Older and incarcerated: policy implications of aging prison populations

Population ageing, incarceration and the growing digital divide: Understanding the effects of digital literacy inequity experienced by older people leaving prison

BACKGROUND

Digital inequity refers to the inequality and exclusion experienced by those who lack the same opportunities or circumstances to support the development of digital skills as the rest of modern society. One rapidly growing and highly vulnerable group to digital inequity is older people attempting to reintegrate into society after release from prison, where technology access is limited. Inadequate support for digital skills in this population entails widespread consequences for public health, human rights, social welfare and recidivism. This qualitative study is the first to: examine digital inequity experienced by older people who have been incarcerated, understand the effects of this on reintegration to society, and begin informing appropriate solutions.

METHOD

Semi-structured interviews were conducted with N = 15 older people (mean age = 57) who had been released from an Australian prison in the last two years, regarding their experiences of digital literacy since leaving prison. Reflexive thematic analysis was conducted under a critical realist lens.

RESULTS

The analysis resulted in six themes that illustrated the extent of digital inequity experienced by this population, and key challenges for improving digital literacy: 'surviving in a digital world', 'stranger in a foreign world', 'questioning the digital divide', 'overcoming your "old" self', 'don't like what you don't know', and 'seeking versus finding help'.

CONCLUSIONS

The digital inequity that older people experience during and after incarceration creates additional challenges for a growing group who are already medically and socially marginalised. Prioritisation of this group for digital literacy initiatives both during incarceration and in the community will have benefits for their health, social and financial reintegration. Their unique life experiences should be considered in designing and delivering these programs. Simultaneously, prisons should be cognizant of the potential detrimental effects of technology restriction on reintegration and criminogenic outcomes.

The Well-Being of Older Offenders on Release in the Community

In Canada and internationally the number of older offenders on parole and living in the community is increasing rapidly. Older offenders in the community are a vulnerable population at high risk for lack of well-being. Semi-structured interviews were conducted with N = 64 offenders aged 50 years and older on conditional release from custody in Canada, including long-term, recidivist, and first-time older offenders. Compared to their non-offender counterparts, older offenders in the community experience many of the same problems of aging and well-being, but are at greater risk for mental health problems, traumatic injuries, and for recidivists, substance abuse. Most long-term and first-time older offenders find themselves living at or below the poverty line. One third of older offenders experience social isolation from community and family due to their criminal history and incarceration. For those with Indigenous ancestry, Indigenous communities, and cultural organizations play a significant role in supporting older offenders.

Interventions for the detection, monitoring, and management of chronic non-communicable diseases in the prison population: an international systematic review

BACKGROUND

High rates of health inequalities and chronic non-communicable diseases exist amongst the prison population. This places people in and/or released from prison at heightened risk of multimorbidity, premature mortality, and reduced quality of life. Ensuring appropriate healthcare for people in prison to improve their health outcomes is an important aspect of social justice. This review examines the global literature on healthcare interventions to detect, monitor and manage chronic non-communicable diseases amongst the prison population and people recently released from prison.

METHODS

Systematic searches of EMBASE, MEDLINE, CINAHL, Web of Science, Scopus, and the Cochrane Library were conducted and supplemented by citation searching and review of the grey literature. The literature searches attempted to identify all articles describing any healthcare intervention for adults in prison, or released from prison in the past 1 year, to detect, monitor, or manage any chronic non-communicable illness. 19,061 articles were identified, of which 1058 articles were screened by abstract and 203 articles were reviewed by full text.

RESULTS

Sixty-five studies were included in the review, involving 18,311 participants from multiple countries. Most studies were quasi-experimental and/or low to moderate in quality. Numerous healthcare interventions were described in the literature including chronic disease screening, telemedicine, health education, integrated care systems, implementing specialist equipment and staff roles to manage chronic diseases in prisons, and providing enhanced primary care contact and/or support from community health workers for people recently released from prison. These interventions were associated with improvement in various measures of clinical and cost effectiveness, although comparison between different care models was not possible due to high levels of clinical heterogeneity.

