The health and health care of US prisoners: results of a nationwide survey

The Effect of Health Insurance on Health Care Utilization in the Justice-Involved Population: United States, 2014-2016

Objectives. To examine the impact of health insurance coverage on utilization of outpatient, hospital, and emergency department care among justice-involved individuals in the United States.Methods. We performed repeated cross-sectional analyses with data from the National Survey of Drug Use and Health. The study population included 6086 adults with justice involvement within the past year. We used logistic regression to examine the odds of health care utilization based on either a dichotomous or categorical measure of health insurance coverage. We used negative binomial regression to examine the number of times a specific type of care was utilized with both a dichotomous measure of health insurance coverage and a categorical measure of type of health insurance.Results. Health insurance was associated with increased utilization of outpatient, inpatient, and emergency department care.Conclusions. Health insurance coverage was associated with increased utilization of outpatient, inpatient, and emergency department health care among justice-involved individuals. Therefore, expanding access to health insurance in this population has the potential to increase care utilization of all types and decrease barriers to medical services.

Barriers to optimal antiretroviral therapy adherence among HIV-infected formerly incarcerated individuals in New York City

In the United States (U.S.), the HIV infection rate is disproportionately high among incarcerated individuals. HIV-infected individuals typically receive antiretroviral therapy (ART) to suppress HIV and reduce the threat of transmission. Although HIV-infected individuals are generally ART-adherent while incarcerated, the public health benefits experienced during incarceration are often lost as HIV-infected individuals struggle to maintain optimal adherence post-incarceration. While the importance of maintaining adherence in the post-incarceration period has been acknowledged, research on barriers to ART adherence during this period is limited. To better understand post-release barriers to ART adherence, we conducted in-depth interviews with 20 HIV-infected formerly incarcerated individuals in New York City; we also followed up with 18 (90%) participants after three months to explore whether their adherence challenges changed over time. Viral load testing results from their most recent physician visit were also recorded at each interview. Interviews were transcribed using transcription software and reviewed for accuracy by a researcher. Thematic coding based on discussion guide prompts were then used to identify commonly mentioned barriers to adherence. The results identified four overarching themes that affected study participants’ efforts to adhere to their ART regimen: medication burden, forgetfulness, mental health and emotional difficulties, and perceived conflict between substance use and medication adherence. These barriers were the most commonly cited and largely persisted at three-month follow-up. The results suggest that interventions addressing these challenges are essential for promoting ART adherence among HIV-infected formerly incarcerated individuals. Effective interventions may include mobile-based text messaging reminders and those that facilitate patient-provider communication. Additionally, interventions or programs that integrate substance use and mental health treatment into HIV-related care, along with other types of behavioral health support, may also be beneficial for this population. Such interventions should be a routine part of discharge planning and support for incarcerated individuals returning to the community.

Measuring Exposure to Incarceration Using the Electronic Health Record

BACKGROUND

Electronic health records (EHRs) are a rich source of health information; however social determinants of health, including incarceration, and how they impact health and health care disparities can be hard to extract.

OBJECTIVE

The main objective of this study was to compare sensitivity and specificity of patient self-report with various methods of identifying incarceration exposure using the EHR.

RESEARCH DESIGN

Validation study using multiple data sources and types.

SUBJECTS

Participants of the Veterans Aging Cohort Study (VACS), a national observational cohort based on data from the Veterans Health Administration (VHA) EHR that includes all human immunodeficiency virus-infected patients in care (47,805) and uninfected patients (99,060) matched on region, age, race/ethnicity, and sex.

MEASURES AND DATA SOURCES

Self-reported incarceration history compared with: (1) linked VHA EHR data to administrative data from a state Department of Correction (DOC), (2) linked VHA EHR data to administrative data on incarceration from Centers for Medicare and Medicaid Services (CMS), (3) VHA EHR-specific identifier codes indicative of receipt of VHA incarceration reentry services, and (4) natural language processing (NLP) in unstructured text in VHA EHR.

RESULTS

Linking the EHR to DOC data: sensitivity 2.5%, specificity 100%; linking the EHR to CMS data: sensitivity 7.9%, specificity 99.3%; VHA EHR-specific identifier for receipt of reentry services: sensitivity 7.3%, specificity 98.9%; and NLP, sensitivity 63.5%, specificity 95.9%.

CONCLUSIONS

NLP tools hold promise as a feasible and valid method to identify individuals with exposure to incarceration in EHR. Future work should expand this approach using a larger body of documents and refinement of the methods, which may further improve operating characteristics of this method.

Emergency medical care of incarcerated patients: Opportunities for improvement and cost savings

In the United States (US), the lifetime incidence of incarceration is 6.6%, exceeding that of any other nation. Compared to the general US population, incarcerated individuals are disproportionally affected by chronic health conditions, mental illness, and substance use disorders. Barriers to accessing medical care are common in correctional facilities. We sought to characterize the local incarcerated patient population and explore barriers to medical care in these patients. We conducted a retrospective, observational cohort study by reviewing the medical records of incarcerated patients presenting to the adult emergency department (ED) of a single academic, tertiary care facility with medical or psychiatric (med/psych) and trauma-related emergencies between January 2012 and December 2014. Data on demographics, medical complexity, trauma intentionality, and barriers to medical care were analyzed using descriptive statistics, unpaired student’s t-test or one-way analysis of variance for continuous variables, and chi-square analysis or Fisher’s exact test as appropriate. Trauma patients were younger with fewer medical comorbidities and were less likely to be admitted to the hospital than med/psych patients. 47.8% of injuries resulted from violence or were self-inflicted. Most trauma-related complaints were managed by the emergency medicine physician in the ED. While barriers to medical care were not correlated with hospital admission, 5.4% of med/psych and 2.9% of trauma patients reported barriers as a contributing factor to the ED encounter. Med/psych patients commonly reported a lack of access to medications, while trauma patients reported a delay in medical care. Trauma-related presentations were less medically complex than med/psych-related complaints. Medical management of most injuries required no hospital resources outside of the ED, indicating a potential role for outpatient management of trauma-related complaints. Additional opportunities for health care improvement and cost savings include the implementation of programs that target violence, prevent injuries, and promote the continuity of medical care while incarcerated.

Diseases and access to treatment by the Peruvian prison population: an analysis according to gender

Objective

In Peru, prisons are spaces with overcrowding, deteriorated infrastructure, poor sanitary conditions and difficult access to medical treatment. The objective of this study is to estimate the burden of disease and access to treatment for different morbidities in the Peruvian inmate population.

Methods

An analysis of secondary data of the First National Penitentiary Census (PCNP) 2016 in Peru was carried out. The absolute frequencies and percentages of each self-reported health condition, the presence of a diagnosis of a disease before entering the prison system and access to treatment were obtained.

Results

74,130 inmates were included in the analysis. The most common diseases in prisons are depression (9.6%), anxiety (8.6%), chronic lung disease (8.4%) and arterial hypertension (6.9%). All diseases included, with the exception of hepatitis, have a diagnostic before the incarceration of less than 60%. Access to medical treatment was higher in women than in men and in general, mental health illnesses had low access to medical treatment.

