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

Providing Equitable Surgical Care to Patients in Law Enforcement Custody: A Review

Importance

Approximately 2 million individuals are incarcerated in the US. Surgical needs increase with age, and an aging prison population means an increasing need for surgical care for incarcerated individuals. Challenges in logistics, privacy, communication, and comorbidities put people in law enforcement custody at risk for suboptimal care and outcomes. Little guidance exists for surgeons seeking to provide equitable care for these patients.

Observations

No national statistics are available on the need for surgery among incarcerated people. Autopsy data suggest that nearly a quarter of deaths among incarcerated individuals were attributable to causes that could have been treated with surgery, yet few received surgical care before death. Across the spectrum of custody, including police detention, jail, prison, probation, and parole, access to consistent preoperative and postoperative care are major challenges, as is sustaining appropriate levels of privacy and communication. Incarcerated people are often accompanied by guards, preventing privacy. Patients are shackled to hospital beds, restricting mobility. For incarcerated individuals, access to postoperative medication may be curtailed when they return to jail or prison. To be effective advocates for patient-centered care and to achieve the best outcomes, surgeons must remain vigilant to specific barriers to care.

Conclusions and Relevance

Individuals in law enforcement custody have particular needs regarding communication, surgical planning, and perioperative and postoperative care. Clinicians must remain alert to these challenges and serve as advocates for these marginalized patients, even adjusting their care practices. Professional societies and health systems can bolster care for this marginalized population by developing and disseminating guidelines and pathways for patient-centered surgical care for individuals in law enforcement custody.

Benefits and Limitations of Teledermatology in German Correctional Facilities: Cross-Sectional Analysis

Background

Teledermatology consultations offer the advantage of rapid diagnosis and care. Since 2019, our institute at the University Medical Center Hamburg-Eppendorf has been part of an interdisciplinary team for teledermatology support in German prisons as an alternative to extramural transports of patients.

Objective

This study aims to analyze the benefits and limitations of teledermatology for patients with limited access to medical specialties.

Methods

We conducted a descriptive cross-sectional analysis of 651 teleconsultations from prisons from February 2020 to April 2023. All cases were performed in a store-and-forward (asynchronous mode) and optional hybrid live (synchronous) consultation for the patient or in-house staff.

Results

The main advantage of this case processing was the avoidance of external transport. Of the 651 teleconsultations, 608 (93.4%) could be finalized with telemedical support and 43 (6.6%) required additional workup, including verifications of the type of tumors (n=22, 51%), which needed biopsies, and open cases that were inflammatory (n=11, 26%) or involved infectious skin conditions (n=5, 12%). Digital imaging of the skin lesions improved with the experience of the personnel but remained a challenge, with the photo quality depending on the technical devices or available broadband supply.

Conclusions

Hybrid teledermatology consultation represents an effective and resource-saving method of providing specialized care to patients in situations with limited access to medical specialties. The video consultations with experts and exchange of knowledge about the cases presented opened the opportunity to support and train intramural colleagues. One of the main challenges remains the quality of digital imaging and transmission.

Cancer and Chronic Disease Comorbidity in Incarcerated Individuals in the United States, Survey of Prison Inmates 2016

PURPOSE

There are limited studies examining the cancer and chronic disease comorbidity in individuals who are incarcerated in the United States.

METHODS

We used the weighted analysis of 20,064 individuals from the 2016 Survey of Prison Inmates in state correctional facilities across 50 states, to examine cancers and other reported comorbid chronic conditions or diseases.

RESULTS

45 % of 20,064 individuals reported living with at least one chronic disease. The proportion of individuals currently having cancer was 1.23 % while 4.82 % reported ever being diagnosed with cancer by a medical professional. Incarcerated individuals with any chronic condition or diseases reported a higher risk of currently having cancer after adjusting for smoking, time incarcerated and age (OR, 2.18; 95 % CI, 1.43-3.31) compared to individuals not reporting having any chronic diseases.

CONCLUSIONS

There is a high burden of chronic diseases in individuals who are incarcerated, and these common chronic conditions are associated with currently having cancer even after adjusting for key risk factors for cancer like prior smoking and age. Efforts to reduce the high prevalence of chronic disease and improve cancer screening policies are necessary to improve the health of individuals who are incarcerated.

Incarceration is associated with higher mortality after trauma: An unreported health care disparity

BACKGROUND

While the United States has the highest incarceration rate worldwide, at nearly 1% of the adult population (more than 2 million people), insights regarding health disparities in this population remain limited. This retrospective cohort study represents the largest national database analysis of incarcerated trauma patients to date and investigates whether incarceration status is an independent risk factor for poor outcomes after trauma for US adults.

METHODS

We analyzed data from the National Trauma Data Bank from 2017 to 2018. Using multilevel logistic regression, we measured risk-adjusted associations between incarceration status (assessed by International Classification of Diseases, Tenth Revision , location codes) and trauma outcomes: mortality, any in-hospital complications, aggregate major complications, and failure to rescue. We report odds ratios and 95% confidence intervals, adjusting for demographics, transfer status, insurance, comorbidities, injury mechanism, injury severity, and presenting vitals. A secondary analysis was performed using nearest neighbor matching with a 2:1 ratio of nonincarcerated to incarcerated patients, followed by multilevel logistic regression.

RESULTS

There were 12,888 incarcerated patients and 1,654,254 nonincarcerated patients. Incarcerated patients were younger (median, 36 vs. 55 years), more likely to be male (94.9% vs. 60.5%), Black (27.9% vs. 13.9%), and Hispanic (15.7% vs. 11.5%) and presented more frequently with minor injuries (Injury Severity Score, <9; 65.4% vs. 48.9%) and with stabbings and other blunt events as mechanisms of injury. Although unadjusted mortality was lower for incarcerated patients, after adjustment, they were significantly more likely to die (adjusted odds ratio (AOR), 1.42 [1.19-1.68]), which was consistent in the matched analysis (AOR, 1.19 [1.03-1.36]). Incarcerated patients were, conversely, less likely to suffer any in-hospital complication (AOR, 0.76 [0.68-0.85]; matched AOR, 0.88 [0.81-0.97]).

CONCLUSION

Our study redemonstrated that incarcerated trauma patients' demographics and injuries differ significantly from nonincarcerated patients. Furthermore, incarceration was an independent risk factor for mortality, a previously unreported disparity. This highlights the need for improved data collection regarding incarceration status and national prospective investigations.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

How competing needs after incarceration lead to adverse health outcomes among people who use criminalized drugs

In the USA, people with a history of criminalized drug use and drug use disorders reentering the community after incarceration frequently experience adverse health outcomes including overdose, suicide, and infectious disease acquisition. This review presents a conceptual model for understanding risk pathways for these outcomes related to post-release psychosocial needs. We first summarize the literature on post-release needs experienced by people who use criminalized drugs during reentry in multiple domains, including basic needs and those related to relationships as well as medical, mental health, and substance use problems. Drawing from a socioecological model, we demonstrate how vulnerability factors related to criminal legal involvement and criminalized drug use operate at intrapersonal (i.e., individual), interpersonal, institutional, community, and policy levels to negatively affect the ability of people who use drugs to meet each of these types of needs. We present research demonstrating that when people leaving incarceration are met with the overwhelming task of addressing competing demands, they often experience strong negative affect, which can lead to risk-conferring behaviors including criminalized drug use. Competing needs also create environmental conditions that amplify risk. We argue for the importance of interventions that address determinants of post-release health at individual and social-environmental levels to prevent adverse outcomes.

"Deaf behind bars": a global scoping review on the situation and experiences of detained people with hearing impairment

PURPOSE

The global prison population is rising, with over 11.5 million people in prison on any given day. Very little is known about hearing impairment in prison populations, despite prisons being a sound-centric closed environment. This study, a scoping review, aims to map and describe what is known about the situation and experiences of detained people with hearing impairment.

