Stigma management during reintegration of older incarcerated adults with mental health issues: A qualitative analysis

INTRODUCTION

The number of older prisoners with mental health issues released from prisons and forensic psychiatric institutions is rising. Their successful integration is important due to its implications for the public's safety and the individual's health and well-being. However, reintegration efforts are hampered due to the double stigma attached to 'mental illness' and 'incarceration history'. To alleviate the burden of such stigma, affected persons and their social networks employ stigma management strategies. This study sought to investigate the stigma management strategies of mental health professionals supporting older incarcerated adults with mental health issues in their reintegration process.

METHODS

Semi-structured interviews with 63 mental health professionals from Canada and Switzerland were carried out as part of the overall project. To address the reintegration topic, data from 18 interviews were used. Data analysis followed the thematic analysis approach.

RESULTS

Mental health professionals emphasized the double stigmatization of their patients which impaired their quest for housing. Lengthy searches for placement frequently resulted in patients' unnecessary long stays in forensic programs. Nevertheless, participants outlined that they were at times successful in finding appropriate housing for their patients due to the use of certain stigma management strategies. They stated that they, first, established initial contacts with outside institutions, second, educated them about stigmatizing labels and, third, provided ongoing collaboration with public institutions.

DISCUSSION

Incarcerated persons with mental health issues face double stigmatization that affects their reentry process. Our findings are interesting as they illustrate ways in which stigma can be reduced, and how the reentry process can be streamlined. Future research should include the perspectives of incarcerated adults with mental health issues to shed more light on the various options that they seek for successful reintegration after imprisonment.

Motivation and training needs of prison healthcare professionals: findings from a qualitative study

Health care in prison is a challenging task. The conditions of imprisonment create distinct difficulties for those providing health care in this setting. These particular circumstances have led to a shortage of quality professionals, working for the health of imprisoned people. The aim of this study is to elaborate reasons for healthcare professionals to work in a prison environment. The main research question is: why do healthcare workers choose to work in prisons? Furthermore, our study identifies training needs in various fields. Interview data that comes from a national project carried out in Switzerland and three other relatively wealthy countries were analyzed using content analysis. One-on-one, semi structured interviews were designed and conducted with professionals working in prison context. A total of 105 interviews were carried out and for this work 83 of them were analyzed and coded into themes responding to the study aim. Most participants chose to work in prison either because of practical reasons, as many reported various forms of contact with the studied prison environment at a younger age, or because of intrinsic reasons, including among others, having the wish to change the system of healthcare in prisons. Even though the education of the participants varied greatly, a lack of specialist training was expressed by many health care professions as an important factor. This study points out the need for more specific training programs for healthcare workers in prison and provides suggestions to ameliorate the recruitment and education for future prison health care workers.

Challenges in providing ethically competent health care to incarcerated older adults with mental illness: a qualitative study exploring mental health professionals' perspectives in Canada

BACKGROUND

The population of incarcerated older adults is the fastest growing demographic in prisons. Older persons in custody have poorer health as compared with those in the community. The unmet and complex health care needs of incarcerated older adults with mental illness raise justice, safety, dignity and fairness in care as ethical concerns. As there exists research gap to better understand these concerns, the current study aimed at exploring the perspectives of mental health professionals on challenges in delivering ethically competent care to mentally ill incarcerated older adults in Canada.

METHODS

Thirty-four semi-structured interviews were conducted between August 2017 and November 2018 with prison mental health professionals in Canada who were selected using purposive and convenience sampling techniques. The audio recorded interviews were transcribed verbatim and analysed inductively to generate themes.

RESULTS

The results were distilled into three main categories and seven subcategories that related to ethical issues in the provision of health care for mentally ill incarcerated older adults. The main categories included imprisoned older persons with special care needs, lack of resources, and the peer-support program.

CONCLUSIONS

Results of this study showed that existing practices of care of mentally ill incarcerated older adults are characterised by challenges that increase their vulnerability to worse health conditions. It is imperative for local authorities, policy makers and representatives to prepare for and respond to the challenges that compromise ethically competent health care for, and healthy ageing of, mentally ill incarcerated older adults.

Defining an age cut-off for older offenders: a systematic review of literature

PURPOSE

In the literature, 65 years is commonly used as the age to designate an older person in the community. When studying older prisoners, there is much variation. The purpose of this paper is to investigate how researchers define older offenders and for what reasons.

