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

Chronic Disease Burden and Healthcare Utilization by Gender Among US Adults with Lifetime Criminal Legal Involvement

BACKGROUND

Criminal legal involvement (CLI) has been associated with increased burden of disease, worse health outcomes, and high healthcare utilization. The health needs of women with CLI are often overlooked despite the rising proportion of women in the US legal system.

OBJECTIVE

Examine differences by binary gender in the prevalence of disease and healthcare utilization among individuals with lifetime CLI.

DESIGN/SETTING

Cross-sectional nationally representative multivariate logistic regression and negative binomial regression.

PARTICIPANTS

Adult respondents with lifetime CLI (N = 37,279) with response rate of 66-69%.

MEASURES

The primary independent variable was binary gender (woman/man). Outcomes included medical conditions, substance use disorders, mental illness, and healthcare utilization. Covariates included sociodemographic confounders.

RESULTS

Women comprised 29.1% of respondents with lifetime CLI and reported 0.83 times the odds of chronic heart disease compared to men (95%CI 0.74, 0.92; p = 0.001), but 1.86 times the odds of COPD (95%CI 1.63, 2.13; p < 0.001), 1.78 times the odds of asthma (95%CI 1.63, 1.93; p < 0.001), and 1.30 times the odds of cancer (95%CI 1.08, 1.53; p = 0.005). While women were less likely to have a substance use disorder (OR 0.84; 95%CI 0.78, 0.90), they were more likely to currently smoke (OR 1.29, 95%CI 1.20, 1.28; p < 0.001) and to have any mental illness (OR 2.45; 95%CI 2.26, 2.63; p < 0.001). Women reported increased rates of all forms of healthcare utilization compared to men after adjustments.

CONCLUSIONS

Women with lifetime CLI experience a different profile of diseases compared to men with increased prevalence of any mental illness and chronic disease, especially respiratory diseases. They also had higher rates of healthcare utilization. Additional research should focus on interventions tailored to the unique needs of this population.

Understanding and improving the quality of primary care for people in prison: a mixed-methods study

Background

People in prison are generally in poorer health than their peers in the community, often living with chronic illness and multimorbidity. Healthcare research in prisons has largely focused on specific problems, such as substance use; less attention has been paid to conditions routinely managed in primary care, such as diabetes or hypertension. It is important to understand how primary care in prisons is currently delivered in the United Kingdom and how it can be improved, in order to reduce health inequalities.

Objective

To understand the quality of primary care in prison, including gaps and variations in care, in order to recommend how quality of prison health care can be improved.

Design

A mixed-methods study with six interlinked work packages.

Setting

Predominantly the North of England.

Methods

Between August 2019 and June 2022, we undertook the following work packages: (1) International scoping review of prison healthcare quality indicators. (2) Stakeholder consensus process to identify United Kingdom focused prison healthcare quality indicators. (3) Qualitative interview study with 21 people who had been in prison and 22 prison healthcare staff. (4) Quantitative analysis of anonymised, routinely collected data derived from prison healthcare records (~ 25,000 records across 13 prisons). (5) Stakeholder deliberation process to identify interventions to improve prison health care. (6a) Secondary analysis of the qualitative data set, focusing on mental health and (6b) analysis of the quantitative data set, focusing on health care of three mental health subgroups.

Findings

Our scoping review found predominantly only papers from the United States of America and of variable rigour with the main finding being that performance measurement is very challenging in the prison healthcare setting. In collaboration with stakeholders, we prioritised, refined and applied a suite of 30 quality indicators across several healthcare domains. We found considerable scope for improvement in several indicators and wide variations in indicator achievement that could not be attributed to differences in prison population characteristics. Examples of indicators with scope for improvement included: diabetes care, medicines reconciliation and epilepsy review and control. Longer length of stay in prison was generally associated with higher achievement than shorter stays. Indicator achievement was generally low compared to that of community general practice. We found some encouraging trends and relatively good performance for a minority of indicators. Our qualitative interviews found that quality of health care is related to factors that exist at several levels but is heavily influenced by organisational factors, such as understaffing, leading to a reactive and sometimes crisis-led service. Our stakeholder deliberations suggested opportunities for improvement, ideally drawing on data to assess and drive improvement. Our mental health work package found that coded mental illness had mixed associations with indicator achievement, while the interviews revealed that mental distress is viewed by many as an inevitable facet of imprisonment.

Limitations

Our analyses of indicator achievement were limited by the quality and coverage of available data. Most study findings are localised to England so international applicability may differ.

Conclusions

Marked variations in the quality of primary care in prisons are likely to be attributable to the local organisation and conditions of care delivery. Routinely collected data may offer a credible driver for change.

Study registration

This study is registered at researchregistry.com (Ref: 5098).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/26) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 46. See the NIHR Funding and Awards website for further award information.