DESIGN/METHODOLOGY/APPROACH

This study is a global scoping review. A comprehensive search confined to the English language was conducted on Web of Science, Scopus and PsycINFO with no date restriction. The final data set of 28 records was charted and analysed thematically.

FINDINGS

Four themes were interpretation deficits in the criminal justice process; detachment, inability to communicate and isolation in the prison soundscape; prison staff communication challenges and discriminatory views; and hearing health in prison.

ORIGINALITY/VALUE

The review is intended to inform the formulation of auditory disability-inclusive criminal justice strategies and practices to support those with hearing impairment when navigating the system.

Cardiovascular Disease in Women's Prisons: A Qualitative Study of Dietary Habits from the Perspective of Professionals

Background: Cardiovascular disease (CVD) is the leading cause of death worldwide and is exacerbated by poor dietary habits, particularly in settings such as women's prisons. Incarcerated women are often exposed to ultra-processed foods, limited nutritional education, and restricted living conditions that increase their risk of CVD. Objectives: This study aimed to explore the challenges perceived by professionals in a Portuguese women's prison regarding the prevention of CVD, particularly through dietary interventions. Methods: A qualitative, exploratory and descriptive study was conducted using a focus group with six professionals. Data were collected in July 2024 and analysed using thematic content analysis. Results: Three thematic categories emerged: (1) contextual challenges of the prison system (e.g., sedentary lifestyle, limited food options); (2) socio-cultural resistance to behavioural change (e.g., low adherence to health programmes, use of food as a coping mechanism); and (3) the need for sustainable and interdisciplinary intervention strategies. Conclusions: The findings highlight the complexity of promoting cardiovascular health in female prisoners. Interventions need to take into account mental health support, prisoner autonomy and institutional constraints. Future research should develop and test targeted, context-specific nutrition programmes in similar settings.

Linkages between incarceration and health for older adults

The aging population in United States (US) correctional facilities has grown dramatically over the last several decades. At present, roughly one in four adults incarcerated in US prisons are at least 50 years of age. Research over the last ten years has likewise expanded to catalog the impacts of incarceration on older adults, and the myriad ways incarceration is unique for this population. In this paper, we summarize the state of the literature at the intersection of incarceration, health, and aging. We begin by outlining the impacts of incarceration on a range of individual health outcomes for older adults. Next, we offer targeted policy implications to address the health consequences of incarceration for older adults. Finally, we conclude by offering a research agenda that emphasizes theory building, jail-based approaches, and expansion of what is known about older women, cognitive impairment, correctional staff perspectives, and interventions to enhance the health of older persons who are incarcerated.

Ophthalmic consultations for incarcerated patients: An 11-year experience at a tertiary care center

INTRODUCTION

Ophthalmic care of incarcerated individuals is understudied, particularly in the inpatient setting. We evaluated ophthalmic consultation findings, interventions and outcomes at a tertiary care center.

METHODS

For this retrospective noncomparative cohort study, data were collected on demographics, diagnoses, interventions, and outcomes for incarcerated patients for whom ophthalmic consultation was ordered at an academic medical center between December 2011 and December 2022.

RESULTS

The study cohort included 163 patients (mean age = 38 years) in custody at Maryland state correctional facilities. The majority of patients were male (95.7 %) and/or Black (71.8 %). The most common reason for consultation was trauma (135 of 163, 82.8 %). Among patients presenting for trauma, the mechanism of injury was documented as assault in 117 cases (86.7 %). Among trauma patients, 56 (41 %) required surgical intervention. In total, 20 open reduction and internal fixation of orbital fractures, 11 open globe repairs, and 36 eyelid laceration repairs, as well as 3 other surgeries (anterior chamber washout, vitrectomy, and placement of an orbital implant after autoenucleation) were performed. Loss to follow-up was high; 68 patients (42 %) had no follow-up visits despite recommendations for follow-up at discharge.

CONCLUSION

Ocular trauma was the most common reason for ophthalmic consultation for incarcerated patients in the hospital setting, accounting for >80 % of consults. Over 40 % of prisoners presenting for ocular trauma required surgery. Even in the custody of the state, inmates are not protected from ocular trauma. These findings suggest a need for creative, humane interventions and policy initiatives to address violence in correctional facilities.

They Judge You By Your Incarceration: A Qualitative Study of Mistrust Among Formerly Incarcerated People Navigating Mental Health Care

The goal of this paper is to explore the experiences of formerly incarcerated people navigating mental health care post-release and understand how mistrust of mental health services and providers is manifested among this population. Interviews were conducted between 2021 and 2022 with 25 people released from incarceration within the past five years. We partnered with community organizations to recruit a diverse sample of participants, using voluntary response and purposive sampling. The interview transcripts were coded using a modified grounded theory approach and the analysis further guided by critical phenomenology in order to center silenced or marginalized perspectives. Mistrust of mental health care was a prominent theme across interviews. Overall, participants felt that they did not have autonomy over their treatment planning and management. Participants described experiencing stigmatizing treatment from providers, suspicion of mandated mental health treatment, and believing that profit over patients was prioritized in the industry-all of which contributed to growing mistrust of the larger mental health system. The participants' experiences of losing control over their lives and treatment, compounded by a perceived complicity between mental health and carceral systems, shaped their mistrust toward mental health care. Nevertheless, many demonstrated remarkable persistence in seeking care and engaging with multiple providers, while also actively seeking to reclaim their autonomy.

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.

A Massive Ear Canal Mass Resulting from an Embedded Arthropod

OBJECTIVE

To describe a case of a massive ear mass obstructing the external auditory canal (EAC) attributed to an embedded arthropod, highlighting the diagnostic and therapeutic challenges posed by unusual etiologies of ear masses.

PATIENTS

The case was a 35-year-old female prisoner who presented with a 5 × 5.5 cm palpable exophytic mass obstructing the right EAC, accompanied by progressive hearing loss, bloody discharge, and persistent tinnitus.

INTERVENTIONS

Surgical excision of the infiltrating mass involving mastoidectomy and canaloplasty.

MAIN OUTCOME MEASURES

Initial pathology suggested a pyogenic granuloma, but further analysis revealed a degenerating arthropod within reactive myofibroblastic and vascular changes. The patient was lost to follow-up despite a multidisciplinary treatment approach and primary surgical excision of the mass.

RESULTS

After surgical excision, the mass was confirmed as a florid reactive myofibroblastic and vascular mass enveloping a degenerating arthropod. The patient responded well to treatment without signs of infection or recurrence during follow-up.

CONCLUSIONS

We report a case that emphasizes the importance of considering unusual etiologies for ear masses, especially in at-risk populations. It underscores the necessity for refined diagnostic and therapeutic strategies to manage similar clinical scenarios in the future.

The Nutritional Assessment of Bureau of Prisons Mid-Atlantic Region Commissary Offerings

The Federal Bureau of Prisons (BOP) has both formal policies and internal guidelines for commissary food items that aim to increase access and provide nutritional information for individuals who experience incarceration. The purpose of this research was to determine (a) the nutritional assessment of commissary offerings by the BOP Mid-Atlantic Region because little is known about the foods offered in commissaries, (b) if the BOP commissaries align with recommended packaged snack food and nutrition standards, and (c) if they follow their own policies and standards for healthy commissary food offerings. Commissary lists for 21 BOP commissaries in the Mid-Atlantic Region were collected. Food items were analyzed and categorized based on the BOP's list of healthy commissary food options. None of the commissaries met all the standards. The BOP does not align its current policy or healthy commissary food options with the U.S. Department of Health and Human Services' Food Service Guidelines for Federal Facilities. Furthermore, the BOP does not follow their own internal policies and standards for healthy commissary food options. The food availability is dominated by a few select items. The omission of adequate healthy options in commissaries increases preventable health risk exposure to individuals experiencing incarceration.

