Restricted care: prescription medicine and the construction of the ‘problem’ patient in prison

BackgroundHealth literacy is an important factor for enabling people to manage their health and live long fulfilling lives. People in prison are frequently from marginalised communities, often out of reach of conventional community based health organisations, and have poorer health outcomes. It is essential to understanding the health literacy profiles of people in prison, and its contribution to the well-established health inequities and outcomes of this population. This study aimed to use a multi-dimensional health literacy measurement tool to describe the strengths and challenges of adults incarcerated in NSW prisons.MethodsA cross-sectional survey was conducted for people in prison across 14 publicly operated metropolitan prisons. Data were collected from 471 participants using the Health Literacy Questionnaire (HLQ). Participant characteristics and health conditions were also collected. Data were analysed using descriptive statistics. Effect sizes (ES) for standardised differences in means were used to describe the magnitude of difference between participant characteristic groups.ResultsParticipants’ median age was 38.0 (range 19 – 91) years. Males comprised 81% of the sample, 21% identified as Aboriginal and/or Torres Strait Islander, and 53% reported a health problem. People in prison had lower scores for all nine HLQ scales when compared to the general Australian population. Small to medium ES were seen for mean differences between most demographic groups. Compared to males, females had lower scores for several of the HLQ scales including ‘having sufficient information to manage health’ (ES 0.30 [95% Confidence Interval (CI) 0.07, 0.53]), ‘ability to actively engage with health care professionals’ (ES 0.30 [95% CI 0.06, 0.53]), ‘navigating the healthcare system’ (ES 0.30 [95% CI 0.06, 0.53]), and, ‘ability to find good health information’ (ES 0.33 [95% CI 0.10, 0.57]). Differing health literacy scale scores with small to medium ES were found when comparing participants by legal status. Mainly small ES were seen when comparing other participant characteristic groups.ConclusionsThis study provides insights into the health literacy strengths and challenges for people in NSW prisons. These findings highlight the important role health literacy could have in addressing health disparities in this vulnerable population and can inform prison health services.

PurposeThe purpose of this paper is to give an overview of the WorldwidE Prison Health Research & Engagement Network (WEPHREN) which aims to improve the evidence base for health and health service delivery within prison settings and so improve the health and wellbeing of people in prison, reduce health inequalities and influence prison health policy.Design/methodology/approachA viewpoint piece that highlights the need for higher quality health research in the field of prison health globally and the potential for WEPHREN to help support this.FindingsThis paper presents an overview of the poor health of many people in prison and the inequalities between countries in terms of research output relating to the health of people in prison. It argues for all those interested in prison health to work together to produce more practitioner and policy relevant health research.Originality/valueThis editorial highlights a unique global network for prison health.

The post-release period is associated with an increased risk of morbidity and mortality. Previous studies have identified deficits in pre-release planning for mentally ill people in prison, particularly in remand settings. We aimed to determine the proportion of mentally ill people in Ireland's main remand prison who were referred for mental health follow up in community and prison settings, who achieved face to face contact with the receiving service. This retrospective observational cohort study was based in Ireland's main male remand prison, Cloverhill. Participants included all those individuals on the caseload of the prison inreach mental health team who were referred for mental health follow up in community and prison settings at the time of discharge, prison transfer or release from custody over a three-year period, 2015 - 2017. Successful transfer of care (TOC) was defined as face-to-face contact with the receiving service, confirmed by written correspondence or by follow up telephone call. Clinical, demographic and offence related variables were recorded for all participants. There were 911 discharges from the prison inreach mental health team within the three-year study period. Of these, 121 were admitted to hospital, 166 were transferred to other prison inreach mental health services and 237 were discharged to community based mental health follow up in psychiatric outpatient or primary care settings. One third (304/911) had an ICD-10 diagnosis of schizophreniform or bipolar disorder (F20-31) and 37.5% (161/911) were homeless. Over 90% (152/166) of those referred to mental health teams in other prisons achieved successful TOC, with a median of six days to first face-to face assessment. Overall, 59% (140/237) of those referred to community psychiatric outpatient or primary care services achieved TOC following referral on release from custody, with a median of nine days from release to assessment. Clinical and demographic variables did not differ between those achieving and not achieving successful TOC, other than having had input from the PICLS Housing Support Service. Successful transfer of care can be achieved in remand settings using a systematic approach with an emphasis on early and sustained interagency liaison and clear mapping of patient pathways. For incarcerated individuals experiencing homelessness and mental health disorders, provision of a housing support service was associated with increased likelihood of successful transfer of care to community mental health supports.