DESIGN/METHODOLOGY/APPROACH

The authors reviewed articles on health and well-being of older offenders to assess terminology used to describe this age group, the chosen age cut-offs distinguishing younger offenders from older offenders, the arguments provided to support this choice as well as the empirical base cited in this context.

FINDINGS

The findings show that the age cut-off of 50 years and the term "older" were most frequently used by researchers in the field. The authors find eight main arguments given to underscore the use of specific age cut-offs delineating older offenders. They outline the reasoning provided for each argument and evaluate it for its use to define older offenders.

ORIGINALITY/VALUE

With this review, it is hoped to stimulate the much-needed discussion advancing towards a uniform definition of the older offender. Such a uniform definition would make future research more comparable and ensure that there is no ambiguity when researchers state that the study population is "older offenders".

Forensic mental health professionals' perceptions of their dual loyalty conflict: findings from a qualitative study

BACKGROUND

Mental health professionals (MHP) working in court-mandated treatment settings face ethical dilemmas due to their dual role in assuring their patient's well-being while guaranteeing the security of the population. Clear practical guidelines to support these MHPs' decision-making are lacking, amongst others, due to the ethical conflicts within this field. This qualitative interview study contributes to the much-needed empirical research on how MHPs resolve these ethical conflicts in daily clinical practice.

METHODS

31 MHPs working in court-mandated treatment settings were interviewed. The interviews were semi-structured and our in-depth analysis followed the thematic analysis approach.

RESULTS

We first outline how mental health professionals perceive their dual loyalty conflict and how they describe their affiliations with the medical and the justice system. Our findings indicate that this positioning was influenced by situational factors, drawing the MHPs at times closer to the caring or controlling poles. Second, our results illustrate how participating MHPs solve their dual loyalty conflict. Participants considered central to motivate the patient, to see the benefits of treatment and its goals. Further, transparent communication with patients and representatives of the justice system was highlighted as key to develop a trustful relationship with the patient and to manage the influences from the different players involved.

CONCLUSIONS

Even though individual positioning and opinions towards dealing with the influences of the justice system varied, the results of our research show that, in spite of varying positions, the underlying practice is not very different across participating MHPs. Several techniques that allow developing a high-quality therapeutic alliance with the patient are key elements of general psychotherapy. Transparency appears as the crucial factor when communicating with the patient and with representatives of the justice system. More specifically, patients need to be informed since the beginning of therapy about the limits of medical confidentiality. It is also recommended to develop guidelines that define the level of detailed information that should be disclosed when communicating with the authorities of the justice system.

Equivalence of care? Accessibility and availability of dialysis services for older prisoners in Switzerland

PURPOSE

According to the principle of equivalence of care, health care in prison has to be of the same standard and quality as in the general population. This study aims to determine the geographic accessibility of dialysis services for older prisoners and the older general population in Switzerland and whether accessibility and availability of dialysis care are equivalent.

DESIGN/METHODOLOGY/APPROACH

Spatial accessibility analysis incorporated four different data types: population data, administrative data, street network data and addresses of prisons and hemodialysis services.

FINDINGS

Analysis revealed that the average travel time to the nearest dialysis service was better for prisoners (11.5 min) than for the general population (14.8 min). However, dialysis service for prisoners is hampered by the necessary lead-time in correctional settings, which, ultimately, leads to longer overall access times (36.5 min). Accordingly, the equivalence of dialysis care for older Swiss prisoners is not entirely respected for availability and accessibility.

ORIGINALITY/VALUE

The strength of the study lies in the combination of ethical principles and the highly tangible results of a spatial accessibility analysis. The ethics-driven empirical analysis provides arguments for policy-makers to review the current practices.

Healthcare in a pure gatekeeping system: utilization of primary, mental and emergency care in the prison population over time

BACKGROUND

This study investigates the prisoner and prison-level factors associated with healthcare utilization (HCU) and the dynamic effects of previous HCU and health events. We analyze administrative data collected on annual adult prisoner-stay HCU (n = 10,136) including physical and mental chronic disease diagnoses, acute health events, penal circumstances and prison-level factors between 2013 and 2017 in 4 prisons of Canton of Vaud, Switzerland. Utilization of four types of health services: primary, nursing, mental and emergency care; are assessed using multivariate and multi-level negative binomial regressions with fixed/random effects and dynamic models conditional on prior HCU and lagged health events.