Conclusions

Chronic and infectious diseases are frequent in those deprived of liberty, with mental health problems being more prevalent in women. In general, access to treatment is low, especially in men and for mental health illnesses. This situation reflects the need to develop intervention programs that promote health and increase the universality of health care in those deprived of liberty.

Health service provision for disease control among prisoners: a conceptual note

Purpose

The aim of present study was to integrate vital noncommunicable diseases (coronary artery disease, hypertension, diabetes mellitus and mental health disorders) into Prison-Based Active Health Services Provision (PAHSP).

Design/methodology/approach

On Jan 1, 2018, there were 230,000 prisoners in Iran. Timely and systematic detection and diagnosis of chronic health conditions among this population are imperative. The collaboration between healthcare providers in prison and members of the multidisciplinary team of the healthcare community outside prison initiated an active health service provision approach for HIV and tuberculosis (TB). Guidelines for the control of HIV and TB in prison were piloted, and the finalized version was named “Prison-based Active Health Services Provision” (PAHSP), which has been scaled up in 16 of 260 Iranian prisons.

Finding

The PAHSP approach emphasizes the importance of early identification of key symptoms and risk factors. This approach provides an opportunity for improved prevention and treatment, enabling prisoners identified at risk or those who have been diagnosed with a target disease to be followed up and receive the appropriate health care.

Originality/value

Initiatives such as screening for chronic health conditions coupled with treatment will reduce the burden of chronic illness among prisoners and the broader community, thereby saving on healthcare costs and lives.

A Pilot Study of Cancer 101 for Incarcerated Male Smokers

Incarcerated men in the United States, an understudied population, have not been the focus of cancer prevention research. This pilot study explored the impact of Cancer 101 for imprisoned male smokers to increase cancer knowledge and promote cancer prevention activities in the prison population. Cancer 101 was pilot tested for adoption with representatives from the target audience in three prison facilities located in the northeastern region of the United States, and based on their feedback, modifications were implemented. Pretest and posttest surveys were used to assess knowledge of attitudes regarding the benefits of cancer prevention activities at baseline and immediately after completing Cancer 101. Furthermore, a paired t test procedure was used to determine whether cancer knowledge improved after participating in the Cancer 101 program. A total of 161 men completed all of the modules, participated in pre/post assessments, and qualitatively described their behavioral intentions to participate in activities that could reduce cancer risk. The mean cancer knowledge scores differed before and after completing Cancer 101, t(163) = -14.67, p < .001. Regarding age, the older the respondent, the higher their cancer knowledge score, r = .29, p < .001. This study showed improvements in cancer knowledge scores and behavioral intentions to participate in activities to reduce cancer. Cancer 101 provides opportunities for inmates to increase cancer knowledge, as well as promote action for cancer control during incarceration.

A longitudinal description of incompetent to stand trial admissions to a state hospital

OBJECTIVE

Evidence is clear that the nation is experiencing an increasing number of incompetent to stand trial (IST) admissions to state hospitals. As a result, defendants in need of treatment can wait in jail for weeks for admission for restoration. This study was conducted to better understand this growing population and to inform hospital administration about the characteristics of IST admissions.

METHODS

The study was conducted at the Department of State Hospitals (DSH) facility in Napa (DSH-Napa), a 1200-bed primarily forensic inpatient psychiatric facility located in northern California. The records of patients found IST and admitted to DSH-Napa for restoration of competence between the dates of 1/1/2009 and 12/31/2016 were eligible for inclusion in the study.

RESULTS

There were a total of 3158 unduplicated IST admissions available during the specified time period. Our data indicate that the number of admissions with more than 15 prior arrests increased significantly, from 17.7% in 2009 to 46.4% in 2016. In contrast, the percent of patients reporting prior inpatient psychiatric hospitalization evidenced a consistent decrease over time from over 76% in 2009 to less than 50% in 2016.

CONCLUSION

Our data add to the body of literature on the potential causes of the nationwide increase in competency referrals. The literature is clear that jails and prisons are now the primary provider of the nation's mental health care. Our data suggest that another system has assumed this role: state hospitals and other providers charged with restoring individuals to competence.

A survey of national trends in psychiatric patients found incompetent to stand trial: reasons for the reinstitutionalization of people with serious mental illness in the United States

OBJECTIVE

Recent information indicates that the number of forensic patients in state hospitals has been increasing, largely driven by an increase in patients referred to state hospitals as incompetent to stand trial (IST). This survey was intended to broaden the understanding of IST population trends on a national level.

METHODS

The authors developed a 30-question survey to gather specific information on IST commitments in each state and the District of Columbia. The survey was administered to all 50 states and the District of Columbia via email. Specific individuals identified as primary administrators responsible for the care and evaluation of IST admissions in each state were contacted.

RESULTS

A total of 50 out of the 51 jurisdictions contacted completed the survey. Fully 82% of states indicated that referrals for competency evaluation were increasing. Additionally, 78% of respondents thought referrals for competency restoration were increasing. When asked to rank factors that led to an increase, the highest ranked response was inadequate general mental health services in the community. Inadequate crisis services were the second ranked reason. Inadequate number of inpatient psychiatric beds in the community was the third highest, with inadequate assertive community treatment services ranking fourth.

CONCLUSIONS

Understanding the national trend and causes behind the recent surge in referrals for IST admissions will benefit states searching for ways to remedy this crisis. Our survey indicates most states are facing this issue, and that it is largely related to insufficient services in the community.

Does in-prison physical and mental health impact recidivism?

Incarceration is definitively linked to poor health, and upon release from prison, many individuals experience difficulty in maintaining good health. Given the complexity of the reentry process, one's health status, both in and out of prison, likely influences additional aspects of reentry, such as abstaining from crime or adhering to parole terms. The purpose of this study is to determine whether in-prison physical and mental health, as well as changes to an individual's health upon release from prison, are related to the likelihood of recidivating. We employ the Serious and Violent Reentry Initiative (SVORI) data, a multi-state sample of formerly incarcerated males who are followed from prison to release into the community and interviewed about a number of post-prison release issues, including health. We use hierarchical logistic and multinomial regressions, where survey waves are nested within people, to assess if in-prison physical and mental health and post-release changes to health are associated with recidivism in two ways: general re-incarceration and re-incarceration due to either a technical violation of parole or a new conviction. With right-censoring due to recidivism or “failure,” our final sample size is 2180 person-periods (i.e., waves) nested within 871 respondents. We find that better physical health, both in-prison and changes in health post-release, is related to a higher likelihood of recidivating. Better mental health, both in-prison and changes to mental health post-release, is related to a decrease in the likelihood of recidivating. Individuals with poor mental health in-prison who make significant improvements after release see the largest reduction in their odds of recidivating. Finally, the combination of better mental health in-prison and increases in mental health post-release is associated with reductions in the likelihood of re-offending for both technical violations and new convictions. In sum, in-prison health continues to influence individuals after prison and is associated with their odds of recidivating, thus contributing to the churning of individuals through the prison system.