Neglect, Recklessness, and Deliberate Indifference in the Face of a Serious Neurosurgical Pathology: Lessons From the Tragic Fate of Prisoner Elliot Earl Williams

The US prison system, which houses nearly 2 million people, depends on its healthcare agents to provide the first line of diagnosis and treatment for any medical needs that arise during incarceration. Given the high rates of illness and injuries in this population, there is a pressing need for high-quality medical care. However, surgeons often observe that the system frequently fails to provide adequate healthcare services to incarcerated individuals. This study examines an instance of neglect, recklessness, and deliberate indifference in the facet of a serious acute traumatic spinal pathology, which made it to the lay press headlines several years ago. This case involves a prisoner who suffered a cervical spine trauma and, because of delayed diagnosis and treatment, ultimately progressed to quadriplegia and death. Through an analysis of the case's background, legal context, and outcomes, alongside a review of the formal legal complaint filed with the US District Court for the Northern District of Oklahoma, this article provides a detailed root-cause analysis of the systemic failures which led to this unfortunate outcome. Ultimately, the tragic case of US Veteran Elliott Earl Williams serves as a unique learning opportunity for surgeons, physicians, healthcare workers, correctional staff, and facility administrators so that the healthcare system for inmates can be improved to prevent future similar cases.

A Primer on Carceral Health for Clinicians: Care Delivery, Regulatory Oversight, Legal and Ethical Considerations, and Clinician Responsibilities

The United States has one of the highest incarceration rates in the world, with approximately 1.7 million individuals detained in jails or federal or state prisons. Chronic medical conditions are more prevalent among adults in custody than among their nonincarcerated counterparts, resulting in needs that often surpass the on-site medical treatment capabilities of carceral facilities. For this reason, many community-based health care professionals will encounter incarcerated patients in an ambulatory or inpatient setting. Yet, although carceral status engenders pragmatic and ethical complexities in patient care, health care professionals in academic and community settings receive little or no education about correctional health. This special article seeks to address this knowledge gap by providing demographic and patient characteristics of this population, describing health care delivery in the criminal legal system, summarizing incarcerated patients' health care rights, conveying the current state of oversight and regulation for correctional health care, and presenting the role of health care professionals in advocating for the ethical care of incarcerated patients. By equipping themselves with this knowledge, clinicians may provide holistic and ethical care for persons involved in the criminal legal system.

Establishing National Standards for Carceral Health Care-The Federal Prison Oversight Act

This Viewpoint discusses how the health care quality that individuals receive while incarcerated is often deficient and how the passage of the Federal Prison Oversight Act represents an opportunity to improve the health of those living and working in carceral facilities.

Structural Determinants of Health Literacy Among Formerly Incarcerated Individuals: Insights From the Survey of Racism and Public Health

BACKGROUND

Formerly incarcerated individuals (FIIs) encounter difficulties with covering the cost of dental and medical care, adhering to medication regimens, and receiving fair treatment from health care providers. Yet, no published research has examined modifiable pathways to increase FIIs' health literacy (HL), which is essential for addressing the health needs of this vulnerable population.

OBJECTIVE

The aim of this article is to examine neighborhood characteristics (neighborhood deprivation, racial and economic polarization, and residential segregation) and public assistance program enrollment as structural determinants of limited health literacy (LHL) among FIIs.

METHODS

Using a socioecological framework, we analyzed a subsample of 578 FIIs from the 2023 Survey of Racism and Public Health, an online cross-sectional survey spanning U.S. Department of Health & Human Services Regions 1, 2, and 3. HL was assessed using the Brief Health Literacy Screen. Logistic regression models estimated unadjusted and adjusted associations of LHL with neighborhood characteristics and public assistance program enrollment. Adjusted models controlled for age, race and ethnicity, gender identity, educational attainment, marital and employment status, number of children, chronic health conditions, and incarceration length.

KEY RESULTS

The 578 FIIs had an average age of 46, with 42% having LHL. We observed a statistically significant association between public assistance program enrollment and LHL (unadjusted odds ratio [OR] = 2.72, 95% confidence interval [CI]: 1.87, 4.01; adjusted OR = 2.50, 95% CI: 1.62, 3.88). We found no statistically significant associations of LHL with neighborhood deprivation, racial and economic polarization, and residential segregation.

CONCLUSIONS

Our findings suggest that there may be an opportunity to develop tailored interventions for increasing HL among FIIs through public assistance programs. Dissemination of HL resources among this marginalized group can improve their self-management of chronic diseases. This is of paramount importance because FIIs must simultaneously navigate other challenges after incarceration (e.g., unstable housing). [HLRP: Health Literacy Research and Practice. 2025;9(1):e8-e18.].

Undernutrition and associated factors among incarcerated people in Bahir Dar and Finote Selam prison sites, Northwest Ethiopia: a cross-sectional study

Background

Prison is designed with punishment, correction and rehabilitation to the community in mind and these goals may conflict with the aims of healthcare. Incarcerated peoples' dependency on the prison-limited food menu, inadequate meal provision and poor-quality food increases the risk of malnutrition.

Objective

To assess the magnitude of undernutrition and associated factors among incarcerated people, Northwest Ethiopia, 2019.

Design

An institution-based cross-sectional study was conducted in Bahir Dar and Finote Selam prison sites, in Northwest Ethiopia.

Methods

This study was conducted from 18 March 2019 to 18 April 2019. 475 systematically selected incarcerated people from each prison site were included in this study. Data were collected using structured interviewer-administered questionnaires. A binary logistic regression model was used to identify the associated factors.

Results

The magnitude of undernutrition among incarcerated people was 19.4%. Not getting family support (adjusted OR (AOR)=3.05, 95% CI=(1.56, 5.96)), not involving with income-generating activities (AOR=2.68, 95% CI=(1.33, 5.40)), diarrhoeal disease (AOR=4.60, 95% CI=(2.14, 9.87)), food allergy (AOR=2.83, 95% CI=(1.47, 5.45)) and chewing khat (AOR=2.93, 95% CI=(1.07, 7.99)) were shown to have a statistically significant association with undernutrition among incarcerated people.

Conclusion

The burden of undernutrition was high. Various factors contribute to undernutrition such as lack of family support, limited involvement in income-generating activities, diarrhoeal disease, food allergy and a history of chewing khat.

Mortality among individuals with substance use disorder-does violent criminal behavior have an impact?

Introduction

Understanding violent criminality and its impact on health and eventually the risk of premature mortality is important for efficient future interventions. This study aimed to explore the effect violent criminality had on premature mortality (i.e., death before the age of 65) among individuals with substance use disorders (SUDs).

Methods

The cohort was created by identifying all Swedish patients diagnosed with SUD between the first of January 2013 and 31st of December 2014. The individuals were split into three age categories.

Results

There were significant differences in standard mortality rates (SMR) in the cohort compared to the general Swedish population across the three age categories. We found differences between the SMRs for individuals convicted of violent and nonviolent crimes in the two younger age categories [age 15-29: violent crime (42.4) vs. non-violent crime (36.6), age 30-44: violent crime (28.0) vs. non-violent crime (23.0)]. A Cox regression analysis showed that each conviction of a violent crime increased the hazard ratio (HR) of premature mortality significantly [age 15-29; HR = 1.10 (95% CI: 1.04-1.17), age 30-44; HR =1.06 (95% CI: 1.03-1.09)]. After correcting for non-violent crimes, the increased risk only remained for the youngest group [HR = 1.06 (95% CI: 1.00-1.13)].

Discussion

This study suggests that criminal behavior constitutes a proxy for the risk behaviors that increase the risk of premature mortality among young individuals with SUD even after controlling for confounders. Longitudinal studies, examining time-dependent risks and protective influences, are needed to explain the different pathways and processes leading to the amplified premature mortality in the groups.