RESULTS

In a prison setting with health screening on detention, removal of financial barriers to care and a nurse-led gatekeeping system, we find that health status, socio-demographic characteristics, penal history, and the prison environment are associated with HCU overtime. After controlling for chronic and past acute illnesses, female prisoners have higher HCU, younger adults more emergencies, and prisoners from Africa, Eastern Europe, and the Americas lower HCU. New prisoners, pretrial detainees or repeat offenders utilize more all types of care. Overcrowding increases primary care but reduces utilization of mental and emergency services. Higher expenditure on medical staff resources is associated with more primary care visits and less emergency visits. The dynamics of HCU across types of care shows persistence over time related to emergency use, previous somatic acute illnesses, and acting out events. There is also evidence of substitution between psychiatric and primary care.

CONCLUSIONS

The prison healthcare system provides an opportunity to diagnose and treat unmet health needs for a marginalized population. Access to psychiatric and chronic disease management during incarceration and prevention of emergency or acute events can reduce future demand for care. Prioritization of high-risk patients and continuity of care inside and outside of prisons may reduce public health pressures in the criminal system. The prison environment and prisoners' penal circumstances impacts healthcare utilization, suggesting better coordination between the criminal justice and prison health systems is required.

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.

Court-Mandated Patients' Perspectives on the Psychotherapist's Dual Loyalty Conflict - Between Ally and Enemy

BACKGROUND

Mental health professionals working in correctional contexts engage a double role to care and control. This dual loyalty conflict has repeatedly been criticized to impede the development of a high-quality alliance. As therapeutic alliance is a robust predictor of outcome measures of psychotherapy, it is essential to investigate the effects of this ethical dilemma.

METHODS

This qualitative interview study investigates patients' perceptions of their therapists' dual role conflict in court-mandated treatment settings. We interviewed 41 older incarcerated persons using a semi-structured interview guide, the interviews were subsequently analyzed following thematic analysis.

RESULTS

We first present the patients' perceptions of their treating psychotherapist's dual loyalty conflict, which was linked to their overall treatment experience. In a second step, we outline the study participants' reasons for this judgment, which were most commonly linked to feelings of trust or betrayal. More specifically, they named certain therapist characteristics and activities that enabled them to develop a trustful therapeutic alliance, which we grouped into four topics: (1) respecting the patient's pace and perceived coercion; (2) patient health needs to be first priority; (3) clarity in roles and responsibilities; and (4) the art of communication - between transparency and unchecked information sharing.

DISCUSSION

Developing a high quality alliance in mandatory offender treatment is central due to its relationship with recovery and desistance. Our findings show that some therapists' characteristics and activities attenuate the negative impact of their double role on the development and maintenance of the alliance. To increase the effectiveness of court-mandated treatments, we need to support clinicians in dealing with their dual role to allow the formation of a high quality therapeutic alliance. Our qualitative interview study contributed to this much-needed empirical research on therapist' characteristics promoting a trustful relationship in correctional settings.

The mental and physical health of older offenders: A systematic review and meta-analysis

A systematic review with meta-analysis was performed to: 1) estimate the prevalence of both mental and physical health problems in older offenders; 2) calculate relative risks for the health conditions in relation to non-offender older adults and; 3) explore the potential confounding role of several variables. We searched five databases up to August 2019. Studies involving offenders older than 50 years old were included. Fifty-five publications met criteria. The pooled prevalence for 18 mental and 28 physical health problems was calculated. In comparison with non-offender older adults, older offenders showed significantly higher risk for Hypertension (RR = 1.16, CI = 1.1, 1.2), Cardiovascular Diseases (RR = 1.24, CI = 1.09, 1.41), Respiratory diseases (RR = 1.75, CI = 1.29, 2.35), and Arthritis (RR = 1.19, CI = 1.12, 1.25). Heterogeneity was significant for all meta-analyses and partially explained by the confounding effect of country, the diagnosis assessment method, and the sample characteristics. Future research should include comparison groups of non-offender older adults and use longitudinal study designs to identify risk factors that can be targeted in preventive programmes.

