been accurately informed about thestudy. Emphasizing the importance and overallbenefit of this research to COs who delegated thecalls minimized these issues.

In the beginning of our recruitment process atboth facilities, we learned that explaining the studyto a group of inmates, instead of individually, couldhave adverse effects. If a single inmate made a neg-ative comment about the study, it was then ampli-fied by the group so that other inmates were lesslikely to express interest in participating. In addi-tion, we distributed approximately 50 flyersdescribing the study to recruit inmates, and onlyreceived a single response informing us that aninmate had moved. Subsequently, we found moreappropriate ways to invite study participation suchas getting support from the ILC to inform inmatesof our study and talking to each inmate separatelyto avoid miscommunication.

Data collectionAt the inception and before each phase of ourstudy, we performed extensive pilot testing to

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assure that data collection methods were feasible,minimally disruptive, and acceptable to staff andinmates. We vetted the questionnaire with inmatesat the outset and throughout the study. In addition,we have conducted meetings, formal presentations,and discussions with prison personnel and inmatesto obtain feedback on a regular basis throughoutthe project. These activities have greatly facilitatedthe smooth functioning of the project.

A wide variety of data sources are available,each with advantages and disadvantages. Thus,researchers have increasingly combined a mix ofdata sources to achieve their research goals(Greifinger, 2007). We reviewed medical files andcomputerized records, collected nares/oropharynxswab samples for microbiologic examination, andconducted interviews with inmates. Any study thatuses self-reported information must address thepossibility of under-reporting or over-reporting dueto issues such as inaccurate or untruthful responsesor misinterpretation of the questions (Fox et al.,2011; Harrison, 1997; Singer, 1978; Stephensonet al., 2006). For example, inmates may be reluc-tant to respond accurately to questions related topersonal information such as drug use or involve-ment in physical fights for fear of being reported toprison authorities. Hence, whenever possible wecompared data available from medical records withinformation obtained from inmate interviews. Ingeneral, agreement between information providedby the inmates and information abstracted fromrecords was high for information available from bothsources, but information from records was some-times unavailable or difficult to locate. In addition,much of the data needed for our study was onlyavailable by self-report. Overall, the inmatesappeared very open and willing to provide informa-tion. In fact, we found a number of duplicate inter-views from inmates who enrolled more than once,making it possible to assess whether their responseswere similar at different time points. In otherinstances, inmates may have no interest in partici-pating or may refuse certain procedures. In ourstudy, for example, some inmates expressed con-cerns that the nasal and oropharyngeal samplesbeing obtained were actually contaminating them.

Maintain inmate’s privacyIt is vital to carefully consider privacy and inmates’rights, as they may feel coerced to participate or

fear that their information will be shared withothers. To alleviate such concerns, we worked toestablish a positive rapport with the inmate popula-tion to earn their trust and respect. We requestedthat the interviews be conducted in private, withoutthe presence of COs or other inmates, to reassurethem that our research team was not affiliated withthe correctional system and that no individualinformation from the research study would bereported to the Department of Corrections or athird party (Fox et al., 2011; Noaks, Wincup &ebrary, 2004; O’Brien & Bates, 2003; Patenaude,2004; Quina et al., 2007). To address these con-cerns, we provided clear and accurate informationand obtained a Certificate of Confidentiality fromthe National Institutes of Health (http://grants.nih.gov/grants/policy/coc/) to help protect inmate pri-vacy. Using these strategies, we were able to attaina recruitment rate of 90.6% in the male and 81.6%in the female maximum security prisons, a ratehigher than has been previously reported (Foxet al., 2011; Moser et al., 2004; Peterson, Braiker,Polich & Rand Corporation, 1981; Struckman-John-son, Struckman-Johnson, Rucker, Bumby & Don-aldson, 1996).The purpose of this article was to describe some ofthe challenges and solutions derived from thedevelopment and implementation of our researchstudy in two maximum security prisons. Althoughnot all prisons have the same issues and policies,many of the challenges we faced are likely to reso-nate with others. Researchers must not underesti-mate the amount of time and preparation requiredfor approval from the IRB and Department of Cor-rections as well as access into the correctional facil-ities. Once granted access, it is crucial forresearchers to establish and maintain a positiverelationship with the COs and inmates, to under-stand rules and security issues to navigate swiftlythrough the prison system for data collection, andto consider all limitations and obstacles throughoutthe process. Such strategies have proven successfulin establishing and maintaining a high rate of studyparticipation and high-quality data collection in thischallenging research setting.

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