Diabetes Self-Management and Care Among Incarcerated Individuals: A Systematic Review

Diabetes is prevalent among incarcerated individuals, necessitating effective management within prison settings. This study aims to assess diabetes management among incarcerated individuals and analyze the methodological aspects of relevant research focusing on incarcerated individuals with diabetes. A systematic search was conducted in PubMed, Web of Science, Scopus, and Google Scholar databases, with data parameters from 1990 to 2021 and following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, to investigate diabetes management in incarcerated individuals. The search yielded 706 records, from which 14 English-language quantitative studies meeting inclusion criteria were selected for analysis. These studies were predominantly retrospective with low levels of evidence. However, they consistently demonstrated the beneficial effects of dietary interventions, educational programs, and nursing guidance on diabetes management in incarcerated populations. This study highlights the need for more comprehensive and high-evidence research to further explore health professionals' practices with incarcerated individuals with diabetes and the effectiveness of diabetes management. Such studies are crucial for improving the quality of care provided to this vulnerable population.

An epidemiological investigation of the prevalence of digestive diseases in the older prisoner population in Taiwan

OBJECTIVE

The prison population has been increasing globally, and prisoner health is an important issue of global health. However, it has not received sufficient attention, especially in developing countries and regions. Among all the prisoners, the health status of older prisoners requires special attention due to their declining health and energy. This study aims to assess the prevalence of digestive diseases among older prisoners in Taiwan.

METHODS

Data on older prisoners from the National Health Insurance Research Database from January 1 to December 31, 2013, were used in this study. Digestive diseases were assessed in 2,215 older prisoners using the International Classification of Diseases, 9th revision Clinical Modification (ICD-9-CM). We identified the most common digestive diseases and explored any sex-specific differences in their prevalence.

RESULTS

The estimated prevalence of digestive system diseases among the prisoners was 51.56%. Older women prisoners had a higher prevalence (62.68%) compared to men prisoners in general (50.80%). Diseases with a prevalence > 10% include esophageal, gastric, and duodenal diseases; diseases of the oral cavity, salivary glands, and jaws; and other intestinal and peritoneal diseases. Women prisoners showed a significantly higher prevalence of diseases of the oral cavity, salivary glands, jaws, esophagus, stomach, duodenum, non-infectious enteritis, and colitis.

CONCLUSION

Our findings indicate that a considerable number of older prisoners in Taiwan experienced digestive diseases, which may be attributable to general deterioration of physical function and poor resistance. Early detection and treatment are crucial for these conditions, and it is important to maintain human rights and justice in prison systems.

Behind Bars: Exploring Health and Geriatric Conditions among Incarcerated Older People in Mexican Prisons

INTRODUCTION

The aging process of the incarcerated population is a growing concern, yet there are few data on older adults in this demographic group. Hence, this study sought to examine the health status of older adults who are incarcerated in Mexican prisons and its association with the duration of their imprisonment.

METHODS

This is a secondary analysis of the 2021 Mexico National Prisons Survey. We analyzed 50-year-old and older prisoners and performed a descriptive analysis of the sample's age, sex, sociodemographic variables, and chronic conditions. Multivariate analysis stratified by age was performed to assess the effect of the time spent in prison on older prisoners' health.

RESULTS

The mean age was 56.95 (±6.4 SD), and the mean duration of imprisonment was 8.93 years (±6.94 SD). Regarding health conditions, 17.80% had diabetes, 29.62% had hypertension, 10.33% had suicidal ideation, and 40.87% were visually impaired, 17.01% had hearing impairment, and 17.64% had mobility impairment. Multivariate analysis revealed that among categories of imprisonment duration, longer time imprisoned was associated with an increased risk of diabetes and hypertension for all groups but was not associated with mobility impairment or suicidal ideation except in the younger group.

CONCLUSION

Longer periods of incarceration appear to be associated with a greater occurrence of diabetes and hypertension in older prisoners. Sensory impairments and suicidal ideation are mainly identified in younger prisoners, while mobility impairments do not appear to be influenced by the time spent in prison. Further research needs to be done in prisons, where the addition of physical performance tests and cognitive tests could help further study geriatric conditions in older prisoners.

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.

Mental health and well-being in prisons and places of detention

PURPOSE

This study aims to address the critical mental health challenges faced by individuals in prisons and places of detention. By introducing and validating a novel conceptual framework that integrates social determinants of health with the stress process model, this study aims to provide actionable insights for improving mental health care in correctional settings. The research seeks to inform policymakers, prison administrators and mental health professionals about effective interventions and systemic reforms that can reduce recidivism, enhance rehabilitation and promote a more humane and just criminal justice system.

DESIGN/METHODOLOGY/APPROACH

This study uses a multi-method research design integrating a systematic literature review, qualitative interviews, multi-criteria evaluation (MCE) and a small-scale empirical study within a correctional facility. The systematic review follows PRISMA guidelines, analysing peer-reviewed articles, government reports and policy documents. Semi-structured interviews with 25 mental health professionals provide practical insights, whereas the MCE assesses intervention effectiveness based on expert consensus. The empirical study involves baseline assessments, intervention implementation and follow-up evaluations using validated tools, providing robust data to validate the proposed conceptual framework that integrates social determinants of health with the stress process model.

FINDINGS

This study finds that mental health disorders are significantly more prevalent in prison populations than in the general population, with interventions like cognitive behavioural therapy (CBT), peer support programs and trauma-informed care showing considerable effectiveness in reducing symptoms. Emerging technologies such as AI and telemedicine present promising avenues for enhancing care but require careful ethical consideration. The research also highlights the critical role of social determinants and the importance of systemic reforms, such as reducing solitary confinement and integrating prison health care with broader public health systems, in improving inmate mental health and reducing recidivism.

RESEARCH LIMITATIONS/IMPLICATIONS

This study's quasi-experimental design, while robust, may limit the generalizability of the findings to other correctional settings because of specific facility characteristics. Additionally, the sample size for qualitative interviews, although diverse, could have been larger to provide more nuanced insights, particularly for underrepresented groups. This study highlights the need for more longitudinal research to assess the long-term effects of interventions and the scalability of approaches across different cultural and legal contexts. Future studies should address these limitations by using more diverse sampling, larger sample sizes and extended follow-up periods.

PRACTICAL IMPLICATIONS

This study provides actionable insights for policymakers and prison administrators, emphasizing the need to integrate evidence-based mental health interventions, such as CBT and trauma-informed care, into prison reform strategies. It highlights the importance of training correctional staff in mental health first aid and the potential of emerging technologies like AI and telemedicine to enhance care delivery in resource-limited settings. Implementing these recommendations could significantly improve inmate mental health outcomes, reduce recidivism rates and promote a more humane and effective correctional system, with broader benefits for public health and social equity.

SOCIAL IMPLICATIONS

Improving mental health care in prisons has significant social implications, particularly in promoting social justice and reducing inequalities. Effective mental health interventions can help break the cycle of incarceration and recidivism, particularly in marginalized communities disproportionately affected by the criminal justice system. By addressing the mental health needs of incarcerated individuals, society can foster safer communities, reduce crime rates and alleviate the economic burden on the criminal justice and health-care systems. Furthermore, enhancing mental health care in prisons reflects a commitment to human dignity, fairness and the rehabilitation of offenders, contributing to a more just and compassionate society.

ORIGINALITY/VALUE

This study introduces a novel conceptual framework that integrates social determinants of health with the stress process model, specifically tailored for correctional facilities. It provides original empirical data from a real-world prison setting, offering new insights into the effectiveness of mental health interventions, such as CBT and trauma-informed care. The study's value lies in its comprehensive approach, combining quantitative and qualitative methods, and its focus on underrepresented populations in correctional settings. By addressing significant gaps in the literature, this research offers practical recommendations for policymakers and practitioners, contributing to improved mental health outcomes and reduced recidivism.