•

We examine the relationship between in-prison and change in post-release health and recidivism.

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Better physical health in-prison and post-release is related to higher recidivism likelihood.

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Better mental health in-prison and post-release is related to lower recidivism likelihood.

•

This mental health benefit applies to both technical violations and new convictions.

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A person's health in prison may be related to prison system churning.

Gender Differences in Health Care Needs and Service Attainment Among Violent Offenders

Research has determined that female inmates experience distinctive challenges both during and after incarceration. There has been little empirical inquiry, however, into the gendered nature of medical health care needs and treatment postrelease. The purpose of this study, therefore, is to examine the differences between male and female inmates with regard to chronic illness diagnoses and health care receipt during reentry. This was done using a subsample of 763 inmates who participated in the Serious and Violent Offender Reentry Initiative multisite impact evaluation who specifically mentioned a need for medical health care treatment. Results of multivariate analyses showed gendered differences for both chronic illness diagnoses and medical treatment receipt postrelease, thus highlighting potential implications for correctional health care policy and resource distribution.

"It's like heaven over there": medicine as discipline and the production of the carceral body

BACKGROUND

Correctional systems in several U.S. states have entered into partnerships with Academic Medical Centers (AMCs) to provide healthcare for people who are incarcerated. This project was initiated to better understand medical trainee perspectives on training and providing healthcare services to prison populations at one AMC specializing in the care of incarcerated patients: The University of Texas Medical Branch at Galveston (UTMB). We set out to characterize the attitudes and perceptions of medical trainees from the start of their training until the final year of Internal Medicine residency. Our goal was to analyze medical trainee perspectives on caring for incarcerated patients and to determine what specialized education and training is needed, if any, for the provision of ethical and appropriate healthcare to incarcerated patients.

RESULTS

We found that medical trainees grapple with being beneficiaries of a state and institutional power structure that exploits the neglected health of incarcerated patients for the benefit of medical education and research. The benefits include the training opportunities afforded by the advanced pathologies suffered by persons who are incarcerated, an institutional culture that generally allowed students more freedom to practice their skills on incarcerated patients as compared to free-world patients, and an easy compliance of incarcerated patients likely conditioned by their neglect. Most trainees failed to recognize the extreme power differential between provider and patient that facilitates such freedom.

CONCLUSIONS

Using a critical prison studies/Foucauldian theoretical framework, we identified how the provision/withholding of healthcare to and from persons who are incarcerated plays a major role in disciplining incarcerated bodies into becoming compliant medical patients and research subjects, complacent with and even grateful for delayed care, delivered sometimes below the standard best practices. Specialized vulnerable-population training is sorely needed for both medical trainees and attending physicians in order to not further contribute to this exploitation of incarcerated patients.

Health Behaviors and Outcomes Associated With Personal and Family History of Criminal Justice System Involvement, New York City, 2017

Objectives. To quantify the association between personal and family history of criminal justice system (CJS) involvement (PHJI and FHJI, respectively), health outcomes, and health-related behaviors.Methods. We examined 2017 New York City Community Health Survey data (n = 10 005) with multivariable logistic regression. We defined PHJI as ever incarcerated or under probation or parole. FHJI was CJS involvement of spouse or partner, child, sibling, or parent.Results. We found that 8.9% reported only FHJI, 5.4% only PHJI, and 2.9% both FHJI and PHJI (mean age = 45.4 years). Compared with no CJS involvement, individuals with only FHJI were more likely to report fair or poor health, hypertension, diabetes, obesity, depression, heavy drinking, and binge drinking. Respondents with only PHJI reported more fair or poor health, asthma, depression, heavy drinking, and binge drinking. Those with both FHJI and PHJI were more likely to report asthma, depression, heavy drinking, and binge drinking.Conclusions. New York City adults with personal or family CJS involvement, or both, were more likely to report adverse health outcomes and behaviors.Public Health Implications. Measuring CJS involvement in public health monitoring systems can help to identify important health needs, guiding the provision of health care and resource allocation.

Global Prison Health Care Governance and Health Equity: A Critical Lack of Evidence

The large and growing population of people who experience incarceration makes prison health an essential component of public health and a critical setting for reducing health inequities. People who experience incarceration have a high burden of physical and mental health care needs and have poor health outcomes. Addressing these health disparities requires effective governance and accountability for prison health care services, including delivery of quality care in custody and effective integration with community health services.Despite the importance of prison health care governance, little is known about how prison health services are structured and funded or the methods and processes by which they are held accountable. A number of national and subnational jurisdictions have moved prison health care services under their ministry of health, in alignment with recommendations by the World Health Organization and the United Nations Office on Drugs and Crime. However, there is a critical lack of evidence on current governance models and an urgent need for evaluation and research, particularly in low- and middle-income countries.Here we discuss why understanding and implementing effective prison health governance models is a critical component of addressing health inequities at the global level.

Employment and Health Among Recently Incarcerated Men Before and After the Affordable Care Act (2009-2017)

Objectives. To explore whether and how the Affordable Care Act (ACA) affects the relationship between employment and health insurance coverage, health care utilization, and health outcomes among recently incarcerated men aged 18 to 64 years in the United States.Methods. With data from the National Survey on Drug Use and Health (NSDUH), we used a difference-in-differences approach to compare changes in outcomes by employment status among recently incarcerated men.Results. Uninsurance declined significantly among recently incarcerated men after ACA implementation. As the uninsured rate of unemployed men fell below that of their employed counterparts, the ACA helped to fully eliminate the effect of employment on insurance coverage among recently incarcerated men. The employment gap in diabetes widened after ACA implementation as unemployed men saw significant increases in diagnosed diabetes. Employment disparities in hospital visits, diagnosed hypertension, and reported mental illness also declined in the period following ACA implementation, but these changes were not statistically significant.Conclusions. These findings highlight how the ACA, by providing a new route to health care, reduces the confounding forces associated with employment that are linked to both incarceration and health.

Injustice in the Justice System: Reforming Inequities for True “Justice for All”

True justice is equitable. Counseling psychologists, through their skills, knowledge, and values, can be a powerful force in reforming a system that oppresses marginalized groups to one that is just. In this paper, we focus on three major aspects of the justice system: laws and the courts, law enforcement, and detention and corrections, and we further describe injustice in these three areas. We then use critical race theory and counseling psychology perspectives to develop a framework to provide counseling psychologists with practical strategies to transform inequities. Such strategies include advocating to change unjust laws, filling the research gap for effective and humane practices, developing evidence-based programs, and providing leadership and training.

