Prisons and COVID-19: A Desperate Call for Gerontological Expertise in Correctional Health Care

The Multiple Punishment of Being an Older Adult Coping With Health Problems in Prison

BACKGROUND AND OBJECTIVES

Studies have examined the vulnerabilities and the extent of health problems experienced by the older adult population in prison. However, reports about the subjective experiences of incarcerated older adults who are coping with health problems are scarce. This is alarming since older adults comprise the fastest-growing demographic in the prison systems of the United States and Europe. The aim of the current study was to bring forth the voices of older adults who are living with diseases in prison and to outline the landscape of struggling with everyday health care management.

RESEARCH DESIGN AND METHODS

An interpretive phenomenological analysis was used to analyze the narratives of 23 individuals aged 60-88 who were coping with health problems in prison.

RESULTS

The narratives revealed 3 major themes: (1) living day to day with illness in prison: fighting prison bureaucracy and public humiliation; (2) coping with complex medical issues: lack of professional medical care and cumulative problems, and (3) what does the future hold? Fear of living with illness out of prison.

DISCUSSION AND IMPLICATIONS

Intersectionality was used as a conceptual framework for understanding the participants' narratives. The cumulative effect of belonging to systematically oppressed and marginalized groups is discussed. The research findings point to issues and experiences that are unique to older adults coping with health problems in prison and can serve as a framework for developing tailored interventions for these individuals.

Devaluing Incarcerated Populations: Deprioritizing Incarcerated Populations for COVID-19 Vaccination

The COVID-19 pandemic has highlighted the need for increased attention to measures in place to protect the health of incarcerated populations. Correctional facilities saw massive COVID-19 outbreaks and correctional nurses have been at the forefront of efforts to control COVID-19 in correctional facilities. Before vaccines were widely available, the National Academies of Science, Engineering, and Medicine developed a framework to guide equitable COVID-19 vaccine allocation. This study assessed the use of the framework by reviewing 15 state COVID-19 vaccination plans to identify how incarcerated populations were prioritized. Thirteen initial plans could be located. Ten of these plans placed incarcerated persons in Phases 1 and 2, while 1 state placed them in Phase 3. However, subsequent versions of the plans revealed that 8 states had deprioritized incarcerated populations by no longer considering them as a unique population. The framework was developed to promote equity, however, incarcerated persons were often dis-included as a high-risk population for vaccine prioritization, prolonging their risk of COVID-19. Engaging in the opportunity to influence both policy and practice, and promote the ethical consideration of incarcerated populations may help to address both the structural (prison) challenges and larger political structures that impacted vaccine availability and ability to provide the best care possible to this high-risk population.

Advanced care planning in the early phase of COVID-19: a rapid review of the practice and policy lessons learned

Background

The importance of advance care planning (ACP) has been highlighted by the advent of life-threatening COVID-19. Anecdotal evidence suggests changes in implementation of policies and procedures is needed to support uptake of ACPs. We investigated the barriers and enablers of ACP in the COVID-19 context and identify recommendations to facilitate ACP, to inform future policy and practice.

Methods

We adopted the WHO recommendation of using rapid reviews for the production of actionable evidence for this study. We searched PUBMED from January 2020 to April 2021. All study designs including commentaries were included that focused on ACPs during COVID-19. Preprints/unpublished papers and Non-English language articles were excluded. Titles and abstracts were screened, full-texts were reviewed, and discrepancies resolved by discussion until consensus.

Results

From amongst 343 papers screened, 123 underwent full-text review. In total, 74 papers were included, comprising commentaries (39) and primary research studies covering cohorts, reviews, case studies, and cross-sectional designs (35). The various study types and settings such as hospitals, outpatient services, aged care and community indicated widespread interest in accelerating ACP documentation to facilitate management decisions and care which is unwanted/not aligned with goals. Enablers of ACP included targeted public awareness, availability of telehealth, easy access to online tools and adopting person-centered approach, respectful of patient autonomy and values. The emerging barriers were uncertainty regarding clinical outcomes, cultural and communication difficulties, barriers associated with legal and ethical considerations, infection control restrictions, lack of time, and limited resources and support systems.