Examining the role of depression in the Filipino elderly's food preferences in prison setting: data from conjoint analysis and SEM

PURPOSE

Previous studies suggest that the care for elderly prisoners is a growing problem. The emerging phenomenon such as the correctional ageing crisis is an urgent concern that needs to be collectively and holistically addressed from a multi-sectoral perspective. In a developing country, like the Philippines, where prison congestion is alarming, the need for more empirical investigations that probe into the prison life and services is warranted to better inform penal policy and practice that would improve health outcomes among incarcerated individuals. The purpose of this study is to examine the extent to which depression among Filipino elderly prisoners shape their food choices.

DESIGN/METHODOLOGY/APPROACH

A survey of 160 Filipino elderly prisoners of age 60 and above from October to November 2018 was conducted using a three-part research instrument, which consists of a personal and nutrition-related checklist, 15-point geriatric depression scale and a set of cards that were ranked and sorted through the balanced incomplete block design.

FINDINGS

Results of the survey were subjected to conjoint analysis and structural equation modeling using the Statistical Package for the Social Sciences 24. Interestingly, taste was the most considered attribute (30.765%) while portion size (9.759%) is the least considered by the Filipino elderly prisoners. Notably, depression has a significant positive effect on their food preferences in all attributes except portion size.

RESEARCH LIMITATIONS/IMPLICATIONS

This study was limited to two prison settings in the Philippines. Considering the results from the conjoint analysis, strategies can be developed in designing an individualized meal plan suitable for the needs of each elderly prisoner. Also, sizeable government appropriations should be in place to ensure the nutritional quality of food served to aging Filipino prisoners.

PRACTICAL IMPLICATIONS

Provisions for a pool of nutritionists working hand in hand with other health members would guarantee a prison system that promotes the overall well-being of each prisoner. Further, this study can contribute valuable inputs in the menu cycle practice of prisons in the country. There may be a need to prioritize the nutritional aspect of these vulnerable and deprived groups so as to promote a better quality of life among elderly prisoners. Also, other forms of psychosocial, physical and spiritual health activities extended to elderly prisoners may prevent depressive symptoms.

ORIGINALITY/VALUE

Conjoint analysis is remarkably gaining prominence in not only the health-care setting (Phillips et al., 2002; Ryan and Farrar, 2000) but also the field of nutrition. It holds a number of unique and practical promises to prison settings.

Polypharmacy and drug-drug interactions among older and younger male prisoners in Switzerland

PURPOSE

The purpose of this paper is to determine the prevalence of polypharmacy and drug-drug interactions (DDIs) in older and younger prisoners, and compared if age group is associated with risks of polypharmacy and DDIs.

DESIGN/METHODOLOGY/APPROACH

For 380 prisoners from Switzerland (190 were 49 years and younger; 190 were 50 years and older), data concerning their medication use were gathered. MediQ identified if interactions of two or more substances could lead to potentially adverse DDI. Data were analysed using descriptive statistics and generalised linear mixed models.

FINDINGS

On average, older prisoners took 3.8 medications, while younger prisoners took 2.1 medications. Number of medications taken on one reference day was higher by a factor of 2.4 for older prisoners when compared to younger prisoners (p = 0.002). The odds of polypharmacy was significantly higher for older than for younger prisoners (>=5 medications: odds ratio = 5.52, p = 0.035). Age group analysis indicated that for potentially adverse DDI there was no significant difference (odds ratio = 0.94; p = 0.879). However, when controlling for the number of medication, the risk of adverse DDI was higher in younger than older prisoners, but the result was not significant.

ORIGINALITY/VALUE

Older prisoners are at a higher risk of polypharmacy but their risk for potentially adverse DDI is not significantly different from that of younger prisoners. Special clinical attention must be given to older prisoners who are at risk for polypharmacy. Careful medication management is also important for younger prisoners who are at risk of very complex drug therapies.

Effect of age, time spent in prison and level of education on the perceived health and quality of life of elderly prisoners

PURPOSE

The purpose of this paper is to assess the level of perceived health and quality of life of elderly prisoners in France, and to see whether there is a link between aging, time spent in prison and level of education and scores for perceived health and quality of life.

DESIGN/METHODOLOGY/APPROACH

The authors' recruited 138 male prisoners aged 50 and over in seven French prisons. The research protocol comprised a semi-structured interview and two scales.