CONCLUSIONS

It is currently unclear which interventions are most effective at monitoring and managing chronic non-communicable diseases in prison. More research is needed to determine the most effective interventions for improving chronic disease management in prisons and how these should be implemented to ensure optimal success. Future research should examine interventions for addressing multimorbidity within prisons, since most studies tested interventions for a singular non-communicable disease.

Effects of interventions on depression and anxiety in older people with physical health problems in the criminal justice system: a systematic review

The demand for health care in older people involved in the criminal justice system is high. The prevalence of mental and physical health conditions for people living in prison is greater than in community populations. After systematically searching 21 databases, we found no targeted interventions to support depression or anxiety for this group of people. 24 studies (including interventions of yoga, creative-arts-based programmes, positive psychology, or mindfulness-based interventions and psychotherapy) did contain people older than 50 years, but this only represented a minority (10%) of the overall study population. No single study reported outcomes of physical health. Future interventions need to consider the needs and views of this vulnerable group. Specific gendered and coproduced interventions are required to enhance the implementation, feasibility, and acceptability of interventions that are delivered in prisons.

Emergency Department Visits by Incarcerated Adults for Nonfatal Injuries - United States, 2010-2019

During 2010-2019, U.S. correctional authorities held 1.4-1.6 million persons in state and federal prisons annually, and 10.3-12.9 million persons were admitted to local jails each year (1,2). Incarcerated persons experience a disproportionate burden of negative health outcomes, including unintentional and violence-related injuries (3,4). No national studies on injury-related emergency department (ED) visits by incarcerated persons have been conducted, but a previous study demonstrated a high rate of such visits among a Seattle, Washington jail population (5). To examine nonfatal injury-related ED visits among incarcerated adults, CDC analyzed 2010-2019 National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) data. During 2010-2019, an estimated 733,547 ED visits by incarcerated adults occurred in the United States. The proportion of ED visits resulting from assault* and self-harm among incarcerated adults was five times as high as those among nonincarcerated adults. Among incarcerated adults, men and adult persons aged <65 years had the highest proportion of assault-related ED visits. Falls accounted for the most ED visits among incarcerated adults aged ≥65 years. A higher proportion of ED visits by incarcerated women than incarcerated men were for overdose or poisoning. These findings suggest that injuries among incarcerated adults differ from those among nonincarcerated adults and might require development and implementation of age- and sex-specific prevention strategies for this population.

The role of substance use in the lives of incarcerated older adults: A qualitative study

Background

The prevalence of drug abuse among older adults has grown over the last decade. Despite the expanding development of a body of research dedicated to studying this phenomenon, drug abuse by incarcerated older adults has been marginalized. Thus, the aim of the present study was to explore drug abuse patterns in the lives of incarcerated older adults.

Method

Semi-structured interviews were conducted with 28 incarcerated older adults, and an interpretive analysis was used to analyze the participants’ narratives.

Findings

Four themes emerged: (1) Growing up around drugs; (2) Prison onset; (3) Professionals, and (4) Lifelong substance abuse.

Conclusion

The study findings reveal a unique typology of drug-related themes in the lives of incarcerated older adults. This typology sheds light on the interplay between aging, drug use, and incarceration and the way these three socially marginalized positions may intersect.

History of Incarceration and Its Association With Geriatric and Chronic Health Outcomes in Older Adulthood

Importance

Although incarcerated older adults experience higher rates of chronic disease and geriatric syndromes, it is unknown whether community-dwelling older adults with a history of incarceration are also at risk for worse health outcomes.

Objective

To evaluate the association between a history of incarceration and health outcomes, including chronic health conditions and geriatric syndromes, in older age.

Design, Setting, and Participants

This cross-sectional study using population-based data from the nationally representative Health and Retirement Study included US community-dwelling adults aged 50 years or older who completed the 2012 or 2014 survey waves assessing self-reported history of incarceration. Statistical analysis was completed from December 2021 to July 2022.