Vaccinations in prison settings: A systematic review to assess the situation in EU/EEA countries and in other high income countries

Background: As the number of people ageing in prison with complex healthcare needs continues to increase, so does the need for palliative care in the restrictive prison context. Palliative care for people in prison is facilitated by correctional officers, and prison- and hospital-based clinicians. A collective analysis of existing research to identify common experiences of these stakeholders globally has not been completed. Aim: To explore the perceptions and experiences of correctional officers and prison- and hospital-based clinicians who facilitate palliative care for people in prison. Design: A systematic review and meta-synthesis. Data sources: Keywords and subject headings related to palliative care and prisons were used to search seven databases with no time limitations. Peer-reviewed research in English, containing qualitative data from stakeholders facilitating palliative care for people in prison were included, and appraised using the CASP tool. Results: Two analytical themes emerged: (i) a prison lens on a palliative approach and (ii) coping complexities. Palliative care is ‘translated’ into the prison setting according to security and environmental constraints. Stakeholders experienced ethical, personal and professional difficulties, because prison-based palliative care did not align with community norms. Ambiguous policy and expectations regarding prioritising care needs and balancing custodial rules led to role stress. Conclusions: Providing palliative care for people in prison is complex and impacts stakeholders and people in prison with palliative care needs. Supporting person-centred care through a multi-service approach, stakeholder education and standards will improve the quality and accessibility of care.

BackgroundVaccine uptake rates have been historically low in correctional settings. To better understand vaccine hesitancy in these high-risk settings, we explored reasons for COVID-19 vaccine refusal among people in federal prisons.MethodsThree maximum security all-male federal prisons in British Columbia, Alberta, and Ontario (Canada) were chosen, representing prisons with the highest proportions of COVID-19 vaccine refusal. Using a qualitative descriptive design and purposive sampling, individual semi-structured interviews were conducted with incarcerated people who had previously refused at least one COVID-19 vaccine until data saturation was achieved. An inductive–deductive thematic analysis of audio-recorded interview transcripts was conducted using the Conceptual Model of Vaccine Hesitancy.ResultsBetween May 19-July 8, 2021, 14 participants were interviewed (median age: 30 years; n = 7 Indigenous, n = 4 visible minority, n = 3 White). Individual-, interpersonal-, and system-level factors were identified. Three were particularly relevant to the correctional setting: 1) Risk perception: participants perceived that they were at lower risk of COVID-19 due to restricted visits and interactions; 2) Health care services in prison: participants reported feeling “punished” and stigmatized due to strict COVID-19 restrictions, and failed to identify personal benefits of vaccination due to the lack of incentives; 3) Universal distrust: participants expressed distrust in prison employees, including health care providers.InterpretationReasons for vaccine refusal among people in prison are multifaceted. Educational interventions could seek to address COVID-19 risk misconceptions in prison settings. However, impact may be limited if trust is not fostered and if incentives are not considered in vaccine promotion.

This paper critically reflects on conducting research with people in prison, including gaining trust and building rapport, and the power imbalances of conducting research in the prison setting. Navigating trust and power is key to successful prison-based research, but these navigations are not confined to the researcher–participant interaction and extend to include researcher entry into the prison and earlier processes such as the ethics application submission. Existing ‘how-to’ guides for prison-based research often draw on ethnographic studies which allow substantial time for the interviewer to build rapport with key prison contacts, including officers, as well as opportunity for people in prison to become familiar with the ethnographer’s presence prior to data collection. Drawing on prison-based research experience from three qualitative health studies pertaining to people in prison living with hepatitis C and/or history of injecting drug use (the primary risk factor for hepatitis C transmission), I consider challenges of access and strategies for on-the-spot rapport building with people in prison. The approaches outlined may be applicable to research with other population groups in which power imbalances may exist.