A qualitative exploration of the implementation facilitators and challenges of a community health worker program to address health disparities for people recently released from incarceration using the consolidated framework for implementation research

BACKGROUND

Despite the potential for community health worker (CHW)-led programs to improve the health of people with justice involvement (PWJI), little is known about the practical implementation of such models. We explored barriers and facilitators to implementation of a municipal CHW program, the Health Justice Network (NYC HJN), led by the New York City Department of Health and Mental Hygiene (DOHMH) in partnership with three reentry-focused community-based organizations (CBOs) and three federally qualified health centers (FQHCs) that was designed to serve the health and social service needs of PWJI.

METHODS

Eighteen in-depth qualitative interviews were conducted with a purposive sample of CHWs, partner site supervisors, and DOHMH staff. Interviews were conducted virtually and transcribed verbatim. Codes and themes were developed using the Consolidated Framework for Implementation Research (CFIR) to understand facilitators and barriers to NYC HJN implementation.

RESULTS

Important facilitators to implementation included: lived experience of CHWs, as well as NYC HJN's voluntary nature, lack of onerous eligibility criteria, and prioritization of participant needs. One barrier was the lack of a formal implementation protocol. Themes identified as facilitators in some instances and barriers in others were CHW integration into site partners, the expansive scope of work for CHWs, the integration of a trauma-informed approach, values alignment and existing infrastructure, leadership engagement, CHW training and support, and input, feedback, and communication.

CONCLUSIONS

Findings will help inform how to successfully implement future CHW-led interventions for PWJI with municipal, health, and social service partners.

Self-identified Race and Ethnicity and How this is Perceived: Associations with the Physical and Mental Health of Incarcerated Individuals

OBJECTIVES

The singular focus on self-identified race and ethnicity in health disparities research may not fully convey the individual and structural components of experiencing race in society, or in a racialized context such as prison. Processes of racialization create boundaries between incarcerated individuals and regulate their daily interactions and access to resources, with possible effects on well-being. However, the relationship between perceived race and health has not been examined within the imprisoned population.

DESIGN

We used data from the 2016 Survey of Prison Inmates (n = 23,010) to assess how self-identified race, perceived race, and the discordance between racial self-identification and perception were associated with the physical (number of chronic conditions) and mental health (psychological distress) of American Indian and Alaska Native, Asian, Black, Latino, White, and multiracial incarcerated individuals.

RESULTS

Reported perception as Latino was associated with better mental and physical health relative to perception as White. Perceived Latino identity was more strongly associated with physical and mental health than a Latino self-identity. Reported perception as Black was associated with less psychological distress than perception as White, but this relationship dissipated after accounting for self-identified race. In contrast, perceived and self-identified multiracial incarcerated individuals reported worse health than their White counterparts. Having a discordant (vs. concordant) racial identity was associated with worse physical and mental health among imprisoned persons regardless of race.

CONCLUSION

The use of a single, unidimensional measure of race and ethnicity in health disparities research does not fully reveal racialization's influence on health, specifically for those experiencing incarceration.

Infectious Disease Education in a Carceral Setting: Insights from a Jail-Based Medical Student-Led Health Literacy Initiative

Incarceration is associated with adverse health outcomes, including higher rates of infectious diseases. Poor health literacy in this population is a likely contributing factor, making health education a potential tool to help address these health disparities. This article aims to describe the implementation of a novel medical student-led educational initiative in the jail setting as a tool to promote health literacy and decrease the infectious disease burden in the correctional setting. A four-part infectious disease health education curriculum was developed and tailored to a carceral context. The course was offered on a voluntary basis to members of a reentry program at a local county jail. Pre- and postcourse surveys were used to evaluate the course effectiveness. The results demonstrated a statistically significant increase in the participants' reported confidence for recognizing the symptoms of and seeking appropriate treatment for common infections, including sexually transmitted, respiratory, and blood-borne infections. To the authors' knowledge, this is one of the first medical student-led programs of its kind to be described in existing literature. This program hopes to continue refining its curricular offerings and serve as a model for medical schools across the country to increase trainee engagement.

Health, Access to Care, and Financial Barriers to Care Among People Incarcerated in US Prisons

Importance

Decades-old data indicate that people imprisoned in the US have poor access to health care despite their constitutional right to care. Most prisons impose co-payments for at least some medical visits. No recent national studies have assessed access to care or whether co-pays are associated with worse access.

Objective

To determine the proportion of people who are incarcerated with health problems or pregnancy who used health services, changes in the prevalence of those conditions since 2004, and the association between their state's standard prison co-payment and care receipt in 2016.

Design, Setting, and Participants

This cross-sectional analysis was conducted in October 2023 and used data from the Bureau of Justice Statistics' 2016 Survey of Prison Inmates, a nationally representative sample of adults in state or federal prisons, with some comparisons to the 2004 version of that survey.

Exposures

The state's standard, per-visit co-payment amount in 2016 compared with weekly earnings at the prison's minimum wage.

Main Outcomes and Measures

Self-reported prevalence of 13 chronic physical conditions, 6 mental health conditions, and current severe psychological distress assessed using the Kessler Psychological Distress Scale; proportion of respondents with such problems who did not receive any clinician visit or treatment; and adjusted odds ratios (aORs) comparing the likelihood of no clinician visit according to co-payment level.

Results

Of 1 421 700 (unweighted: n = 24 848; mean [SD] age, 35.3 [0.3] years; 93.2% male individuals) prison residents in 2016, 61.7% (up from 55.9% in 2004) reported 1 or more chronic physical conditions; among them, 13.8% had received no medical visit since incarceration. A total of 40.1% of respondents reported ever having a mental health condition (up from 24.5% in 2004), of whom 33.0% had received no mental health treatment. A total of 13.3% of respondents met criteria for severe psychological distress, of whom 41.7% had not received mental health treatment in prison. Of state prison residents, 90.4% were in facilities requiring co-payments, including 63.3% in facilities with co-payments exceeding 1 week's prison wage. Co-payments, particularly when high, were associated with not receiving a needed health care visit (co-pay ≤1 week's wage: aOR, 1.43; 95% CI, 1.10-1.86; co-pay >1 week's wage: aOR, 2.17; 95% CI, 1.61-2.93).

Conclusions and Relevance

This cross-sectional study found that many people who are incarcerated with health problems received no care, particularly in facilities charging co-payments for medical visits.

Healthcare Disparities and the Impact on Mortality in Incarcerated Patients

This article addresses the healthcare disparities and potential impact on mortality among incarcerated patients with chronic kidney disease (CKD). Incarcerated individuals are more likely to suffer from acute and chronic health conditions and have inconsistent access to healthcare services. Demographic trends, behavioral health trends, and lack of insurance coverage are major contributing factors to healthcare disparities among incarcerated individuals. This article highlights the need for a new model of care, which includes clinical programs focusing on the transition period from incarceration to the community and linking individuals to post-incarceration healthcare utilizing community health workers and clinicians to establish rapport with individuals prior to their release. Addressing healthcare disparities and providing adequate healthcare to incarcerated individuals is crucial because a conviction should not deprive an individual of basic human rights, including the right to healthcare.

Lifetimes of Vulnerability: Childhood Adversity, Poor Adult Health, and the Criminal Legal System

On average, incarcerated people have higher rates of poor health, mental illness, and histories of adverse childhood experiences (ACEs) than the general population. This mixed-methods analysis examines the relationship between ACEs and poor adult health among a sample of formerly incarcerated people. The quantitative analysis (N = 122) shows childhood adversity is associated with various health conditions in adulthood, although the strength of this relationship varies by the kinds of ACEs respondents encountered. The qualitative analysis of life history timelines (N = 42) reveals two pathways relating ACEs to poor health and legal system involvement: (1) violence and victimization and (2) drug use as a coping mechanism. Unaddressed mental health challenges in the aftermath of adversity emerged as an important precursor to both pathways. Prisons lack a meaningful consideration of these early life events and the social structures that result in the high rates of vulnerable people in its care.

