Globally, the health and well-being of young men who enter prison are often among the poorest in any given country [1,2]. Moreover, men involved in the criminal justice system have some of the poorest sexual health with especially high rates of sexually transmitted infections (STIs), including HIV and viral hepatitis [3-9]. Most of these young men will have experienced circumstances of structural and political adversity and many will have been exposed to the toxic trio in relation to their risk of harm, that is, parental mental ill health, substance misuse, and domestic violence [10-13]. Due to their circumstances, lower socioeconomic status, and lower levels of education, they may have experienced chaotic lifestyles and developed risky sexual behaviors that are grounded in a particular form of hegemonic masculinity, which exhibits patriarchal attitudes toward women, sex, and contraception [14-16]. Such behaviors may include poorer use of condoms and engaging in more frequent casual sex with partners whose sexual behaviors also place themselves and others at increased risk of STI and HIV, etc, (eg, commercial sex workers and intravenous drug users) both during incarceration as well as before and after. In many ways, the prison population is reflective of marginalized disadvantaged men more broadly, but incarceration may further compound these young men’s marginalization, future economic prospects, as well as their potential to form safe and secure relationships [5,17]. Importantly, sexual health issues greatly affect not only economically and socially marginalized young men’s lives but also that of their partners and communities [15,18-21]. The public health issues in prison are one part of the risk and the public health issue once they leave is another [2,5,22]. Hence, to address sex-related and other communicable diseases effectively, prisoners are identified in national and international sexual health strategies and guidelines as a key population in greater need of targeted sexual health promotion, education, and services [2,23-30].

However, the challenge is how to engage and communicate about sexual health with marginalized incarcerated young men in a way that is informative and effective, while not reifying hegemonic representations of masculinity that underpin “ high risk-low concern behaviors, and in a way that respects, protects, and fulfills their human rights [18,19,29,31]. Equally important is the representation of partners who for the most part will be external to prison. To be meaningful, sexual health promotion must address partnering-up scenarios relevant to the young men’s lived experience both within and beyond prison walls. Men’s sexual behaviors and practices do not occur in a vacuum but intersect with the gender and power, emotions, wants, needs, and rights of another person. Therefore, there is also a need for a more gender-relational approach [21] to sexual health promotion that seeks to empower marginalized young men to engage better with their partners to look after each other’s sexual health together.

According to recent reviews [32-36], engaging men and boys in developing sexual health and well-being interventions is crucial to enable positive change for all. Tailored interventions that empower them by using male-friendly language, speaking to men’s potential, and ensuring young men’s active participation are effective [33,34,36-38]. The use of videos, dramas, and digital media has also been shown to be more successful for men than some cognitive behavioral change models [32,34,35,38-40]. In addition, providing men with opportunities to critique stereotypical gender ideologies and explore the sexual rights of women may encourage partner and peer support and communication, which are enablers to positive sexual health [28,29,37,40]. In relation to the prison environment, the creation of a nurturing and safe space within the prison setting is crucial for encouraging the relationship building between the facilitators and the young men; it is also critically crucial for the relationship building between the facilitators and the prison management [41]. Some research suggests that men in prison might have greater opportunities to engage with health services and in activities and therapies to improve their well-being [2,5,12,42]. The potential for them to regress in prison and develop poorer health behaviors, arguably greater access to drugs, is also a concern [43].

This paper describes the development of a pioneering Web-based sexual health promotion intervention made for and with young men in prisons from inception to production, alongside the development of a partnership approach to sexual health care between the primary care providers (prison nurses) and the young men they serve. We begin by describing the human rights-based (RB) approach employed, which resulted in a Web-based animated-style sexual health promotion intervention entitled Dick loves Doot (1.42 min). An RB approach was chosen as our preferred way of working with young incarcerated men, as in this approach, they are viewed as rights-holders, and mechanisms can be put in place to create an environment in which their voices can be heard, to enable them to participate in developing services that are relevant for them, as opposed to duty-bearers providing support or services on an assumed needs basis and the young men typically having no say in what action is taken.

Mechanisms for assisting rights-holders to claim their rights include the following:

Drawing from this RB axiom, outlined in Figure 1, the young men have the right to take part in educational activities to enhance their rehabilitation and their reintegration back into society. On the basis of the principles of inclusion, empowerment, capacity building, and accountability, the RB approach ensures that concepts such as respect, voice, and equality converge with participation rights [56-59]. In this way, the young men are viewed as experts on their situation and are invited to participate as consultants on the project to offer guidance and advice. The young men are identified as the rights-holders, whose rights to appropriate health and education may have been violated. The duty-bearers (agents of state—state employees) currently involved in the young men’s lives are (1) the prison nurses, who are obligated by law to uphold the young men’s rights by providing relevant sexual health information and treatment and (2) the prison staff, who are obligated to provide access to appropriate health and education for these young men.