Conclusion

The pandemic has provided opportunities for rapid implementation of ACP in creative ways to circumvent social distancing restrictions and high demand for health services. This review suggests the pandemic has provided some impetus to drive adaptable ACP conversations at individual, local, and international levels, affording an opportunity for longer term improvements in ACP practice and patient care. The enablers of ACP and the accelerated adoption evident here will hopefully continue to be part of everyday practice, with or without the pandemic.

Racial, Ethnic, Sex, and Age Differences in COVID-19 Cases, Hospitalizations, and Deaths Among Incarcerated People and Staff in Correctional Facilities in Six Jurisdictions, United States, March-July 2020

OBJECTIVES

To examine disparities by sex, age group, and race and ethnicity in COVID-19 confirmed cases, hospitalizations, and deaths among incarcerated people and staff in correctional facilities.

METHODS

Six U.S. jurisdictions reported data on COVID-19 confirmed cases, hospitalizations, and deaths stratified by sex, age group, and race and ethnicity for incarcerated people and staff in correctional facilities during March 1- July 31, 2020. We calculated incidence rates and rate ratios (RR) and absolute rate differences (RD) by sex, age group, and race and ethnicity, and made comparisons to the U.S. general population.

RESULTS

Compared with the U.S. general population, incarcerated people and staff had higher COVID-19 case incidence (RR = 14.1, 95% CI = 13.9-14.3; RD = 6,692.2, CI = 6,598.8-6,785.5; RR = 6.0, CI = 5.7-6.3; RD = 2523.0, CI = 2368.1-2677.9, respectively); incarcerated people also had higher rates of COVID-19-related deaths (RR = 1.6, CI = 1.4-1.9; RD = 23.6, CI = 14.9-32.2). Rates of COVID-19 cases, hospitalizations, and deaths among incarcerated people and corrections staff differed by sex, age group, and race and ethnicity. The COVID-19 hospitalization (RR = 0.9, CI = 0.8-1.0; RD = -48.0, CI = -79.1- -16.8) and death rates (RR = 0.8, CI = 0.6-1.0; RD = -11.8, CI = -23.5- -0.1) for Black incarcerated people were lower than those for Black people in the general population. COVID-19 case incidence, hospitalizations, and deaths were higher among older incarcerated people, but not among staff.

CONCLUSIONS

With a few exceptions, living or working in a correctional setting was associated with higher risk of COVID-19 infection and resulted in worse health outcomes compared with the general population; however, Black incarcerated people fared better than their U.S. general population counterparts.

Public Health and Prisons: Priorities in the Age of Mass Incarceration

Mass incarceration is a sociostructural driver of profound health inequalities in the United States. The political and economic forces underpinning mass incarceration are deeply rooted in centuries of the enslavement of people of African descent and the genocide and displacement of Indigenous people and is inextricably connected to labor exploitation, racial discrimination, the criminalization of immigration, and behavioral health problems such as mental illness and substance use disorders. This article focuses on major public health crises and advances in state and federal prisons and discusses a range of practical strategies for health scholars, practitioners, and activists to promote the health and dignity of incarcerated people. It begins by summarizing the historical and sociostructural factors that have led to mass incarceration in the United States. It then describes the ways in which prison conditions create or worsen chronic, communicable, and behavioral health conditions, while highlighting priority areas for public health research and intervention to improve the health of incarcerated people, including decarceral solutions that can profoundly minimize-and perhaps one day help abolish-the use of prisons.

"Prison life is very hard and it's made harder if you're isolated": COVID-19 risk mitigation strategies and the mental health of incarcerated women in California

PURPOSE

This study aims to describe the COVID-19 risk mitigation strategies implemented in California prisons and the impact of these policies on the mental health of incarcerated women.