Exposures

Self-reported history of incarceration.

Main Outcomes and Measures

Geriatric health outcomes included cognitive impairment, mobility impairment, vision impairment, hearing impairment, urinary incontinence, and impairment of activities of daily living (ADLs). Chronic health outcomes included high blood pressure, diabetes, chronic lung disease, heart disease, stroke, mental health conditions, heavy alcohol use, and self-reported health. Survey weights were applied to adjust for the survey design.

Results

Among 13 462 participants, 946 (7.6%) had experienced incarceration (mean [SD] age, 62.4 [7.8] years); compared with 12 516 people with no prior incarceration (mean [SD] age, 66.7 [10.0] years), previously incarcerated adults were more likely to be male (83.0% vs 42.8%; P < .001) and in the lowest quartile of wealth (44.1% vs 21.4%; overall P < .001). After adjusting for age, sex, race and ethnicity, wealth, educational attainment, and uninsured status, a history of incarceration was associated with a 20% to 80% increased risk of all geriatric syndromes evaluated, including impairment of ADLs (relative risk [RR], 1.62; 95% CI, 1.40-1.88) and hearing impairment (RR, 1.22; 95% CI, 1.04-1.44). Incarceration was also associated with increased risk of some chronic diseases, including chronic lung disease (RR, 1.56; 95% CI, 1.27-1.91), mental health conditions (RR, 1.80; 95% CI, 1.55-2.08), and heavy alcohol use (RR, 2.13; 95% CI, 1.59-2.84). Prior incarceration was not associated with diabetes or cardiovascular conditions.

Conclusions and Relevance

In this study, at least 1 in 15 older US adults reported a history of incarceration in their lifetime. Past incarceration was associated with many chronic diseases and geriatric syndromes even after accounting for socioeconomic status. These findings suggest that attention to incarceration history may be an important consideration in understanding and mitigating health risks in older age.

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.

Gathering Health Perspectives of the Justice Involved: A Multisite Needs Assessment Survey

The well-being of justice-involved individuals must be of high priority to achieve health equity, reduce health disparities, and improve community health. To better understand the health interests and needs of justice-involved individuals, a survey was administered inquiring about health information-seeking behavior and health topics of interest. The survey was administered using secure tablet computers and completed by 1,888 incarcerated participants in 35 jails in 17 states. Salient themes that emerged from this research include the relatively equal use of the internet and health care providers as resources for health information; the extensive interest in learning about multiple health care topics; and demographic variations in health information-seeking behaviors and health topics of interest. Tailoring correctional health education programs to coincide with the interests and needs of the justice-involved population may attract more participants and thus result in better self-care management skills and health outcomes upon reentering communities.

Prevalence of HCV in prisons in Wales, UK and the impact of moving to opt-out HCV testing

BACKGROUND

Viral hepatitis is a leading cause of death worldwide. The World Health Organisation introduced a target to reduce hepatitis C virus (HCV) as a public health threat by 2030. Testing and treatment of those at elevated risk of infection in prison is key to achieving disease elimination. An opt-out testing policy for those in prison was introduced in Wales, UK, in 2016.

METHODS

We analysed all Wales laboratory data where the testing site was a prison. We analysed numbers tested and positivity for a 14-month period before and after the introduction of opt-out testing policy.

RESULTS

Between September 2015 and December 2017, 6949 HCV tests were from prison settings in Wales, equating to 29% of admissions to prison (P < 0.001). All but one prison increased testing following the introduction of opt-out policy. Percentage positivity for HCV remained at 11% before and after opt-out policy (P = 0.572). Short-stay prisons saw higher rates of HCV positivity than long stay.

CONCLUSION

Data suggest implementation of opt-out policy improved uptake and diagnosis of HCV amongst those in prison; however, further effort is required to fully embed screening for all. Positivity remains high amongst those in prison, particularly in short-stay prisons. Laboratory data can support audit of opt-out policy.