Impact of a Pharmacist-Led Diabetes Clinic in a Correctional Setting

Incarcerated patients often have a high disease burden and poor access to care in the community. In an effort to ensure glycemic control and appropriate initiation of statin therapy for cardiovascular (CV) risk reduction, a pilot program of pharmacist-led diabetes clinic (PLDC) was implemented in a large inner-city jail. A pre-post study was conducted as a quality improvement initiative. Inclusion criteria were inmate-patients (IPs) diagnosed with type 2 diabetes mellitus, treated with oral antidiabetic medications, managed by PLDC, and with at least 2 glycosylated hemoglobin A_1cs (HbA_1c). The primary outcome was the change in HbA_1c after PLDC. The secondary outcome was the frequency of statin therapy. A total of 240 IPs met the inclusion criteria. Mean HbA_1c was 8.2% at baseline and 7.6% at the last follow-up encounter, a change of -0.7% (95% confidence interval [CI]: -0.41% to -0.93%). The most dramatic change was seen in the group with the highest initial HbA_1c (HbA_1c ≥ 10%), from a mean baseline HbA_1c of 11.6% to 8.5%, a change of -3.1% (95% CI: -2.5% to -3.7%). IPs with an initial HbA_1c between 7% and 9.9% showed a change in mean HbA_1c from 8.4% to 8.0%, a change of -0.4% (95% CI: -0.1% to -0.7%). Of the 240 included IPs, 141 were not on a statin at baseline. The frequency of statin use increased by 50.4% after PLDC. PLDC significantly improved glycemic control and guideline concordance for CV risk reduction. Adding PLDC to multidisciplinary care teams has the potential to improve population health outcomes for this medically complex, yet underserved patient population.

Results of the Brief Jail Mental Health Screen Across Repeated Jail Bookings

OBJECTIVE

The Brief Jail Mental Health Screen (BJMHS) is widely used at intake in county jails to identify detainees who may have serious mental illness and who should be referred for further mental health evaluation. The BJMHS may be administered multiple times across repeated jail bookings; however, the extent to which results may change over time is unclear. To that end, the authors examined the odds of screening positive on the BJMHS across repeated jail bookings.

METHODS

Data were drawn from the administrative and medical records of a large, urban county jail that used the BJMHS at jail booking. The study sample comprised BJMHS results for the 12,531 jail detainees who were booked at least twice during the 3.5-year period (N=41,965 bookings). Multilevel logistic modeling was used to examine changes over time overall and within the four decision rules (current psychiatric medication, prior hospitalization, two or more current symptoms, and referral for any other reason).

RESULTS

Results show that the odds of a positive screen overall increased with each jail booking, as did the odds of referral for any other reason. In contrast, the odds of screening positive for two or more current symptoms and prior hospitalization decreased. There was no change in the odds of screening positive for current psychiatric medication across bookings.

CONCLUSIONS

Findings show that BJMHS results changed across bookings. Further research is needed to determine whether changes reflect true changes in mental health status, issues with fidelity, the repeated nature of the screening process, or other factors.

Prevention in Prison: The Diabetes Prevention Program in a Correctional Setting

PURPOSE

The purpose of this study was to determine whether an adaptation of the Diabetes Prevention Program (DPP) could be successfully implemented in a correctional environment to promote weight loss, lower A1C, and improve other cardiometabolic outcomes.

METHODS

A quasi-experimental, staggered-start control study was conducted in a female and male federal correctional institution. Twenty-six male and 21 female incarcerated, overweight individuals with prediabetes or at high risk for developing diabetes were randomly assigned to two groups. Data were measured at 6-month intervals starting at baseline for 18 months. Group 1 participated in the 12-month Group Lifestyle Balance intervention program from baseline to 12 months. Group 2 served as a control group from baseline for 6 months and then completed the intervention program from months 6 to 18.

RESULTS

Participants were ethnically diverse and mostly >44 years of age. At baseline, members of the two study groups were not significantly different with regard to sex, race/ethnicity, age, or prediabetes status. About half of participants (51%) completed the program, with participants in group 1 significantly more likely to be completers (P <0.05). At 6 months, participants in the intervention group had significantly more weight loss on average (12 lb) than those in the control/delayed-start group (5 lb) (P <0.001). However, both groups (active intervention and control) experienced significant decreases in weight, BMI, triglycerides, and A1C levels after 6 months. In combined analysis, after the 12-month intervention, participants in both groups demonstrated significant decreases in BMI (P <0.001) and A1C (P <0.001) from baseline.

CONCLUSION

The DPP may be an effective method for reducing the impact of diabetes in the correctional environment addressed. Larger studies should be conducted to confirm these outcomes. Study findings were affected by high attrition rates, primarily due to transfers and releases from the institution.

Unmet mental health and substance use treatment needs among older homeless adults: Results from the HOPE HOME Study

AIMS

To examine the prevalence of and factors associated with unmet need for mental health and substance use treatment in older homeless adults.

METHODS

Among 350 homeless adults aged ≥50, we examined prevalence of mental health and substance use problems and treatment. Using logistic regression, we examined factors associated with unmet treatment need.

RESULTS

Among those with a mental health problem, being aged ≥65 was associated with an increased odds, while having a regular healthcare provider and case manager were associated with a decreased odds of having unmet need for mental health treatment. A first homelessness episode at age ≥50 was associated with increased, while spending time in jail/prison or having a case manager was associated with decreased odds of unmet needs for substance use treatment.

CONCLUSION

Older homeless adults have a high prevalence of unmet behavioral health treatment need. There is a need for targeted services for this population.

Are Medicaid Coverage Gaps Associated with Higher Health Care Resource Utilization and Costs in Patients with Schizophrenia?

The objective was to assess the association of Medicaid coverage gaps with health care resource utilization (HRU) and costs of patients with schizophrenia. Patients with schizophrenia were identified from the Medicaid database. The beginning of the first eligible gap was defined as the index date. Per-patient per-month (PPPM) HRU and costs before versus after a gap were assessed, and the association between gap duration and PPPM HRU and costs was examined up to 12 months post index. Together with 95% confidence intervals, HRU differences were reported in rate ratios (RRs), and cost differences were reported in 2016 US dollars. A subgroup of males with substance use disorder (SUD; risk factors for incarceration) also was analyzed. Total PPPM health care costs increased significantly by $711.04 following a coverage gap (P < 0.001). Gaps of 180-365 days were associated with a significant increase in inpatient visits (RR = 1.27; P < 0.001) relative to gaps of <90 days. Gaps of 90-179 days were associated with significantly more PPPM inpatient visits (RR = 1.14; P = 0.024) relative to a gap of <90 days. Inpatient costs were particularly increased for gaps of 180-365 days versus those of <90 days (cost difference = $101.81 PPPM; P = 0.0008). Similar results were found in male patients with SUD, in whom HRU and cost differences appeared larger. In patients with schizophrenia, longer Medicaid coverage gaps were associated with increases in inpatient admissions, emergency room visits, and inpatient costs, particularly among patients with risk factors for incarceration. These results support policies that aim to facilitate Medicaid reinstatement for patients with schizophrenia.

Attachment to primary care and team-based primary care: Retrospective cohort study of people who experienced imprisonment in Ontario

OBJECTIVE

To examine attachment to primary care and team-based primary care in the community for people who experienced imprisonment in Ontario, and to compare these attachment data with data for the general population.

DESIGN

Population-based retrospective cohort study.

SETTING

Ontario.