Enhancing healthcare accessibility through telehealth for justice impacted individuals

Telehealth is a great tool that makes accessing healthcare easier for those incarcerated and can help with reentry into the the community. Justice impacted individuals face many hardships including adverse health outcomes which can be mitigated through access to telehealth services and providers. During the federally recognized COVID-19 pandemic the need for accessible healthcare was exacerbated and telehealth use surged. While access to telehealth should be considered a necessity, there are many challenges and barriers for justice impacted individuals to be able to utilize this service. This perspective examines aspects of accessibility, pandemic, policy, digital tools, and ethical and social considerations of telehealth in correctional facilities. Carceral facilities should continue to innovate and invest in telehealth to revolutionize healthcare delivery, and improve health outcomes for justice impacted individuals.

Supporting equitable care of patients transferred from police watch-houses to the emergency department: A qualitative study of the perspectives of emergency doctors

OBJECTIVE

People detained in short-term police custody often have complex health conditions that may necessitate emergency care, yet little is known about their management in EDs. The present study aimed to understand ED doctors' experiences and perceptions regarding the appropriateness and management of detainee transfers from police watch-houses to the EDs.

METHODS

A qualitative descriptive study, using semi-structured interviews undertaken with ED doctors working in five purposively sampled EDs across Queensland, Australia. Data were analysed using inductive content analysis.

RESULTS

Fifteen ED specialists and trainees participated. Participants reported that their overarching approach was to provide equitable care for watch-house detainees, as they would for any patient. This equitable approach needed to be responsive to complicating factors common to this population, including presence of police guards; restraints; complexity (physical/mental/social) of presentation; reliance on police to transport; ED doctors' often limited understanding of the watch-house environment; justice processes and uncertain legal disposition; communication with the watch-house; and detainees misreporting symptoms. Thresholds for assessment and treatment of detainees were contextualised to the needs of the patient, ED environment, and imperatives of other relevant agencies (e.g. police). Participants often relied on existing strategies to deliver quality care despite challenges, but also identified a need for additional strategies, including education for ED staff; improved communication with watch-houses; standardised paperwork; extended models of watch-house healthcare; and integrated medical records.

CONCLUSIONS

Providing equitable healthcare to patients transported from watch-houses to the EDs is challenging but essential. Numerous opportunities exist to enhance the delivery of optimal care for this underserved population.

Understanding Vaccine Hesitancy in U.S. Prisons: Perspectives from a Statewide Survey of Incarcerated People

Much of the American response to the COVID-19 pandemic was characterized by a divergence between general public opinion and public health policy. With little attention paid to individuals incarcerated during this time, there is limited direct evidence regarding how incarcerated people perceived efforts to mediate the harms of COVID-19. Prisons operate as a microcosm of society in many ways but they also face unique public health challenges. This study examines vaccine hesitancy-and acceptance-among a sample of individuals incarcerated within adult prisons in Pennsylvania. Using administrative records as well as rich attitudinal data from a survey of the incarcerated population, this study identifies a variety of social and historical factors that are-and are not-associated with an incarcerated person's willingness to receive the COVID-19 vaccine. Our findings highlight vaccination challenges unique to the carceral context and offer policy recommendations to improve trust in credible health messengers and health service provision for this often overlooked but vulnerable population.

Factors associated with non-treatment for long-term illness among incarcerated individuals

PURPOSE

The prison population is seldom studied and often overlooked in many countries despite their vulnerability to long-term illness. This study aims to explore the factors associated with the non-treatment for long-term illnesses among incarcerated individuals.

DESIGN/METHODOLOGY/APPROACH

This study is a cross-sectional analysis. The authors conducted a secondary data analysis using information collected in the Peruvian census of incarcerated individuals. The study population consisted of incarcerated individuals diagnosed with a long-term illness. To evaluate the factors associated with non-treatment, the authors used a Poisson regression model.

FINDINGS

The authors included 12,512 incarcerated individuals (age: 40.9 ± 13.1 years), and 39% of them did not receive treatment for their long-term illness. The authors observed that non-treatment was statistically associated with gender, age, having children, use of the Spanish language, sexual identity, judicial situation, penitentiary location, discrimination inside the penitentiary and health insurance before incarceration. However, only having children (prevalence ratio [PR]: 1.11, confidence interval [CI]95% 1.03-1.19), using the Spanish language (PR: 1.15, CI95%: 1.01-1.31), being in a penitentiary not in Lima (PR: 1.11, CI95%: 1.06-1.17) and perceiving discrimination inside the penitentiary (PR: 1.12, CI95% 1.06-1.18) increased the prevalence of non-treatment.

ORIGINALITY/VALUE

Identifying the factors associated with non-treatment will allow us to implement measures for prioritizing groups and developing strategies for the evaluation, close follow-up of their health and management of comorbidities.

Prompt access to outpatient care post-incarceration among adults with a history of substance use: Predisposing, enabling, and need-based factors

INTRODUCTION

As expanded Medicaid coverage reduces financial barriers to receiving health care among formerly incarcerated adults, more information is needed to understand the factors that predict prompt use of health care after release among insured adults with a history of substance use. This study's aim was to estimate the associations between characteristics suggested by the Andersen behavioral model of health service use and measures of health care use during the immediate reentry period and in the presence of Medicaid coverage.

METHODS

In this retrospective cohort study, we linked individual-level data from multiple Wisconsin agencies. The sample included individuals aged 18-64 released from a Wisconsin State Correctional Facility between April 2014 and June 2017 to a community in the state who enrolled in Medicaid within one month of release and had a history of substance use. We grouped predictors of outpatient care into variable domains within the Andersen model: predisposing- individual socio-demographic characteristics; enabling characteristics including area-level socio-economic resources, area-level health care supply, and characteristics of the incarceration and release; and need-based- pre-release health conditions. We used a model selection algorithm to select a subset of variable domains and estimated the association between the variables in these domains and two outcomes: any outpatient visit within 30 days of release from a state correctional facility, and receipt of medication for opioid use disorder within 30 days of release.

RESULTS

The size and sign of many of the estimated associations differed for our two outcomes. Race was associated with both outcomes, Black individuals being 12.1 p.p. (95 % CI, 8.7-15.4, P < .001) less likely than White individuals to have an outpatient visit within 30 days of release and 1.3 p.p. (95 % CI, 0.48-2.1, P = .002) less likely to receive MOUD within 30 days of release. Chronic pre-release health conditions were positively associated with the likelihood of post-release health care use.

CONCLUSIONS

Conditional on health insurance coverage, meaningful differences in post-incarceration outpatient care use still exist across adults leaving prison with a history of substance use. These findings can help guide the development of care transition interventions including the prioritization of subgroups that may warrant particular attention.

Prior incarceration, restrictive housing, and posttraumatic stress disorder symptoms in a community sample of persons who use drugs

BACKGROUND

Criminalization of drugs in the United States (US) has extensive consequences for people who use drugs (PWUD). Incarceration and substance use overlap with 65% of the US prison population meeting substance use disorder (SUD) criteria. Exposure to the criminal-legal system negatively impacts the health of PWUD. PTSD is commonly comorbid with SUDs, and exposure to restrictive housing (RH) during incarceration may worsen mental health. Because PWUD are disproportionately incarcerated, experiences occurring during incarceration, such as RH, may contribute to the development or exacerbation of PTSD and SUDs. This study of PWUD investigated prior criminal-legal system exposure and its association with PTSD symptoms in community-dwelling PWUD.