FINDINGS

The results revealed low levels of perceived health and quality of life among the elderly inmates. They also showed that age was not statistically associated with most of the dimensions of perceived health on the Nottingham Health Profile (NHP), with the exception of poor mobility. By contrast, age was statistically associated with most of the dimensions of quality of life on the WHOQOL-Bref. Time spent in prison was only associated negatively with the "sleep" dimension of the NHP. Emotional reactions were perceived most positively by the inmates with the highest level of education.

PRACTICAL IMPLICATIONS

It seems particularly important to assess the perceived health and quality of life of elderly prisoners in order to ensure their appropriate treatment and management.

ORIGINALITY/VALUE

Very few studies have examined the perceived health and quality of life of prisoners, even though this population is particularly vulnerable in terms of physical and mental health.

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.

Prescription of pain medication in prisons: A comparative analysis of younger and older male prisoners

PURPOSE

In prison populations, treating pain is particularly challenging, especially for the growing number of older prisoners. The objective was to find out about prevalence, frequency, and types of pain medications prescribed to older prisoners (≥50 years) in comparison with younger prisoners (<50 years).

METHODS

Data were collected in Switzerland as part of a study on ageing prisoners' health. Fifteen prisons (out of 26 of the total eligible population) agreed to take part, and data from medical records of 190 older and 190 younger male prisoners were analysed. Descriptive statistics on pain medication prescriptions (excluding drugs used in opioid dependence) were carried out and differences between the 2 age groups tested for statistical significance.

RESULTS

More than half of younger and older prisoners were prescribed pain medication during the past 180 days, while 10% of younger and 15% of older prisoners were prescribed pain medication on a daily basis. Nonsteroidal anti-inflammatory drugs and "other analgesics and antipyretics" were most frequently prescribed. Significantly (P < .05), more younger than older prisoners were prescribed NSAIDs and drugs to treat muscle skeletal pain. Tramadol was the opioid most often prescribed.

CONCLUSIONS

This is the first empirical study investigating prescriptions of pain medication in Swiss prisoners on a national level. It shows that nonopioid pain medication is an important part of health care provision inside prison, while there are only few prescriptions of strong opioids. Research is needed to investigate whether the standard set by the principle of equivalence is met regarding treatment of pain in prison.

Identity as an older prisoner: findings from a qualitative study in Switzerland

The increasing numbers of aging prisoners raise the issue of how they maintain their personal identity and self-esteem in light of long-standing detention. This study sought to answer this question since identity and self-esteem could influence mental and physical health. We conducted a secondary analysis of 35 qualitative interviews that were carried out with older inmates aged 51-75 years (mean age: 61 years) living in 12 Swiss prisons. We identified three main themes that characterized their identity: personal characterization of identity, occupational identity, and social identity. These main themes were divided into sub-themes such as familial network, retirement rights or subjective social position. Personal characterization of identity mostly happened through being part of a network of family and/or friends that supported them during imprisonment and where the prisoner could return to after release. Individual activities and behavior also played an important role for prisoners in defining themselves. Occupational identity was drawn from work that had been carried out either before or during imprisonment although in some cases the obligation to work in prison even after reaching retirement age was seen as a constraint. Social identity came from a role of mentor or counselor for younger inmates, and in a few cases older prisoners compared themselves to other inmates and perceived themselves as being in a higher social position. Identity was often expressed as a mix between positive and negative traits. Building on those elements during incarceration can contribute to better mental health of the individual prisoner which in turn influences the chances for successful rehabilitation.

The determinants of individual health care expenditures in prison: evidence from Switzerland

BACKGROUND

Prison health systems are subject to increasing pressures given the specific health needs of a growing and aging prison population. Identifying the drivers of medical spending among incarcerated individuals is therefore key for health care governance in prisons. This study assesses the determinants of individual health care expenditures within the prisons of the canton of Vaud, a large region of Switzerland.

METHODS

We use a unique dataset linking demographic and prison stay characteristics as well as objective measures of morbidity to detailed medical invoice data. We adopt a multivariate regression approach to model total, somatic and psychiatric outpatient health care expenditures.

RESULTS

We find that chronic infectious, musculoskeletal and skin diseases are strong predictors of total and somatic costs. Schizophrenia, neurotic and personality disorders as well as the abuse of illicit drugs and pharmaceuticals drive total and psychiatric costs. Furthermore, cumulating psychiatric and somatic comorbidities has an incremental effect on costs.

CONCLUSION

By identifying the characteristics associated with health care expenditures in prison, this study constitutes a key step towards a more efficient use of medical resources in prison.