This study reports on an assessment of mental health needs among Scotland's prison population which aimed to describe the scale and nature of need as well as identify opportunities to improve upon the services available. The project was commissioned by the Scottish Government to ensure that future changes to the services available to support the mental health and wellbeing of people in prison would be evidence-based and person-centered. A standardized approach to health needs assessments was employed. The study was comprised of four phases. In phase I a rapid literature review was undertaken to gather evidence on the prevalence of mental health needs experienced by people in prison in the UK. In Phase II a multi-method and multi-informant national mapping exercise involving providers to all Scottish prisons was undertaken to describe the mental health services available, and any gaps in these services, for people in and leaving prison. In Phase III prevalence estimates of several mental health needs were derived for Scotland's current prison population, modeled from a national survey dataset of Scotland's community population using logistic regression. Finally in Phase IV, professional stakeholders and individuals with lived experience were interviewed to understand their experiences and insights on challenges to supporting the mental health and wellbeing of people in prison, and ideas on how these challenges could be overcome. Evidence across the four phases of this needs assessment converged indicating that existing provision to support the mental health of people in prison in Scotland was considered inadequate to meet these needs. Barriers to effective partnership working for justice, health, social work and third sector providers appear to have led to inadequate and fragmented care, leaving prisoners without the support they need during and immediately following imprisonment. Joint and coordinated action from justice, health and social care, and third sector providers is needed to overcome enduring and structural challenges to supporting the mental health of people in prison. Eighteen evidence-based recommendations were proposed to the Scottish Government relating to the high-level and operational-level changes required to adequately meet the prison population's mental health needs.

Crime and human nature : by James Q. Wilson and Richard J. Herrnstein Simon and Schuster (Rockfeller Center, 1230 Avenue of the Americas, New York, New York 10020), 1985, 639 pp., hardcover —$22.95

People in prison have a larger burden of disease than the general public. The high prevalence of disease in this population is recognized as a significant public health issue. Given the high turnover of the prison population, prisons present a complex challenge for public health. Addressing the health needs of the prison population can also have a positive impact on the wider community. SEHSCT has the remit to provide Healthcare in Prison in the 3 Northern Ireland Prisons for a population of approximately 1600 people. A multidisciplinary team provide primary and secondary care. The Health Engagement team are providing support to health and wellbeing. The time of committal into custody is recognised as a time of high risk for many. In-depth interviews were conducted with 160 people entering custody the regional survey 10000 Voices was adapted for a prison The survey highlighted the need for improved communication at the time of committal about the accessing healthcare services, the prison regime and how to keep well in prison. In 2019 Healthcare Peer Mentors were introduced to HMP Maghaberry. Their initial role was to navigate people towards healthcare services and support people in their time of entering custody. Ask HIM (Health Information Mentor) Peer Mentors connect with people in the first 48 hours of entering custody, focusing on those first time in prison, helping navigate complex prison systems. Mentors lead induction sessions, health information groups and are a rich source of referrals across all Healthcare in Prison (HiP) services. They have had over 2000 engagement encounters since the pilot resulting in more than 1100 healthcare referrals. To systemise the peer mentor network it was essential to establish an inter-agency Peer Mentor Hub. The steering committee included NI Prison Service governors, in-reach agencies, people in custody, HiP clinical and support staff with senior management sponsorship to support and operationalise plans. A mapping exercise was conducted to understand the current status of mentoring and an iterative design process was adapted to establish the Hub. This has developed a new way of working across organisations, coproducing the Peer Mentor Hub with the mentors themselves. Peer Mentor Hub Core Pillars: Standardised Recruitment process for all agencies mentors Training Courses in advocacy and mentorship by Belfast Met College. Supervision of mentors with the HiP psychology team Monthly mentor sessions to meet share food and relax Outcomes of Peer Mentor Hub A robust evaluation measurement plan includes: Quality of Life Measures Impact on Incidents Impact on Complaints Mentor Qualifications The Peer Mentor Hub and Network have been evaluated and are evidencing the improvement of the committal time of custody, reducing risk, demystifying the regime and increasing access to care. The impact on the mentors has been positive with reported increase in confidence, qualifications and hope. A Peer Mentor Network is a challenge to cede power and challenge to command and control hierarchy, in a prison it take braves leadership to recognise the potential of social capital.