We discussed our RB approach with the nursing and prison management staff who agreed to become involved in the project, and we also discussed that the young men had the right, the skills, aspirations, and expertise required to be included in the project also as consultants. This was important as for a participatory process to be successful and the end product to be relevant, we needed the right people around the table and all collaborators to share a mutual understanding of the expertise each brought to the team [60]. However, some ways of working may create distance with affected populations, which can impede the building of relationships on the basis of mutual respect [60,61]. Reflecting on the imbalances of power between the young men and prison officers, it was agreed that the prison officers, in this case, would be excluded from the working group. However, every effort was made to convey information about the study to keep them informed and invested, and their support was critical in allowing the young men to participate and providing the team with access, space, and technology to engage with the young men during our participatory meetings.

Consequently, the young men and the prison nurses were deemed the two significant parties to bring together in a collaborative partnership to create a useable solution. We sought to build their capacity around developing a mutual understanding of the determinants that cause poor sexual health outcomes and a lack of individual agency and autonomy for these young men, in the context of broader social structures [62,63]. In the collaborative partnership, key health messages that the young men need to know are shared by the health professionals and the young men share information on their experience of the issues and the reality of their lives. Both parties collaborate to decide how best to share positive sexual health messages with their peers in a way they will hear, listen to, and act upon. The coproduction approach to knowledge realizes the human rights of the young men by empowering them to share their relevant expertise, alongside duty-bearers, who are also empowered to fulfill their obligations to provide appropriate health-related education and information [61].

The products of this type of coproduction can lead to the creation of tailored and targeted interventions that are relevant and meaningful to the young men’s lives. This empowering approach can increase knowledge and awareness of gendered norms that intersect with intergenerational poverty and lack of social and economic opportunity for the young men. Developing health promotion messages together in this way can also increase both the nurses’ and young men’s sense of efficacy and control and it can create a greater sense of community and social support and thus ensure that the nurses protect, fulfill, respect, and deliver the young men’s rights to appropriate sexual health and education, which may lead to positive behavior change around sexual health communication and services, for both the health care professionals and their patients [62,63]. This paper focuses on the development of the intervention and the importance of the participatory intervention design with a preliminary evaluation of the young men’s participatory experience. Please see Figure 2 for an overview of the RB process.

Hydebank Wood College (HBW) is one of 3 prison sites in Northern Ireland, United Kingdom. The college accommodates young men between the ages of 18 and 21 years and all female prisoners who are separately housed, 172 prisoners in total as of May 24, 2018. HBW college has a focus on education, learning, and employment, and it was the first young offenders’ institution in the United Kingdom to transition to secure school status (April 2015), which has required a major rethink about the role of punishment and the remit of prisons in young people’s lives. Notable changes have included the introduction of universal vocational training and employability skills and a new educational curriculum provided in-house, placed firmly at the heart of rehabilitation. Importantly, the inclusion of health behaviors, particularly relationships and sexuality education (RSE), is now being recognized as a critical element of the rehabilitation process within this prison context too [64]. The health promotion intervention is developed with the men’s prison section only. However, the development of the clinical sexual health service within the prison is made available to both the women and men.

Ethical approval was awarded by the Office for Research Ethics Committees Northern Ireland (reference: 17/NI/0082) and Governance permissions and security clearance from the Northern Ireland Prison Service and South Eastern Health and Social Care Trust. Verbal approval was given by the voiceover actors to use their image as part of the study.

There were 2 stages to the study, Stage 1 involved upskilling the prison nurses, and Stage 2 involved upskilling the young men by coproducing the sexual health promotion animation. The project ran over 1 year from January 2017 to December 2017.

In conversations during the workshops, the 6 young men in the group claimed they had gained a better understanding of the impact of their behaviors, and all self-referred to the nurses to have their first sexual health checkup. Having reviewed the final storyboard, they were excited for the launch of the animation, Dick loves Doot, which was launched at HBW on March 15, 2018. It is hosted on the Queen’s University Belfast, School of Nursing and Midwifery, YouTube channel [65]. (Please contact the authors if you are having trouble accessing the animation). It has been agreed to play this on television screens throughout all 3 Northern Ireland prisons, and we are also exploring useful contexts to use this with other young men via the university and with community health promotion colleagues. This promotion tool will also be included in the sexual health module of a broader program of work we are developing in the prison—a Relationships and Future Fatherhood intervention for young incarcerated men.

A focus group was arranged at the end of the project to explore issues around the experience of participation and the final product. Unfortunately, because of the transient nature of the prison population, only 2 members of the young men’s group were available to attend. Overall, they said they enjoyed their participation in the project, found it interesting, and fun:

They also regarded it as useful learning and made speaking up and asking questions about their bodies and their health easier:

The young men agreed that their voices had been listened to and that the intervention reflected their real-life issues and concerns, while also portraying a clear message that would be useful to other young men.