Patterns of older and younger prisoners' primary healthcare utilization in Switzerland

Purpose The purpose of this paper is to identify primary health concerns prompting older and younger prisoners in Switzerland to consult a nurse or a general practitioner (GP) within the prison healthcare setting, and explores if these reasons for visits differ by age group (49 years and younger vs 50 years and older). The authors used 50 years and older as the benchmark for older prisoners in light of literature indicating accelerated aging among prisoners. Design/methodology/approach Retrospective information from medical records of 406 prisoners were collected for a period of six months. This study analyzed the reasons for which prisoners visited the nurses and GPs available to them through the prison healthcare service. These reasons were coded using the International Classification of Primary Care-version 2. Data were analyzed descriptively and four generalized linear models were built to examine whether there was an age group difference in reasons for visiting nurses and GPs. Findings The health reasons for visiting nurses and GPs by 380 male prisoners from 13 Swiss prisons are presented. In the six month period, a total of 3,309 reasons for visiting nurses and 1,648 reasons for visiting GPs were recorded. Prisoner participants' most common reasons for both visits were for general and unspecified complaints and musculoskeletal problems. Older prisoners sought significantly more consultations for cardiovascular and endocrine problems than younger prisoners. Research limitations/implications Nurses play an important role in addressing healthcare demands of prisoners and coordinating care in Swiss prisons. In light of age-related healthcare demands, continuing education and training of both nurses and GPs to adequately and efficiently address the needs of this prisoner group is critical. Allowing prisoners to carry out some care activities for minor self-manageable complaints will reduce the demand for healthcare. Originality/value This study presents unique data on healthcare concerns for which prisoners visit prison nurses and GPs. It highlights the varied needs of older prisoners as well as how these needs are addressed based on the availability of the primary healthcare provider within the prison.

Exploring differences in healthcare utilization of prisoners in the Canton of Vaud, Switzerland

Prison healthcare is an important public health concern given the increasing healthcare needs of a growing and aging prison population, which accumulates vulnerability factors and suffers from higher disease prevalence than the general population. This study identifies the key factors associated with outpatient general practitioner (GP), nursing or psychiatric healthcare utilization (HCU) within prisons. Cross-sectional data systematically collected by the prison medical staff were obtained for a sample of 1664 adult prisoners of the Canton of Vaud, Switzerland, for the year 2011. They contain detailed information on demographics (predisposing factors), diagnosed chronic somatic and psychiatric disorders (needs factors), as well as prison stay characteristics (contextual factors). For GP, nurse and psychiatric care, two-part regressions are used to model separately the probability and the volume of HCU. Predisposing factors are generally not associated with the probability to use healthcare services after controlling for needs factors. However, female inmates use higher volumes of care, and the volume of GP consultations increases with age. Chronic somatic and psychiatric conditions are the most important predictors of the probability of HCU, but associations with volumes differ in their magnitude and significance across disease groups. Infectious, musculoskeletal, nervous and circulatory diseases actively mobilize GP and nursing staff. Schizophrenia, illicit drug and pharmaceuticals abuse are strongly positively associated with psychiatric and nurse HCU. The occupancy rate displays positive associations among contextual factors. Prison healthcare systems face increasingly complex organizational, budgetary and ethical challenges. This study provides relevant insights into the HCU patterns of a marginalized and understudied population.

Growing Old Behind Bars: Health Profiles of the Older Male Inmate Population in the United States

OBJECTIVE

This study examines patterns of multimorbidity among elderly male inmates across four domains of health (chronic medical conditions, drug- and alcohol-related diseases, impairments, and mental and behavioral health) to understand the complex health care needs of this growing population.

METHOD

We use the 2004 Survey of Inmates in State Correctional Facilities and Latent Class Regression Analysis to examine 22 health problems among 1,026 men aged 50 and older.

RESULTS

There are four groups of elderly male inmates: (a) relatively healthy (45.1%), (b) substance users with behavioral health issues (23.4%), (c) chronic unhealthy with impairments and violence/injury (23.6%), and (d) very unhealthy across all domains (7.9%). These groups have unique sociodemographic background and incarceration history characteristics.

CONCLUSION

This study demonstrates the complexity of health for elderly inmates. Prison health should continue to be monitored to aid correctional and community health programs in understanding clinical risks, exposures, and health care needs for this population.