PARTICIPANTS

All persons released from provincial prison in Ontario to the community in 2010 who were linked with provincial health administrative data, and an age- and sex-matched general population group.

MAIN OUTCOME MEASURES

Primary care attachment and team-based primary care attachment in the 2 years before admission to provincial prison (baseline) and in the 2 years after release in 2010 (follow-up) for the prison release group, and for the corresponding periods for the general population group.

RESULTS

People in the prison release group (n = 48 861) were less likely to be attached to primary care compared with the age- and sex-matched general population group (n = 195 444), at 58.9% versus 84.1% at baseline (P < .001) and 63.0% versus 84.4% during follow-up (P < .001), respectively. The difference in attachment to team-based primary care was small in magnitude but statistically significant, at 14.4% versus 16.1% at baseline (P < .001) and 19.9% versus 21.6% during follow-up (P < .001), respectively.

CONCLUSION

People who experience imprisonment have lower primary care attachment compared with the general population. Efforts should be made to understand barriers and to facilitate access to high-quality primary care for this population, including through initiatives to link people while in prison with primary care in the community.

Reproductive justice for incarcerated mothers and advocacy for their infants and young children

The United States has seen unprecedented growth in the number of incarcerated women, most of whom are mothers with minor children. Major public health concerns relate to the reproductive health of women in prisons and jails and the well-being of their infants and young children. In the current article, we use a reproductive justice framework to examine the intersection of incarceration and maternal and child health. We review (a) current research on the reproductive health of incarcerated women, (b) characteristics and experiences of pregnant incarcerated women, (c) outcomes of infants and young children with incarcerated parents, (d) implications of research findings for policy and practice, and (e) the need for increased research, public education, and advocacy. We strongly recommend that correctional policies and practices be updated to address the common misconceptions and biases as well as the unique vulnerabilities and health needs of incarcerated women and their young children.

Influence of drugs on prison suicide - A retrospective case study

The prevalence of mental disorders and comorbidity with substance abuse and personality disorders is high in prisoners. Furthermore, drug abuse in prison is a widespread problem throughout prisons around the world. In this retrospective study, we analyzed the prison deaths over six years (2012-2017). For each death, we collected data of the Berlin prison system, the prison hospital and the State Institute for Forensic and Social Medicine Berlin and the Institute of Legal Medicine and Forensic Sciences, Charité Medical University Berlin. In total, 33 prisoners died during our study period, of which 24 committed suicide. In 25% of the suicide cases, forensic toxicology reports were positive for drugs without cases of lethal intoxication. A direct influence of drug intoxication on prisoner deaths and suicide was not common in our data. Small sample size, a missing control group, and the retrospective study design limit generalizability of the results.

Perceived Social Ties and Mental Health Among Formerly Incarcerated Men in New York City

The incarcerated population has been substantially burdened by syndemic productions involving mental health illness and substance abuse problems. The present analysis describes the mental health symptoms of a nonprobability sample of 225 formerly incarcerated men and establishes the types of perceived support they received during incarceration as predictors of their psychological well-being upon release. The men were between 35 and 67 years of age; the mean age was 47.27 (SD = 6.64), and Blacks and Latinos were about equally represented. Most respondents did not finish high school, were unemployed, convicted of a nonviolent crime, and were housed in a New York state prisons. The majority were also single (never married) and had children. The findings indicate that greater social, community, and spiritual support were correlated with lower mental health scores. The strongest predictor was perceived social support. Access and use of social resources, including social support, are important factors in influencing the psychological functioning among formerly incarcerated men.

Prison primary care and non-communicable diseases: a data-linkage survey of prevalence and associated risk factors

BACKGROUND

The size and mean age of the prison population has increased rapidly in recent years. Prisoners are a vulnerable group who, compared with the general population, experience poorer health outcomes. However, there is a dearth of research quantifying the prevalence of non-communicable diseases (NCDs) among prisoner populations.

AIM

To explore both the prevalence of NCDs and their risk factors.

DESIGN & SETTING

A cross-sectional survey was undertaken that was compared with clinical records in two male prisons in the north of England.

METHOD

Self-report surveys were completed by 199 prisoners to assess sociodemographic characteristics, general health, NCD prevalence, and risk factor prevalence. Data were checked against that retrieved from prison clinical records.

RESULTS

It was found that 46% reported at least one NCD and 26% reported at least one physical health NCD. The most common self-reported NCD was 'anxiety and depression' (34%), followed by 'respiratory disease' (17%), and 'hypertension' (10%). Having a physical health NCD was independently associated with increasing age or drug dependence.The level of agreement between clinical records and self-report ranged from 'fair' for alcohol dependence (kappa 0.38; P<0.001) to 'very good' for diabetes (kappa 0.86; P<0.001).

CONCLUSION

Compared with mainstream populations and despite high prevalence of risk factors for NCDs physical illness NCDs, with the exception of respiratory disease, are less common. However, poor mental health is more common. These differences are possibly owing to the younger average age of prison populations, since prevalence of risk factors was reported as high.Secondary data analysis of clinical records is a more methodologically robust way of monitoring trends in prisoner population disease prevalence.

Prevalence and correlates of diabetes among criminal justice-involved individuals in the United States

PURPOSE

Diabetes is one of the most prevalent and fastest-growing adverse health conditions in the United States and disproportionately affects those demographic and socioeconomic groups that are also more likely to be involved with the criminal justice (CJ) system. This study examines the prevalence and correlates of diabetes among CJ-involved individuals in the United States.

METHODS

Using traditional statistical modeling and modern machine learning methods, data from the National Study on Drug Use and Health were analyzed to compare the correlates and predictive interactions of diabetes diagnosis among those respondents on probation and parole to a sample, matched by age and gender, who were not.

RESULTS

Subjects involved in the CJ system were 15% more likely (1.66% vs. 1.44%, P = .015) to report a past-year diagnosis of diabetes than a sample of noninvolved individuals matched by age and sex, although this association was not statistically significant after adjusting for demographic and behavioral confounders. Similar trends in diabetes prevalence emerged for the non-CJ and CJ groups with regard to income, depression (OR of 2.38 and 1.65 for the CJ and non-CJ groups, respectively) and attainment of college education (OR of 0.64 and 0.30 for the CJ and non-CJ groups, respectively, compared with those with less than a high school education). Results also suggested that a generally high propensity toward risk taking had a negative effect on diabetes for the non-CJ group (OR 0.78; 95% CI 0.69-0.87), yet increased the odds of diabetes (OR 1.38; 95% CI 1.02-1.85) for the CJ group.

CONCLUSIONS

Involvement in the U.S. CJ system is correlated with a higher prevalence of diabetes and differing risk factors for diabetes diagnosis. Further research is necessary, however, to unpack the precise causal pathways that underlie the associational trends in the current analysis.