They also felt grateful to, and valued by, the prison authorities for providing the opportunity for them to participate in something that was relevant to them and other young men:

In relation to accessing the sexual health services that had been set up inside the prison, the young men had made full use of this, which is reflected in the number of tests being carried out in the clinics, and were encouraging others to do so as well:

The nurses’ evaluations of the 3-day training course, which prepared them to better understand and engage with their patients on sexual health matters, described how much they enjoyed and greatly benefitted from this knowledge; they highly recommended the course to their colleagues who work in other prison sites:

Importantly, the nurses described developing a completely fresh attitude on becoming upskilled to assess asymptomatic sexual health concerns, particularly in the manner in which they approached sexual health communication with their male patients. This also included, for the first time, delivering health promotion in a group setting with their patients within prison sites, and this experience exceeded their expectations. The following quote illustrates a common reaction from all the nurses on completing the course:

This study adds to the scant literature on conducting sexual health promotion research with hard-to-reach young men within prison and describes an empowering RB method on how to engage them in developing health interventions that are relevant to their particular needs, that is, made by them, for them. These young men tend to have multiple and complex problems and often lack the personal assets and opportunities on which to draw on to build healthy lifestyles [1,10,12]. This example describes how health care professionals can come together with a target audience to share information and communicate health messages in a way that is relevant and engaging [29].

This RB process used is designed to empower both the service-user (young men in prison) to take responsibility to improve their own health and agents of state (duty-bearers—nurses) to fulfill their obligations under human rights legislation to provide appropriate and accessible health and education [12]. Such an inclusive approach can reduce the young men’s risk behaviors upon release and assist with their reintegration back into the community [66]. Working within the prison environment and employing an RB approach provided an opportunity to work with a group of marginalized young men and support and advance the concept of healthy prisons [20,28,41], that is, to reinforce the idea that prison health is public health and that prisoners should benefit from rehabilitation strategies that empower them to be released back into the community in better health than they entered, for the good of themselves, their families, and communities [2,23,25,26,28].

This study also adds to our understanding of how health promotion can be cocreated in the prison context. According to our methodology, the responsibility is on agents of state to provide health and education information that is accurate, accessible, and useable. Our approach to developing fun and engaging sexual health promotion materials within prisons can help normalize sexual health among a high-risk population in an accurate yet accessible and meaningful way. Consequently, incarceration can provide an opportunity for health researchers to reach this high-need and typically hard-to-reach group. Although this situation can enable access to participants, an effort was still required on their part to continue to attend and engage at each meeting. Factors that fed into their engagement centered on the focus on their rights, and the amount of decision-making power and autonomy they were given to input into the content, design, and mode of communication of the Web-based intervention, which also added legitimacy to the end product [57,61]. The young men found the meetings fun and informative, which impelled them to attend. They learned lots, felt valued and listened to, and seeing their ideas reflected in the products created in them a sense of ownership and pride over the intervention.

Focusing on the needs of society’s most marginalized young men by helping them to maintain good sexual health is a powerful way of addressing health inequalities overall [15,16]. Situating their sexual health in the wider context of human rights is a strong argument for the inclusion of their voices, which have largely been missing in the sexual and reproductive health research and education agenda to date. The findings support the contention that a human RB approach to coproduction, particularly for marginalized groups, can add insider value to interventions that can empower incarcerated young men to make positive healthier decisions about their lives and their partner’s lives, and thus support their rehabilitation. The experience at Hydebank has shown that strong collaborations among academics, health and social care, prison management, and the young men themselves can be forged to support learning and skills development and enhance the overall rehabilitation experience of young men in prisons.

The support we received for our RB participatory work from the Northern Ireland Prison Service and the Department of Justice in Northern Ireland has been crucial to allow us to provide the space for prisoner voice to be heard, which was key to the success of this project. As such, Northern Ireland is leading the way in promoting innovative approaches to developing education and health behaviors as part of the rehabilitation of young men. This project demonstrates what can be achieved when agencies work together around a common goal of reforming and rehabilitating these young men to encourage good health behaviors within, and on leaving, their incarceration. Future steps of this research will be evaluation of the intervention.

Participants in this study were restricted to 1 prison site in Northern Ireland (United Kingdom), which could mean that the issues and priorities they presented may not be representative or generalizable. However, the literature suggests that their experiences are consistent with young men residing in other marginalized areas and contexts. The evaluation of the animation and participatory process discussed during the 1 focus group at the end of the project included only 2 participants who shared similar positive views. However, the broader generalization we advance in this study is the approach and not the product.

The RB participatory approach to prison health advanced in this study can provide invaluable insider knowledge and strategies by which to target the health inequities that affect young incarcerated men. It provides a means to (1) understand the impact of structural determinants on health and health inequalities, (2) create inclusive opportunities for developing bespoke targeted interventions, and (3) galvanize collaborative teams to work together to disrupt the structures and processes that lead to, and encourage, health inequities. To reduce future risk, effective treatment, coupled with coproduced interventions that transmit relevant health messages in a way that is meaningful, is key to success.