METHODS

This cross-sectional study recruited PWUD from syringe service programs (SSP). Inclusion criteria were: age 18+, current or past opioid use disorder, and SSP enrollment. Data collected included: sociodemographics; incarceration, substance use, SUD treatment history, and PTSD assessments (Life Events Checklist for DSM-5 and the PTSD Checklist for DSM-5). Bivariate testing and multivariate logistic regression analyses, with probable PTSD as the dependent variable and a three-level variable for criminal legal history as the independent variable, were conducted to determine whether incarceration and RH were associated with probable PTSD.

RESULTS

Of 139 participants, 78% had an incarceration history with 57% of these having a history of RH. 57% of participants screened positive for probable PTSD, and physical assault was the most common traumatic exposure. Any history of incarceration was not associated with probable PTSD diagnosis; however, in multivariate testing, adjusting for age, sex, and substance use, a history of RH (adjusted odds ratio [aOR]: 3.76, 95% CI 1.27-11.11) was significantly associated with probable PTSD.

CONCLUSIONS

RH and PTSD were both exceptionally common in a sample of SSP participants. RH can be detrimental to physical and mental health. Clinicians and policy makers may not consider incarceration as a traumatic experience for PWUD; however, our data suggest that among highly marginalized PWUD, prior exposure to incarceration and RH may add an additional burden to their daily struggles, namely PTSD.

Prisoners' perceived oral and general health and their experience with accessing, understanding and assessing health information: A qualitative study

Prisoners' oral health and general health are closely connected and generally poorer than that of the wider population. Moreover, knowledge of prisoners' health literacy is scarce. This study aimed to explore prisoners' perceived oral and general health and how they accessed, understood and assessed health information to gain insight into their health literacy. Twelve prisoners in a high-security prison and a halfway house participated in individual semi-structured interviews. Data was analysed through thematic analysis, which identified five themes: inconsistent self-reporting of general and oral health; autonomous health behaviour through utilizing personal resources; preference for personalized adapted health information; psychological and physical proximity; and barriers. The prisoners perceived their oral and general health as good despite several health problems. They expressed scepticism towards health information from public authorities and made their own health-related choices based on previous experiences, their own 'common sense' and the experiences of people they trusted. Health information was considered useful when adjusted to their needs. Obtaining health-related information through physical encounters was considered more accessible than through online platforms. Adapting the communication to prisoners' expressed needs and their health literacy can enhance the accessibility to improve their oral and general health. In-person encounters would be preferable.

Best practice guidelines for evaluating patients in custody in the emergency department

Patients in custody due to arrest or incarceration are a vulnerable population that present a unique ethical and logistical challenge for emergency physicians (EPs). People incarcerated in the United States have a constitutional right to health care. When caring for these patients, EPs must balance their ethical obligations to the patient with security and safety concerns. They should refer to their institutional policy for guidance and their local, state, and federal laws, when applicable. Hospital legal counsel and risk management also can be helpful resources. EPs should communicate early and openly with law enforcement personnel to ensure security and emergency department staff safety is maintained while meeting the patient's medical needs. Physicians should consider the least restrictive restraints necessary to ensure security while allowing for medical evaluation and treatment. They should also protect patient privacy as much as possible within departmental constraints, promote the patient's autonomous medical decision-making, and be mindful of ways that medical information could interact with the legal system.

Approaching a Fork in the Road: A Case of Aborting Endoscopy After Discovering a Retained Foreign Object

We describe a case of a 53-year-old female who presented for elective esophagogastroduodenoscopy (EGD) and eventually needed surgical intervention to remove a plastic fork that she accidentally swallowed twenty years prior while in prison. This article highlights approaches to retrieving a foreign object within the stomach via endoscopy, the importance of recognizing the risks of endoscopy, and serves as a reminder that we must be aware of the social determinants of health that pertain to our patients.

Does the immigrant health advantage extend to incarcerated immigrants?

•Existing immigrant health research does not include institutionalized populations.•The immigrant health advantage does not extend to all incarcerated immigrant groups.•Differences in health exist by race/ethnicity, U.S. citizenship, and health outcome.•The incarcerated immigrant population has unique health profiles and needs.

Police-mental health co-response versus police-as-usual response to behavioral health emergencies: A pragmatic randomized effectiveness trial

BACKGROUND

People with mental illness are overrepresented in United States (US) criminal legal systems. In response, alternatives to traditional police response to behavioral health emergencies have become more common, despite limited evidence for their effectiveness. We conducted the first randomized controlled trial of a police-mental health co-response team to determine program effectiveness relative to a police-as-usual response on key outcomes identified by community stakeholders.

METHODS

Between January 2020 and March 2021, we randomized behavioral health emergency calls for service in one of six police districts in Indianapolis, Indiana to receive a co-response or police-as-usual response during operational hours between 10 a.m. and 5 p.m. Mondays - Fridays. Eligible calls for service were determined via pre-specified phrases indicating a behavioral health incident over the police dispatch radio. Researchers then communicated random assignment with the co-response team to indicate whether they should respond or withhold. Logistic and negative binomial regression were used to assess group differences in emergency medical services (EMS) events within 12 months of the randomized incident along with jail booking, outpatient encounters, and emergency department visits.

FINDINGS

We randomized 686 calls for service with co-response completed in 264 cases and police-as-usual response in 267 cases. The overall rate of attrition was similar across conditions and the final sample included 211 co-responses and 224 police-as-usual responses. We found no significant differences in any EMS event (odds ratio [OR]: 1.26; 95% confidence interval [CI]: 0.85-1.88, p = .246) or event counts (incidence rate ratio [IRR]: 0.85; 95% CI: 0.52-1.37, p = .504). We also found no differences in secondary outcomes (jail booking, outpatient encounters, and emergency department visits).

DISCUSSION

A police-mental health co-response team model was not more effective than traditional police response on key outcomes. Co-response team models, such as the one reported here, may unintentionally foster emergency services utilization among persons with behavioral health needs. Without a functioning national mental health system, communities in the US will continue to struggle to identify solutions to meet the needs of community members with complex behavioral health issues.

Chronic Psychotic Disorders and Correctional Involvement: A Population-Based Matched Case-Control Study in Ontario, Canada

OBJECTIVE

Individuals with chronic psychotic disorders are overrepresented in correctional facilities, but little is known about factors that increase the risk of correctional involvement. The objective of this study was to compare individuals with chronic psychotic disorders who were released from correctional facilities in Ontario to individuals with chronic psychotic disorders but no correctional involvement on sociodemographic, clinical, and prior mental health-related health service utilization characteristics.

METHOD

All individuals with chronic psychotic disorders who were released from a provincial correctional facility in Ontario in 2010 were matched (1:2) by age and sex to Ontario residents with chronic psychotic disorders and no correctional involvement. Covariates included sociodemographic (rural residence, marginalization such as residential instability quintile, material deprivation quintile, dependency quintile, and ethnic concentration quintile) and clinical (duration of chronic psychotic disorder and comorbidities) characteristics, and mental health-related health service utilization characteristics (primary care physician, psychiatrist and emergency department visits, and hospitalizations) 1 and 3 years prior to correctional involvement. The association between correctional involvement and prior health service utilization was measured by estimating incidence rate ratios using Poisson and negative-binomial regressions.

RESULTS

Individuals with correctional involvement (N = 3,197) lived in neighbourhoods with higher material deprivation and residential instability, and had a shorter duration of illness, and more psychosocial comorbidities (e.g., behavioural issues and depression) than individuals without correctional involvement (N = 6,393). Adjusting for sociodemographic and clinical variables, individuals with correctional involvement had a higher rate of mental health-related primary care physician visits, emergency department visits, and hospitalizations but a lower rate of psychiatrist visits prior to correctional involvement, compared to individuals without correctional involvement.

CONCLUSIONS

Despite higher mental health-related comorbidities and higher rates of accessing acute mental health services among individuals with chronic psychotic disorders and correctional involvement, visits to psychiatrists prior to involvement were low.