Cigarette Smoke and Cancer Health Among Incarcerated Men in U.S. Northeastern Prison Facilities

Incarcerated men, an understudied population, have not been the focus of cancer prevention studies. The Cancer Risk in Incarcerated Men Study was developed to examine smoking behaviors and cancer health among 236 incarcerated men. The participants were between 19 and 86 years of age. Only 30.5% of the sample reported receiving a cancer screening test and less than 5% reported being diagnosed with cancer. In terms of the cancer screening test provided, 43.6% reported having had a prostate-specific antigen test, 19.2% a fecal occult blood test, and 11.4% a sigmoidoscopy or a colonoscopy. Age was the only significant predictor of having a cancer screening procedure (B = .10, p < .001). This study demonstrates the need to promote cancer prevention studies among incarcerated populations.

Arrest and Trait Aggression Correlates of Emergency Department Use

This study examined the associations between arrest and incarceration, trait aggression, and emergency department (ED) use. Data were collected from 525 clients who visited the Center for Behavioral Research and Services in Long Beach, CA, using the following instruments: Risk Behavior Assessment, Risk Behavior Follow-Up Assessment, the Aggression Questionnaire (AQ), the Displaced AQ, and the parole and Legal Status section of the Addiction Severity Index. The bivariate analysis suggested that ED use was significantly associated with trait aggression and trait-displaced aggression among those with a history of incarceration. In the logistic regression, weapons offenses, manslaughter/homicide, being male, and being Black were significantly associated with ED use. Identification and management of aggressive trait personality are important in improving the management of postrelease care in transition to clinical networks and community-based health care settings.

Staying Quit After Release (SQuARe) trial protocol: a randomised controlled trial of a multicomponent intervention to maintain smoking abstinence after release from smoke-free prisons in Victoria, Australia

INTRODUCTION

Smoke-free policies have been introduced in prisons internationally. However, high rates of relapse to smoking after release from prison indicate that these policies typically result in short-term smoking cessation only. These high rates of relapse, combined with a lack of investment in relapse prevention, highlight a missed opportunity to improve the health of a population who smoke tobacco at two to six times the rate of the general population. This paper describes the rationale and design of a randomised controlled trial, testing the effectiveness of a caseworker-delivered intervention promoting smoking cessation among former smokers released from smoke-free prisons in Victoria, Australia.

METHODS AND ANALYSIS

The multicomponent, brief intervention consists of behavioural counselling, provision of nicotine spray and referral to Quitline and primary care to promote use of government-subsidised smoking cessation pharmacotherapy. The intervention is embedded in routine service delivery and is administered at three time points: one prerelease and two postrelease from prison. Control group participants will receive usual care. Smoking abstinence will be assessed at 1 and 3 months postrelease, and confirmed with carbon monoxide breath testing. Linkage of participant records to survey and routinely collected administrative data will provide further information on postrelease use of health services and prescribed medication.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Corrections Victoria Research Committee, the Victorian Department of Justice Human Research Ethics Committee, the Department of Human Services External Request Evaluation Committee and the University of Melbourne Human Research Ethics Committee. Results will be submitted to major international health-focused journals. In case of success, findings will assist policymakers to implement urgently needed interventions promoting the maintenance of prison-initiated smoking abstinence after release, to reduce the health disparities experienced by this marginalised population.

TRIAL REGISTRATION NUMBER

ACTRN12618000072213; Pre-results.

A systematic scoping review of environmental health conditions in penal institutions

Adequate environmental health conditions in penal institutions are necessary to protect and promote the health of prisoners and prison workers. We conducted a scoping systematic review to: describe the environmental health conditions in penal institutions and the associated exposures and health outcomes; identify effective approaches to prevent environmental health concerns; and identify evidence gaps on environmental health in penal institution populations. PubMed, Web of Science, EBSCOhost, Scopus, and ProQuest were searched. Peer-reviewed studies that reported original data and on environmental health conditions and/or exposures in penal institutions were included. Seventy-three studies met these criteria. The most common risk factor identified was contaminated food and/or beverages prepared or handled in the institution's kitchen. Overcrowding, inadequate ventilation, and a lack of, or sharing of, soap and other hygiene products increased the risk of adverse health outcomes. Common responses included isolating infectious patients, educating prisoners and prison staff on improved sanitation and hygiene practices, improving ventilation, and disinfecting contaminated surfaces and/or water sources. Inadequate environmental health conditions in penal institutions are common, and adversely impact the health of prisoners and prison staff, yet are preventable. Few studies have been conducted in low- and middle-income countries, biasing our results. The development and implementation of national guidelines for essential environmental health in prisons, monitoring of conditions, and greater accountability of facility managers are needed to secure the health, rights, and well-being of prisoners.

A conceptual model for understanding post-release opioid-related overdose risk

Post-release opioid-related overdose mortality is the leading cause of death among people released from jails or prisons (PRJP). Informed by the proximate determinants framework, this paper presents the Post-Release Opioid-Related Overdose Risk Model. It explores the underlying, intermediate, proximate and biological determinants which contribute to risk of post-release opioid-related overdose mortality. PRJP share the underlying exposure of incarceration and the increased prevalence of several moderators (chronic pain, HIV infection, trauma, race, and suicidality) of the risk of opioid-related overdose. Intermediate determinants following release from the criminal justice system include disruption of social networks, interruptions in medical care, poverty, and stigma which exacerbate underlying, and highly prevalent, substance use and mental health disorders. Subsequent proximate determinants include interruptions in substance use treatment, including access to medications for opioid use disorder, polypharmacy, polydrug use, insufficient naloxone access, and a return to solitary opioid use. This leads to the final biological determinant of reduced respiratory tolerance and finally opioid-related overdose mortality. Mitigating the risk of opioid-related overdose mortality among PRJP will require improved coordination across criminal justice, health, and community organizations to reduce barriers to social services, ensure access to health insurance, and reduce interruptions in care continuity and reduce stigma. Healthcare services and harm reduction strategies, such as safe injection sites, should be tailored to the needs of PRJP. Expanding access to opioid agonist therapy and naloxone around the post-release period could reduce overdose deaths. Programs are also needed to divert individuals with substance use disorder away from the criminal justice system and into treatment and social services, preventing incarceration exposure.

Health needs and risky behaviours among inmates in the largest prison of eastern Nepal

PURPOSE

The purpose of this paper is to assess the health status and risky behaviours of inmates in Nepal.

DESIGN/METHODOLOGY/APPROACH

This cross-sectional study was conducted in Jhumka Regional Prison, the largest male prison in eastern Nepal from September 2014 to August 2015. Data were collected through face-to-face interviews from 434 randomly selected incarcerated participants using semi-structured questionnaires.

FINDINGS

The mean age of 434 participants was 35.7 years (SD 13.3). The majority (84 per cent) had at least one current health problem, of which the commonest were respiratory (50 per cent), skin (38 per cent) and digestive (26 per cent). Alcohol (73 per cent) and cigarettes (71 per cent) were the most commonly used substances prior to imprisonment. Approximately, 27 and 11 per cent reported illicit drug use and injectable drug use prior to incarceration, respectively. A total of 204 inmates reported having intercourse with sex workers. Of these, 49 per cent did not use a condom in their last intercourse with a sex worker.