DESIGN/METHODOLOGY/APPROACH

The authors conducted semi-structured qualitative interviews with ten women who were over the age of 50 and/or had a chronic illness and had been incarcerated in California prisons during the COVID-19 pandemic. The authors also interviewed ten health-care providers working in California jails or prisons during the pandemic. Interviews were analyzed using a grounded theory coding framework and triangulated with fieldnotes from ethnographic observations of medical and legal advocacy efforts during the pandemic.

FINDINGS

Participants described being locked in their cells for 23 hours per day or more, often for days, weeks or even months at a time in an effort to reduce the spread of COVID-19. For many participants, these lockdowns and the resulting isolation from loved ones both inside and outside of the prison were detrimental to both their physical and mental health. Participants reported that access to mental health care for those in the general population was limited prior to the pandemic, and that COVID-19 risk mitigation strategies, including the cessation of group programs and shift to cell-front mental health services, created further barriers.

ORIGINALITY/VALUE

There has been little qualitative research on the mental health effects of the COVID-19 pandemic on incarcerated populations. This paper provides insight into the mental health effects of both the COVID-19 pandemic and COVID-19 risk mitigation strategies for the structurally vulnerable older women incarcerated in California prisons.

The Impact Of COVID-19 On The Health Of Incarcerated Older Adults In California State Prisons

The number of older adults (age fifty-five or older) incarcerated in US prisons reached an all-time high just as COVID-19 entered correctional facilities in 2020. However, little is known about COVID-19's impact on incarcerated older adults. We compared COVID-19 outcomes between older and younger adults in California state prisons from March 1, 2020, to October 9, 2021. Adjusted odds ratios (aORs) revealed an increasing risk for adverse COVID-19 outcomes among older age groups (ages 55-64, 65-74, and 75 or older) compared with younger adults, including for documented infection (aOR, 1.3, 1.4, and 1.4, respectively) and hospitalization with COVID-19 (aOR, 4.6, 8.7, and 15.1, respectively). Moreover, although accounting for 17.3 percent of the California state prison population, older adults represented 85.8 percent of this population's COVID-19-related deaths. Yet a smaller percentage of older adults than younger adults were released from prison during the pandemic. The differential rates of morbidity and mortality experienced by incarcerated older adults should be considered in future pandemic response strategies regarding prisons.

A stepwise guide for healthcare professionals requesting compassionate release for patients who are incarcerated

PURPOSE

Compassionate release is a process that allows for the early release or parole of some incarcerated people of advanced age, with life-limiting illness, complex medical care needs or significant functional decline. Despite the expansion of State and Federal compassionate release programs, this mechanism for release remains underutilized. Health-care professionals are central to the process of recommending compassionate release, but few resources exist to support these efforts. The purpose of this paper is to provide a guide for health-care professionals requesting compassionate release for patients who are incarcerated.

DESIGN/METHODOLOGY/APPROACH

This study is stepwise guide for health-care professionals requesting compassionate release for patients who are incarcerated.

FINDINGS

This study describes the role of the health-care professional in requesting compassionate release and offers guidance to help them navigate the process of preparing a medical declaration or request for compassionate release.

ORIGINALITY/VALUE

No prior publications have created a step-wise guide of this nature to aid health-care professionals through the compassionate release process.

Age and COVID-19 mortality in the United States: a comparison of the prison and general population

PURPOSE

The USA has a rapidly aging prison population that, combined with their poorer health and living conditions, is at extreme risk for COVID-19. The purpose of this paper is to compare COVID-19 mortality trends in the US prison population and the general population to see how mortality risk changed over the course of the pandemic. The authors first provide a national overview of trends in COVID-19 mortality; then, the authors assess COVID-19 deaths among older populations using more detailed data from one US state.