Perceptions of incarcerated people: prison conditions, public health, and justice in the United States

Carceral conditions in the United States may serve as a proxy for crises within justice and health systems. This study seeks to consider and measure prison climate from the perspective of incarcerated people. By examining within-facility differences in carceral experiences, results shed light on the complex nexus between the carceral context, health, and justice. We administered the Prison Climate Questionnaire (PCQ) to the complete population of incarcerated men in a correctional facility located in the Eastern United States. In this facility, housing units hold distinct populations, fulfill different functions, and can offer unique programming. We regress select items from the PCQ on a set of dummies corresponding to different residential units within the facility. Responses indicate low but relatively uniform perceptions of overall personal health, as well as access to, and satisfaction with, medical care. Between-unit differences emerge regarding staff relationships, experiences of discrimination, and levels of isolation. The perspectives of incarcerated people can, and should, play a role in understanding and conceptualizing the nature of the prison environment. Policy responses, especially those that impact the health and well-being of currently and formerly incarcerated people, can be informed by these perspectives.

Prison healthcare service use and associated factors: a cross sectional study in Northwestern Ethiopia

Introduction

Studies on inmates' Health Care Service (HCS) utilization are scarce globally, infrequent in Ethiopia while findings about the factors associated with HCS utilization are inconsistent. The present study, therefore, examined inmates' HCS utilization and associated socio-demographic and imprisonment related factors in Northwestern Ethiopia.

Methods

The study employed institution-based cross sectional research design and data was collected using questionnaire from 422 inmates in three prisons. The questionnaire collected data about prisoners' demographic characters, imprisonment related information and HCS utilization. Descriptive statistical techniques as well as bi-variate and multiple logistic regressions were used to analyse the data.

Results and discussions

The study found that 72.5%, 66.1% and 13.3% of the inmates, respectively, used medical services, guidance and counseling services, and psychiatric services. Inmates with primary education, with secondary education, and who know the availability of the services were more likely to use medical services. Inmates with accused status were less likely to use medical services than inmates with convict status. Divorced marital status and knowledge of the service availability were associated with high guidance and counseling service use. An increase in the length of stay in the prison was associated with a decrease in psychiatry service use while knowledge of service availability was associated with higher odds of psychiatry service use. There are high medical care service utilization while low mental health care service utilization among inmates in Northwestern Ethiopia. Results of the study implied that there is a critical need for immediate health care service promotion and education measures. Besides, there are also needs for large scale, longitudinal and potentially cross-cultural studies to better understand additional factors that influence inmates' HCS utilization.

Healthcare utilization and psychiatric morbidity in violent offenders: findings from a prospective cohort study

PURPOSE

Although persistent offenders with histories of imprisonment and violence have disproportionate high rates of psychiatric disorders, little is known of their psychiatric healthcare utilization (HCU) and HCU-associated factors. This study aimed to explore psychiatric HCU, psychiatric morbidity, and psychotropic prescription drugs in violent offenders with a history of incarceration.

METHODS

Male offenders aged 18-25 (n = 266) imprisoned for violent and/or physical sexual offenses were clinically assessed in 2010-2012 and prospectively followed in Swedish national registries through 2017. Register-based information regarding HCU, psychiatric morbidity, and psychotropic drugs was tracked and compared with a general population group (n = 10,000) and across offending trajectory groups. Baseline risk factors were used to explain prospective psychiatric HCU in violent offenders.

RESULTS

Violent offenders used less general healthcare and psychiatric outpatient care, but more psychiatric inpatient care and were more often given psychiatric diagnoses and psychotropic drugs than the general population. Participants previously assigned to persisting offending trajectory groups had higher rates of psychiatric HCU than those assigned to a desisting trajectory. In multivariable regression models, psychiatric HCU was associated with anxiety disorders, prior psychiatric contact, placement in a foster home, psychopathic traits, low intellectual functioning, and persistent offending.

CONCLUSIONS

Violent offenders are burdened by extensive and serious psychiatric morbidity and typically interact with psychiatric healthcare as inpatients rather than outpatients. Knowledge about their backgrounds, criminal behaviors, and psychiatric statuses can aid the planning of psychiatric services for this troublesome group.

Perceived health status and satisfaction with healthcare services of detained male individuals: a survey in Italy

OBJECTIVES

This study investigated the perceived health status and satisfaction with prison healthcare services of detained male individuals in Italy.

STUDY DESIGN

A cross-sectional study was performed between March and June 2021.

METHODS

Of 800 male detained individuals who were invited to participate in the study, 632 returned the self-administered questionnaire, resulting in a response rate of 79%.

RESULTS

Overall, 72.8% of participants reported that they were moderately or completely satisfied with their health status, and 27.2% stated that they were not at all satisfied. Moreover, 66.2% of participants reported that they had at least one health problem or disease, compared with 34% at the time of incarceration, with 35% reporting multiple health problems/diseases. In total, 10.1% of participants requested healthcare when a health problem occurred, and 12.4% were always satisfied with the healthcare that they received. Significant determinants of dissatisfaction with health status were older age, reported health problems/diseases, suicide attempts, emotional problems and no working activity in prison. Significant determinants of dissatisfaction with healthcare services were younger age, health problems at incarceration, suicide attempts and multiple experiences of incarceration.

CONCLUSIONS

This study shows that detained male individuals have multiple and frequently unmet health needs. Some of the reported health problems or diseases were present at the time of incarceration, but these often worsened and/or increased during detention. This study highlights the need to promote evidence-based intervention to strengthen the role of healthcare services provided in prisons.