RESEARCH LIMITATIONS/IMPLICATIONS

This paper illustrates that a wide range of physical and mental health problems exist among incarcerated people in Nepal. The study may lack generalisability, however, as it was conducted in a single male prison.

PRACTICAL IMPLICATIONS

The paper suggests a need for medical, psychiatric and substance abuse care in correctional settings to improve the health status of the prison population. It is also important to develop screening policies for blood-borne viral and other infectious diseases in the prison.

ORIGINALITY/VALUE

This is the first study of its kind drawn from prisons in Nepal.

Barriers and facilitators of maintained smoking abstinence following release from smoke-free prisons: A qualitative enquiry

BACKGROUND

The prevalence of smoking among people entering prisons is high. Despite increasing adoption of prison smoke-free policies, relapse to smoking after release from prison is nearly universal, and policy to effectively mitigate this is largely absent. Informed by a risk environment framework, we aimed to identify key barriers and facilitators to maintaining smoking abstinence among former smokers released from smoke-free prisons.

METHOD

Twenty-one people released from smoke-free prisons in Queensland, Australia, were followed up from a larger survey of 114 former prisoners. Semi-structured interviews were used to explore the perceived barriers and facilitators of maintained smoking abstinence.

FINDINGS

Identified barriers to continued abstinence included pre-release intention to resume smoking; normalisation of smoking in home or social environments, resumption of smoking as a symbolic act of freedom and resistance from and to a restrictive environment; a perception that smoking provides stress relief to their difficult lives, and the use of tobacco/smoking to cope with cravings experienced on release for illicit substances. A number of interviewees were unable to provide clear reflective reasons for relapse. For those who did manage to remain abstinent for a period of time, identified facilitators included an awareness of the health and financial benefits of smoking abstinence, the use of intrinsic motivation, distraction from nicotine cravings using alternative activities, and social support from family and peers.

DISCUSSION

Interventions promoting continued smoking abstinence among people exiting smoke-free prisons should focus on targeting the perceived individual- and environmental-level barriers to maintained smoking abstinence while simultaneously promoting perceived facilitators, so as to reduce smoking-related health and economic disparities in this marginalised population.

Beyond the Employment Dichotomy: An Examination of Recidivism and Days Remaining in the Community by Post-Release Employment Status

Criminological research has tended to consider employment in a dichotomy of employed versus unemployed. The current research examines a sample of individuals 1-year post-release to assess the extent to which four distinct employment categories (full-time, part-time, disabled, and unemployed) are associated with reincarceration and days remaining in the community. Findings indicate disabled individuals remain in the community longer and at a higher proportion compared with other employment categories. Furthermore, unique protective and risk factors are found to be associated with each employment category while some risk factors (e.g., homelessness) highlight the importance of addressing reentry barriers regardless as to employment status.

Correlates of physical, psychological, and social frailty among formerly incarcerated, homeless women

Frailty is a deficit accumulation in physical, psychological and social domains. Correlates of frailty were explored among formerly incarcerated, homeless women (N = 130, Mage = 38.9). Significant correlates of physical frailty were age, years homeless, prior violence, witnessing less violence, drug dependence, PTSD symptoms and tangible support. Significant correlates of psychological frailty were age, years homeless, witnessed violence, jail time, divorced less, drug use/dependence, prison time, methamphetamine use, and bodily pain. Significant correlates of social frailty were drug use, emotional regulation, and daily alcohol use. Reentry interventions are needed for formerly incarcerated, homeless women who experience physical, psychological and social frailty.

Prevalence and Correlates of Disability Among a Sample of Victimized Women on Probation and Parole

The purpose of this exploratory study was to establish the prevalence of disability as measured by self-reported Social Security Disability Insurance (SSDI) receipt among a sample of women on probation and parole who have experienced interpersonal victimization in childhood and/or adulthood. Women receiving SSDI were more likely to be older, White, to live alone, and to score lower on measures of social support compared to women not receiving SSDI. SSDI recipients were also more likely to report poorer health, chronic pain, and more frequent health care service utilization. High rates of adverse childhood experiences, rape, adult victimization, and an overall greater severity of post-traumatic stress disorder symptomatology were observed for women receiving SSDI. Groups had similar overall mental health profiles and diverged primarily on trauma variables. Findings support the need for trauma-informed care and highlight the possibility that some criminal justice system-involved women likely qualify for SSDI, yet are not receiving it.

The psychiatric management of prisoners on hunger strike: developing a management algorithm using the Delphi technique

PURPOSE

The assessment and management of prisoners on hunger strikes in a custodial setting is complex. There is limited clinical guidance available for psychiatrists to draw upon in such cases. The purpose of this paper is to develop a management algorithm through expert elicitation to inform the psychiatric care of prisoners on a hunger strike.

DESIGN/METHODOLOGY/APPROACH

A Delphi method was used to elicit views from Irish forensic psychiatrists, a legal expert and an expert in ethics using a structured questionnaire. Themes were extracted from the results of the questionnaire to propose a management algorithm. A consensus was reached on management considerations.

FINDINGS

Five consultant forensic psychiatrists, a legal expert and an expert on psychiatric ethics ( n=7) consented to participation, with a subsequent response rate of 71.4 per cent. Consensus was achieved on a proposed management algorithm. Assessment for mental disorder, capacity to refuse food and motivation for food refusal are seen as key psychiatric tasks. The need to work closely with the prison general practitioner and the value of multidisciplinary working and legal advice are described. Relevant aspects of law included mental health, criminal law (insanity) and capacity legislation.

ORIGINALITY/VALUE

This study outlines a management algorithm for the psychiatric assessment and management of prisoners on a hunger strike, a subject about which there is limited guidance to date. Although written from an Irish perspective, this study outlines key considerations for psychiatrists in keeping with international guidance and therefore may be generalisable to other jurisdictions.

Black/white differences in mortality among veteran and non-veteran males

U.S. military veterans are a large and racially heterogeneous population. There are reasons to expect that racial disparities in mortality among veterans are smaller than those for non-veterans. For example, blacks are favorably selected into the military, receive relatively equitable treatment within the military, and after service accrue higher socioeconomic status and receive health and other benefits after service. Using the 1997-2009 National Health Interview Survey (N = 99,063) with Linked Mortality Files through the end of 2011 (13,691 deaths), we fit Cox proportional hazard models to estimate whether racial disparities in the risk of death are smaller for veterans than for non-veterans. We find that black/white disparities in mortality are smaller for veterans than for non-veterans, and that this is explained by the elevated socioeconomic resources of black veterans relative to black non-veterans. Leveraging birth cohort differences in military periods, we document that the smaller disparities are concentrated among All-Volunteer era veterans.