Experiences of quitting smoking in prisons: A qualitative study of people in custody

INTRODUCTION

Smoking prevalence among people in custody (PIC) is extremely high, and prison-based smoking cessation interventions are needed. The study explored the quitting experiences of PIC who participated in the 'Quit to Win' contest (QTW).

METHODS

This qualitative study, conducted from 2019 to 2021 in two Hong Kong prisons, included semi-structured individual interviews with 26 PIC (13 men and 13 women) who were participants in QTW and two correctional staff who coordinated QTW. A semi-structured interview guide with open-ended questions was developed to examine multilevel factors that promote or impede smoking cessation in prisons. Maximum variation sampling was used to ensure a diverse range of social, demographic, and smoking profiles. Data were managed and analyzed using thematic analysis.

RESULTS

Two themes were identified from the data: 1) quitting in prison: barriers and facilitators; and 2) QTW in prison: a trigger for behavior change. Barriers (i.e. stress, boredom, isolation, lack of self-autonomy, nicotine dependence and lack of cessation medication, barriers to moving to a different wing) and facilitators (i.e. concerns about health, money savings, and the smoke-free wing) that impeded or supported smoking cessation during incarceration were identified. QTW provided health education, quitting incentives, and social support that helped PIC overcome the barriers of quitting by serving as a trigger for behavior change. Notably, social visits with family were identified as key drivers of PIC's quitting success, whereas their suspension during the COVID-19 pandemic disincentivized their abstinence.

CONCLUSIONS

This study introduced the QTW contest to prisons and provided qualitative evidence on the multilevel factors promoting or impeding smoking cessation in prison. QTW helped PIC overcome the barriers of quitting by serving as a trigger for behavior change. Future prison-based interventions should leverage social support, enhance stress-coping skills, facilitate access to pharmacotherapy, and collaborate with correctional services agencies.

Posttraumatic Stress Disorder Symptoms and Incarceration: The Impact on Sexual Risk-Taking, Sexually Transmitted Infections, and Depression Among Black Sexual Minority Men in HIV Prevention Trials Network (HPTN) 061

Black men and people belonging to sexual minority groups are disproportionately impacted by criminal legal involvement and sexually transmitted infections (STIs). Traumatic experiences are often associated with later criminal legal involvement, depression symptoms, sexual risk behavior, and STIs. Research on the joint influence of trauma and incarceration on STI risk among racial and/or sexual minority people is limited. This study tested the association between post-traumatic stress disorder (PTSD) symptoms and incarceration on sexual risk behavior and STI among Black sexual minority men, a population that may be at higher risk for contracting STIs. Using data from the HIV Prevention Trials Network 061 Study, a longitudinal study of adult Black sexual minority men in six U.S. cities (N = 855), we tested associations between past six-month incarceration and subsequent sexual risk behavior, STI, and depression symptoms, for those with and without pre-incarceration PTSD symptoms. PTSD symptoms were elevated among participants who reported Hispanic ethnicity, having sex with both men and women, and previous incarceration. Although there were not significant differences between recent incarceration and sexual risk for those with and without PTSD, incarceration was linked to some sexual risk behaviors regardless of PTSD symptoms. Among people with PTSD symptoms, there was a higher prevalence of sexual risk and depression symptoms, regardless of incarceration. These findings suggest a potentially compounding influence of PTSD symptoms and incarceration on sexual risk and infection among Black sexual minority men.

Healthcare accessibility in the prison environment: oral health

This article aims to assess the importance of caring for oral health among prisoners, as an often-overlooked aspect of general health well-being in prisons. The incidence of oral disease among prisoners compared to the general population is much higher due to many factors such as limited access to dental care, unhealthy lifestyles and overcrowded cells. The research review confirms the need to increase access to dental care and promote hygiene awareness among inmates. Differences between genders and the impact of the length of the sentence on oral health are also pointed out.

Associations Between Incarceration History and Risk of Hypertension and Hyperglycemia: Consideration of Differences among Black, Hispanic, Asian and White Subgroups

BACKGROUND

Studies have shown that adults with a history of incarceration have elevated cardiovascular (CVD) risk. Research on racial/ethnic group differences in the association between incarceration and CVD risk factors of hypertension and hyperglycemia is limited.

OBJECTIVE

To assess racial/ethnic group differences in the association between incarceration and hypertension and hyperglycemia.

DESIGN

We performed a secondary data analysis using the National Longitudinal Survey of Adolescent to Adult Health (Add Health). Using modified Poisson regression, we estimated the associations between lifetime history of incarceration reported during early adulthood with hypertension and hyperglycemia outcomes measured in mid-adulthood, including incident diagnosis. We evaluated whether associations varied by self-reported race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, and Asian).

PARTICIPANTS

The analytic sample included 4,015 Add Health respondents who self-identified as non-Hispanic White, Non-Hispanic Black, Hispanic, and Asian, and provided incarceration history and outcome data.

MAIN MEASURES

Outcome measures included (1) hypertension (2) systolic blood pressure  ≥ 130 mmHg, and (3) hyperglycemia.

KEY RESULTS

In non-Hispanic Black and non-Hispanic White participants, there was not evidence of an association between incarceration and measured health outcomes. Among Hispanic participants, incarceration was associated with hyperglycemia (Adjusted Risk Ratio (ARR): 2.1, 95% Confidence Interval (CI): 1.1-3.7), but not with hypertension risk. Incarceration was associated with elevated systolic blood pressure (ARR: 3.1, CI: 1.2-8.5) and hypertension (ARR: 1.7, CI: 1.0-2.8, p = 0.03) among Asian participants, but not with hyperglycemia risk. Incarceration was associated with incident hypertension (ARR 2.5, CI 1.2-5.3) among Asian subgroups.

CONCLUSIONS

Our findings add to a growing body of evidence suggesting that incarceration may be linked to chronic disease outcomes. Race/ethnic-specific results, while limited by small sample size, highlight the need for long-term studies on incarceration's influence among distinct US groups.

The Associations Between Medical and Mental Health Conditions and Health Care Utilization in US Adults with Past-Year Criminal Legal Involvement

BACKGROUND

Every year, millions of US adults return home from prison or jail, and they visit the emergency department and experience hospitalizations at higher rates than the general population. Little is known about the primary conditions that drive this acute care use.

OBJECTIVE

To determine the individual and combined associations between medical and mental health conditions and acute health care utilization among individuals with recent criminal legal involvement in a nationally representative sample of US adults.

DESIGN

We examined the association between having medical or mental, or both, conditions (compared to none), and acute care utilization using negative binomial regression models adjusted for relevant socio-demographic covariates.

PARTICIPANTS

Adult respondents to the National Survey of Drug Use and Health (2015-2019) who reported past year criminal legal involvement.

MAIN MEASURES

Self-reported visits to the emergency department and nights spent hospitalized.

RESULTS

Among 9039 respondents, 12.4% had a medical condition only, 34.6% had a mental health condition only, and 19.2% had both mental and medical conditions. In adjusted models, incident rate ratio (IRR) for ED use for medical conditions only was 1.32 (95% CI 1.05, 1.66); for mental conditions only, the IRR was 1.36 (95% CI 1.18, 1.57); for both conditions, the IRR was 2.13 (95% CI 1.81, 2.51). For inpatient use, IRR for medical only: 1.73 (95% CI 1.08, 2.76); for mental only, IRR: 2.47 (95% CI 1.68, 3.65); for both, IRR: 4.26 (95% CI 2.91, 6.25).

CONCLUSION

Medical and mental health needs appear to contribute equally to increased acute care utilization among those with recent criminal legal involvement. This underscores the need to identify and test interventions which comprehensively address both medical and mental health conditions for individuals returning to the community to improve both health care access and quality.