COVID-19-The Case for Rethinking Health and Human Rights in Prisons

This article considers health and human rights implications for people deprived of liberty during the COVID-19 crisis. The health risks of incarceration for individual and community health, particularly in overcrowded and underresourced prisons and detention centers, are well known, but with the COVID-19 pandemic have become a public health emergency.Physical distancing in prisons is hardly manageable, and protective means are poor or lacking. Emergency releases have been shown to be feasible in terms of public safety but lack sustainability in reducing the number of people living in detention, and, globally, only a small proportion of them have been released. Without controlling the infection inside prisons, global efforts to tackle the spread of the disease may fail. People living in detention are not only more vulnerable to infection with COVID-19 but they are also especially vulnerable to human rights violations induced by inappropriate restrictions under the pretext of infection control. Therefore, alternatives for detention should be promoted and the number of incarcerated people radically decreased.This article calls on policymakers and all professionals involved in public health and criminal justice not to waste the opportunities provided by the crisis but to act now.

Death and Dying in Prison: An Integrative Review of the Literature

OBJECTIVE

The purpose of this integrative review was to synthesize and explore the qualitative research literature that describes the experience of being terminally ill while incarcerated, in order to inform future inquiry when it comes to the end-of-life (EOL) needs of incarcerated persons.

BACKGROUND

Mass incarceration has been a major issue in the United States, with rates sharply increasing since the 1970s. In the past two decades, the number of older incarcerated persons has grown by 500%, highlighting the importance of EOL care and decisions among this demographic.

METHODS

The search terms included prison OR incarceration AND "death and dying" OR "end of life." Primary research articles were considered in the search parameters. The Joanna Briggs Institute critical appraisal checklist for qualitative research was coupled with ConQual to score the quality of the selected qualitative studies.

RESULTS

Searches yielded 233 articles published after 2000. Following screening, 29 full-text articles were assessed for eligibility, and 7 qualitative studies met criteria and were included in the review. The ConQual scores of the synthesized findings were determined to be either "low" or "moderate."

DISCUSSION

Five main categories were observed across the themes elicited by the studies: EOL services in prison, social contact and human interactions, thoughts of death and fear of dying, wishes and decision-making, and guilt and coping. Many of these themes may be considered by correctional nurses who provide supportive "good death" care for incarcerated persons who are dying.

Could Physical Activity Have any Role in Cardiovascular Disease Prevention in Prisoners? A Systematic Review

More than 10.74 million people are currently held in penal institutions worldwide. Moreover, there is also evidence that the percentage of elder and female prisoners has been consistently growing. Cardiovascular diseases are the leading cause of death worldwide. Exercise training and physical activity help to prevent both primary and secondary cardiovascular events. Data on the influence of physical activity on the well-being in prison population is scarce. Here, we discussed, in a systematic review, the general health conditions and the cardiovascular risk profile in the prisoners compared to the general population and evaluated whether or not exercise could be a valuable tool in preventing these diseases in inmates. We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement: 769 were initially identified, and a total of 24 studies were finally included. Nine studies evaluated the health conditions in prisoners, five studies evaluated the incidence of cardiovascular disease (CVD) and coronary heart disease (CHD) in the prison population, and 10 studies evaluated the feasibility and the effectiveness of exercise programs in prisoners. Sports-educational programs can benefit prison inmates. It appears that supervised exercise training is an effective coping strategy to deal with incarceration. Moreover, it seems the sports programs might be a useful tool in improving physical and mental health of prisoners as well as in decreasing cardiovascular risk factors.

L, E. D, Brooks NJ. Exploring health and wellbeing in prison: a peer research approach

Purpose

Those in prison have expert knowledge of issues affecting their health and wellbeing. The purpose of this paper is to report on work undertaken with male prisoners. This paper presents learning and findings from the process of engaging imprisoned men as peer researchers.