Education and Health Conditions among the Currently Incarcerated and the Non-Incarcerated Populations

Previous research has found a strong link between educational attainment and health, where the highly educated live longer and healthier lives than those with lower levels of education. Because such research has relied on samples of the non-institutionalized population, previous research has not explored the association between education and specific chronic and infectious health conditions among the currently incarcerated. Analyzing the relationship between education and health conditions among the incarcerated, whom tend to be less healthy and for whom many of the intermediate mechanisms between education and health are held relatively constant in prison, may yield new insights. Using the 2002-2004 National Health Interview Study (N=74,881), the 2004 Survey of Inmates in State and Federal Correctional Facilities (N=17,553), and interaction terms from logistic regression models, I compared the strength of the association between educational attainment and the presence of chronic and infectious health conditions among the incarcerated and non-incarcerated populations. These models indicated generally stronger negative associations between educational attainment and chronic conditions among the non-incarcerated, while the negative relationship between education and hepatitis was stronger for the incarcerated. These results suggest that while education may play a lesser role for chronic conditions for the incarcerated, it can still important for avoiding risky health behaviors.

Social determinants of health among Canadian inmates

Purpose International studies indicate that offenders have higher rates of infectious diseases, chronic diseases, and physical disorders relative to the general population. Although social determinants of health have been found to affect the mental health of a population, less information is available regarding the impact of social determinants on physical health, especially among offenders. The purpose of this paper is to examine the relationship between social determinants and the physical health status of federal Canadian offenders. Design/methodology/approach The study included all men admitted to federal institutions between 1 April 2012 and 30 September 2012 ( n=2,273) who consented to the intake health assessment. Logistic regression analyses were used to explore whether age group, Aboriginal ancestry, and each of the individual social determinants significantly predicted a variety of health conditions. Findings The majority of men reported having a physical health condition and had experienced social determinants associated with adverse health outcomes, especially men of Aboriginal ancestry. Two social determinants factors in particular were consistently related to the health of offenders, a history of childhood abuse, and the use of social assistance. Research limitations/implications The study is limited to the use of self-report data. Additionally, the measures of social determinants of health were indicators taken from assessments that provided only rough estimates of the constructs rather than from established measures. Originality/value A better understanding of how these factors affect offenders can inform strategies to address correctional health issues and reduce the impact of chronic conditions through targeted correctional education and intervention programmes.

A novel care pathway for prisoners with intellectual disability designed through a Delphi process

Purpose

Individuals with an intellectual disability (ID) form a significant minority in the Irish prison population and worldwide prison populations. There is growing recognition that specialist services for such individuals are in need of development. The purpose of this paper is to propose a care pathway for the management of individuals with an ID who present in prison, based on expert elicitation and consensus.

Design/methodology/approach

A convenience sample of professionals with a special interest in forensic intellectual disabilities was invited to participate in a Delphi exercise. In total, 12 agreed to participation and 10 subsequently completed the study (83.3 per cent). Expert views were elicited using a semi-structured questionnaire. Content analysis was completed using NVivo 11 software. A care pathway was subsequently proposed, based on the outcomes of the analysis, and circulated to participants for debate and consensus. A consensus was reached on management considerations.

Findings

Ten experts across a range of disciplines with a combined experience of 187 years participated in the study. Current provision of care was seen as limited and geographically variable. The vulnerability of prisoners with ID was highlighted. The need for equivalence of care with the community through multidisciplinary input and development of specialist secure and residential placements to facilitate diversion was identified. Consensus was achieved on a proposed care pathway.

Originality/value

This study proposes a care pathway for the assessment and management of prisoners with an ID and is, therefore, potentially relevant to those interested in this topic internationally who may similarly struggle with the current lack of decision-making tools for this setting. Although written from an Irish perspective, it outlines key considerations for psychiatrists in keeping with international guidance and, therefore, may be generalisable to other jurisdictions.

Transformative Consciousness of Health Inequities: Oppression is a Virus and Critical Consciousness is the Antidote

Oppression has been identified as a fundamental cause of disease. Like a self-replicating virus, it infects systems from the biological to the political, contributing to personal (e.g., substance use, low self-esteem) and social (e.g., community violence, mass incarceration) dysfunction. Paulo Freire's critical consciousness (CC) is a philosophical, theoretical and practice-based framework that has been identified as an antidote to oppression. Critical consciousness constitutes an awareness of, and action against, institutional, historical, and systemic forces that limit or promote opportunities for certain groups. Although CC theory has been used to address inequity, very few scholars have attempted to conceptualize, operationalize and describe the development process of CC. In response to the conceptual inconsistencies widely noted in the CC literature, this paper presents a new construct, Transformative Consciousness (TC), composed of three domains: Awareness, Behavioral-Response, and Consequence, for each level of the socio-ecosystem. The staged process of TC development is also described. The theoretical framework of TC can be applied to various social issues, such as violence, mass incarceration, homelessness, HIV/STI infection, and substance use - all of which have tremendous implications for health and well-being as a human right. With further research, Transformative Consciousness may prove necessary to move persons in the direction of anti-oppressive, individual and collective action to overcome and dismantle oppression, creating a healthier and more just and liberated society.

Primary care utilization in people who experience imprisonment in Ontario, Canada: a retrospective cohort study

Background

Access to primary care is an important determinant of health, and data are sparse on primary care utilization for people who experience imprisonment. We aimed to describe primary care utilization for persons released from prison, and to compare utilization with the general population.

Methods

We linked correctional data for all persons released from provincial prison in Ontario, Canada in 2010 with health administrative data. We matched each person by age and sex with four general population controls. We compared primary care utilization rates using generalized estimating equations. We adjusted rate ratios for aggregated diagnosis groups, to explore this association independent of comorbidity. We examined the proportion of people using primary care using chi squared tests and time to first primary care visit post-release using the Kaplan-Meier method.

Results

Compared to the general population controls, the prison release group had significantly increased relative rates of primary care utilization: at 6.1 (95% CI 5.9-6.2) in prison, 3.7 (95% CI 3.6-3.8) in the week post-release and between 2.4 and 2.6 in the two years after prison release. All rate ratios remained significantly increased after adjusting for comorbidity. In the month after release, however, 66.3% of women and 75.5% of men did not access primary care.

Conclusions

Primary care utilization is high in prison and post-release for people who experience imprisonment in Ontario, Canada. Increased use is only partly explained by comorbidity. The majority of people do not access primary care in the month after prison release. Future research should identify reasons for increased use and interventions to improve care access for persons who are not accessing care post-release.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3660-2) contains supplementary material, which is available to authorized users.

Enrolling in Clinical Research While Incarcerated: What Influences Participants' Decisions?

As a 2006 Institute of Medicine report highlights, surprisingly little empirical attention has been paid to how prisoners arrive at decisions to participate in modern research. With our study, we aimed to fill this gap by identifying a more comprehensive range of factors as reported by prisoners themselves during semistructured interviews. Our participants described a diverse range of motives, both favoring and opposing their eventual decision to join. Many are well-recognized considerations among nonincarcerated clinical research participants, including a desire for various forms of personal benefit, altruism, and concern about study risks and inconveniences. However, a number of influences seem unique to prisoners. Participants did not report that they were not coerced into enrolling, and they have even been under pressure not to enroll. However, many sought to enroll in order to obtain access to better health care, raising a concern about whether they were unfairly exploited.