DESIGN/METHODOLOGY/APPROACH

The authors used multiple publicly available data sets (e.g. Centers for Disease Control and prevention, COVID Prison Project) and indirect and direct standardization to estimate standardized mortality rates covering the period from April 2020 to June 2021 for the US and for the State of Texas.

FINDINGS

While 921 COVID-19-related deaths among people in US prisons were expected as of June 5, 2021, 2,664 were observed, corresponding to a standardized mortality ratio of 2.89 (95%CI 2.78, 3.00). The observed number of COVID-19-related deaths exceeded the expected number of COVID-19-related deaths among people in prison for most of the pandemic, with a substantially widening gap leading to a plateau about four weeks after the COVID-19 vaccine was introduced in the USA. In the state population, the older population in prison is dying at younger ages compared with the general population, with the highest percentage of deaths among people aged 50-64 years.

RESEARCH LIMITATIONS/IMPLICATIONS

People who are incarcerated are dying of COVID-19 at a rate that far outpaces the general population and are dying at younger ages.

ORIGINALITY/VALUE

This descriptive analysis serves as a first step in understanding the dynamic trends in COVID-19 mortality and the association between age and COVID-19 death in US prisons.

Factors Associated with Incarceration in Older Adults Experiencing Homelessness: Results from the HOPE HOME Study

BACKGROUND

In the US, the median age of adults experiencing homelessness and incarceration is increasing. Little is known about risk factors for incarceration among older adults experiencing homelessness. To develop targeted interventions, there is a need to understand their risk factors for incarceration.

OBJECTIVE

To examine the prevalence and risk factors associated with incarceration in a cohort of older adults experiencing homelessness.

DESIGN

Prospective, longitudinal cohort study with interviews every 6 months for a median of 5.8 years.

PARTICIPANTS

We recruited adults ≥50 years old and homeless at baseline (n=433) via population-based sampling.

MAIN MEASURES

Our dependent variable was incident incarceration, defined as one night in jail or prison per 6-month follow-up period after study enrollment. Independent variables included socioeconomic status, social, health, housing, and prior criminal justice involvement.

KEY RESULTS

Participants had a median age of 58 years and were predominantly men (75%) and Black (80%). Seventy percent had at least one chronic medical condition, 12% reported heavy drinking, and 38% endorsed moderate-severe use of cocaine, 8% of amphetamines, and 7% of opioids. At baseline, 84% reported a lifetime history of jail stays; 37% reported prior prison stays. During follow-up, 23% spent time in jail or prison. In multivariable models, factors associated with a higher risk of incarceration included the following: having 6 or more confidants (HR=2.13, 95% CI=1.2-3.7, p=0.007), remaining homeless (HR=1.72, 95% CI=1.1-2.8, p=0.02), heavy drinking (HR=2.05, 95% CI=1.4-3.0, p<0.001), moderate-severe amphetamine use (HR=1.89, 95% CI=1.2-3.0, p=0.006), and being on probation (HR=3.61, 95% CI=2.4-5.4, p<0.001) or parole (HR=3.02, 95% CI=1.5-5.9, p=0.001).

CONCLUSIONS

Older adults experiencing homelessness have a high risk of incarceration. There is a need for targeted interventions addressing substance use, homelessness, and reforming parole and probation in order to abate the high ongoing risk of incarceration among older adults experiencing homelessness.

Community Reintegration of Previously Incarcerated Older Adults: Exploratory Insights from a Canadian Community Residential Facility Program

This paper addresses an immediate gap in knowledge about community reintegration of previously incarcerated older adults. It presents an exploratory case study of a community residential facility program in Ontario, Canada, focusing on the experiences and perspectives of older residents, staff members, and community stakeholders on the community reintegration of previously incarcerated older men. Findings provide insights into the aging-related reintegration issues such as the older men's ability to access health and medical services upon community reentry, the challenges and opportunities of the continuum of support (or lack thereof) to help ease the reintegration process, and stigma and other barriers the older men face as they attempt to access long-term care upon release from correctional institutions. Emergent questions for research, policy, and practice are highlighted and discussed to set an agenda for expanding the thread of inquiry into the community reintegration of previously incarcerated older adults. Future research calls for further investigation into the diversity of experiences (e.g., gender, race/ethnicity, geographical locale) to advance the field of study as it relates to aging and social policy.