Design/methodology/approach

The peer researcher approach offers an emic perspective to understand the experience of being in prison. The authors established the peer research role as an educational initiative at a long-stay prison in Wales, UK to determine the feasibility of engaging imprisoned men as peer researchers. Focus groups, interviews and questionnaires were used by the peer researchers to identify the health and wellbeing concerns of men in prison.

Findings

The project positively demonstrated the feasibility of engaging imprisoned men as peer researchers. Four recurring themes affecting health and wellbeing for men in a prison vulnerable persons unit were identified: communication, safety, respect and emotional needs. Themes were inextricably linked demonstrating the complex relationships between prison and health.

Originality/value

This was the first prison peer-research project to take place in Wales, UK. It demonstrates the value men in prison can play in developing the evidence base around health and wellbeing in prison, contributing to changes within the prison to improve health and wellbeing for all.

Mental health and offending in older people: Future directions for research

BACKGROUND

The number of older people and their proportion of the prison population in high-income countries is increasing substantially. This pattern is mirrored by the age profile in forensic hospital services, and both trends seem counter to the age-crime curve concept. How do we understand this and what are the mental health needs of this growing group?

AIM

The aim of this review is to identify existing research robust enough to inform policy and practice in relation to mental health in older offenders and the knowledge gaps that should drive future research.

METHODS

A keyword-based search strategy of the databases Embase, PsychINFO, Medline, and grey literature 2008-2018. Article selection was limited to empirical research with the potential to inform policy or practice and findings synthesised narratively.

RESULTS

Much of the research in this field focuses on prevalence and the increased psychiatric morbidity of the older offender population. Older prisoners and those older patients in secure hospitals have needs that differ in some respects from their younger counterparts and community-dwelling older people. There are few studies of interventions for mental health in older prisoners or into the challenges of timely release given their complex needs. Discharge of older individuals from secure settings is also an area where further research is required in order to inform policy and service provision.

CONCLUSIONS

The older population in prisons and secure settings is growing, and there is much concern as to how far facilities and services have been able to identify and meet the mental health needs of those of older age. Cooperation between researchers and services and between disciplines will be essential if we are to secure a more robust evidence base in this respect. Engaging service users in such research and considering the whole criminal justice pathway including diversion remains a priority.

A systematic integrative review of programmes addressing the social care needs of older prisoners

BACKGROUND

The number of older prisoners has risen exponentially over the last two decades, especially in high-income countries. Due to the increased and somewhat inadequately met health and social care needs of this group of prisoners, coupled with their vulnerability arising from higher levels of isolation, poverty and exploitation, financial costs have spiralled and human rights concerns have grown. This review aimed to present an overview of programmes that addressed older prisoners' social care needs, a particularly underdeveloped area, with a view to assessing the extent to which they could inform policy and practice.

METHODS

Following Whittemore and Knafl's (J Adv Nurs 52:546-553, 2005) integrative review approach, a comprehensive search - including 16 electronic databases and hand searching - was undertaken up to May 2017 using search terms related to context, function and disability. The quality of included papers was assessed, data were extracted using a review-specific form based on the PICO formula, and research questions addressed using a narrative synthesis approach. Additionally, reporting followed PRISMA guidelines.

RESULTS

A total of 29 papers were selected for inclusion, the majority of which focused on hospice programmes, with the remainder describing personal care-focused services, structured day programmes, and adaptations to prison operations (regime) and accommodation in support of prisoners' social care needs. Whilst the programmes were reported to have some positive impacts on prisoners and the prison overall, and programmes were perceived to be cost-effective or cost-neutral, outcomes regarding staff were more mixed. Findings were tempered by the methodological shortcomings of the included papers, with many assessed as low quality, with a lack of prisoner participation, and an absence of experimental studies.

CONCLUSIONS

The evidence base for programmes addressing older prisoners' social care needs appears to be at an embryonic stage. Further robust studies evaluating the effectiveness and cost-effectiveness of programmes addressing older prisoners' social care needs are imperative in better informing policy and practice in support of this highly vulnerable group.

Comparing health status, disability, and access to care in older and younger inmates in the New South Wales corrections system

PURPOSE

The purpose of this paper is to compare the rates of chronic illness, disability and access to care between older and younger inmates who took part in a large epidemiological study in New South Wales, Australia.

DESIGN/METHODOLOGY/APPROACH

Data are presented from a cross-sectional study based on a sample of inmates from correctional sites in NSW. The inclusion of results here was guided by the literature with regard to their relevance to older people, and older inmates in particular.

FINDINGS

Results indicate that a higher proportion of older inmates suffer a range of chronic illnesses, with prevalence often many times higher than that of younger inmates. Older inmates are more likely to be classified as disabled and have a disability which impacts their mobility. Older inmates also reported accessing medical services in prison more recently than younger inmates and were more likely to have seen both nurses and general practitioners.

PRACTICAL IMPLICATIONS

Older inmates appear to be considerably more resource intensive than younger inmates. The increasing proportion of inmates who are classified as older thus poses a pressing challenge to those working in the carceral space and, in particular, those responsible for providing healthcare to incarcerated people.

ORIGINALITY/VALUE

The impact of aging prisoners on resource demand has yet to be effectively measured. This study provides an important first step towards that goal.

Understanding and Improving the Health of People Who Experience Incarceration: An Overview and Synthesis

The world prison population is growing at a rate that exceeds the rate of population growth. This issue of Epidemiologic Reviews comprises articles in which researchers summarize what is known about some of the key health issues facing people in prison, particularly in relation to human immunodeficiency virus and other blood-borne viral infections. A key recurring theme is that addressing the health needs of people in prison is important to reducing health inequalities at the population level—that prisoner health is public health. The reviews also highlight some critical evidence gaps, notably the lack of evidence from low- and middle-income countries, and the limited number of longitudinal studies in which health behaviors, health outcomes, or health service experiences after release from prison are documented. Despite growing evidence of the poor health of detained adolescents, none of the included reviews considered this population. Further research on the health of young people who cycle through juvenile detention should be a priority. Despite a rapidly growing literature on the health of people who experience incarceration, some critical health issues remain poorly understood, and there has been insufficient attention devoted to co-occurring health conditions and the consequent need for coordinated care. Key populations in custodial settings remain understudied, limiting capacity to develop targeted, evidence-based responses to their health needs. The quality of many studies is suboptimal, and although rigorous, independent research in correctional settings can be challenging, it is not impossible and is critical to laying the groundwork for evidence-based reform.

Older adults in jail: high rates and early onset of geriatric conditions

BACKGROUND

The number of older adults in the criminal justice system is rapidly increasing. While this population is thought to experience an early onset of aging-related health conditions ("accelerated aging"), studies have not directly compared rates of geriatric conditions in this population to those found in the general population. The aims of this study were to compare the burden of geriatric conditions among older adults in jail to rates found in an age-matched nationally representative sample of community dwelling older adults.

METHODS

This cross sectional study compared 238 older jail inmates age 55 or older to 6871 older adults in the national Health and Retirement Study (HRS). We used an age-adjusted analysis, accounting for the difference in age distributions between the two groups, to compare sociodemographics, chronic conditions, and geriatric conditions (functional, sensory, and mobility impairment). A second age-adjusted analysis compared those in jail to HRS participants in the lowest quintile of wealth.

RESULTS

All geriatric conditions were significantly more common in jail-based participants than in HRS participants overall and HRS participants in the lowest quintile of net worth. Jail-based participants (average age of 59) experienced four out of six geriatric conditions at rates similar to those found in HRS participants age 75 or older.

CONCLUSIONS

Geriatric conditions are prevalent in older adults in jail at significantly younger ages than non-incarcerated older adults suggesting that geriatric assessment and geriatric-focused care are needed for older adults cycling through jail in their 50s and that correctional clinicians require knowledge about geriatric assessment and care.