Visitation and quality of life among older adults in jail

PURPOSE

The purpose of this paper aims to examine differences in measures of and relationships between visitation and quality of life (QOL) among older and younger jailed adults. The authors also explored the contribution of visitation to QOL among adults in this setting. The authors anticipated fewer visits and lower QOL among older adults. Framed by psychosocial developmental theory, the authors also anticipated a larger effect in the relationship between visitation and QOL among older rather than younger adults and that visitation would contribute most readily to psychological QOL.

DESIGN/METHODOLOGY/APPROACH

Cross-sectional data from a large US jail were used (n = 264). The authors described the sample regarding visitation and QOL measures among older (≥45) and younger adults (≤44) and examined differences in measures of and relationships between visitation and QOL using independent sample t-tests and bivariate analyses. The authors explored the contribution of visitation to psychological, social relationships, physical and environmental QOL among jailed adults using hierarchical multiple linear regression.

FINDINGS

Older adults had fewer family visits and lower physical QOL than younger adults, disparities were moderate in effect (d range = 0.33-0.35). A significant difference also emerged between groups regarding the visitation and environmental QOL relationship (z = 1.66, p <0.05). Visitation contributed to variation in physical and social relationships QOL among jailed adults (Beta range = 0.19-0.24).

ORIGINALITY/VALUE

Limited research exists among jailed older adults and scholars have yet to examine the relationship between visitation and QOL among persons in these settings.

Health and Health Service Needs: Comparison of Older and Younger Women with Criminal-Legal Involvement in Three Cities

Objectives: We profiled the health and health services needs of a sample of older adult women (age 50+) with criminal-legal system (CLS) involvement and compared them with younger women (age 18-49), also CLS-involved. Methods: Using survey data collected from January to June 2020 from adult women with CLS involvement in three US cities, we profiled and compared the older adult women with younger women on behavioral and structural risk factors, health conditions, and health services access and use. Results: One-third (157/510) were age 50+. We found significant differences (p < .05) in health conditions and health services use: older women had more chronic conditions (e.g., hypertension and stroke) and more multimorbidity and reported more use of personalized care (e.g., private doctor, medical home, and health insurance). Discussion: Although older women with CLS involvement reported good access to health services compared with younger women, their chronic health conditions, multimorbidity, and functional declines merit attention.

Providing Ethical and Humane Care to Hospitalized, Incarcerated Patients With COVID-19

The COVID-19 pandemic is devastating the health of hundreds of thousands of people who live and work in U.S. jails and prisons. Due to dozens of large outbreaks in correctional facilities, tens of thousands of seriously ill incarcerated people are receiving medical care in the community hospital setting. Yet community clinicians often have little knowledge of the basic rights and ethical principles governing care of seriously ill incarcerated patients. Such patients are legally entitled to make their own medical decisions just like non-incarcerated patients, and retain rights to appoint surrogate decision makers and make advance care plans. Wardens, correctional officers, and prison health care professionals should not make medical decisions for incarcerated patients and should not be asked to do so. Dying incarcerated patients should be offered goodbye visits with their loved ones, and patients from federal prisons are legally entitled to them. Community health care professionals may need to advocate for this medically vulnerable hospitalized patient population to receive ethically appropriate, humane care when under their care in community hospitals. If ethical care is being obstructed, community health care professionals should contact the prison’s warden and medical director to explain their concerns and ask questions. If necessary, community clinicians should involve a hospital’s ethics committee, leadership, and legal counsel. Correctional medicine experts and legal advocates for incarcerated people can also help community clinicians safeguard the rights of incarcerated patients.