A joint report by the UK prison service and the National Health Service (Department of Health (DoH), 1999) suggested that a 'formal partnership' between the two organizations would enhance the health care of people in prison. Through such a partnership it is hoped that prisoners will be able to receive the same level of care as those who are treated within the wider community. Nurses attempting to achieve the goals of palliative care within a prison setting may encounter environmental constraints to their work and may be further deterred by their own lack of specialist knowledge. This article discusses how such problems can be overcome through the professional development of prison nurses.

Background: The collection of patient experience feedback (PEF) has seen a marked global increase in the past decade. Research about PEF has concentrated mainly on hospital settings albeit a recent interest in primary care. There has been minimal research about PEF in the prison healthcare setting. The aim of this study was to explore the role of prison PEF, the different forms it might take and the perceptions of healthcare staff and people in prison. Methods: Qualitative face to face interview study involving 24 participants across two prisons (male and female) in the North of England, involving 12 healthcare staff and 12 patients. Framework analysis was undertaken. Results: PEF sources were variable, from informal and verbal through to formal and written. The willingness of people in prison to give PEF related to whether they felt sufficiently comfortable to raise concerns, with some feeling too frightened and having apprehension about anonymity. It was viewed as disheartening to give PEF but not be informed of any outcome. Healthcare staff opinions about PEF were divergent but they found PEF unhelpful when it was about prison regime issues rather than healthcare. Suggestions for improving the PEF process were put forward and included accessibility, anonymity and digitalisation. Conclusions: This is the first study to report findings about prison PEF. There are broad similarities between our findings and research examining hospital-based PEF. Prison healthcare services seem to be listening to patients but the ways in which PEF is collected, considered and used could be improved.

Background: People in prison are at high risk of hepatitis C virus (HCV) infection and often have a history of injection drug use and mental health disorders. Simple test-and-treat regimens which require minimal monitoring are critical. Methods: This integrated real-world analysis evaluated the effectiveness of once daily sofosbuvir/velpatasvir (SOF/VEL) in 20 prison cohorts across Europe and Canada. The primary outcome was sustained virological response (SVR) in the effectiveness population (EP), defined as patients with a valid SVR status. Secondary outcomes were reasons for not achieving SVR, adherence and time between HCV RNA diagnosis and SOF/VEL treatment. Results: Overall, 526 people in prison were included with 98.9% SVR achieved in the EP (n = 442). Cure rates were not compromised by drug use or existence of mental health disorders. Conclusion: SOF/VEL for 12 weeks is highly successful in prison settings and enables the implementation of a simple treatment algorithm in line with guideline recommendations and test-and-treat strategies.

BackgroundThe impact of COVID-19 has been exceptional, particularly on the National Health Service which has juggled COVID affected patients alongside related staff shortages and the existing (and growing) health needs of the population. In prisons too, healthcare teams have been balancing patient needs against staffing shortfalls, but with additional strains unique to the prison population. Such strains include drastic lockdown regimes and prolonged isolation, the need to consider health alongside security, known health inequalities within prisoner groups, and an ageing and ethnically diverse population (both groups disproportionately affected by COVID). The aim of this paper is to contribute to emerging research on the impact of COVID-19 on prison healthcare.MethodsWe conducted 44 in depth interviews (over phone or video) across three groups: prison leavers, healthcare staff and decision makers, between July and December 2021. Framework analysis was undertaken.ResultsThree themes were found. First, we found that Covid-19 had a significant impact on prison healthcare which involved reduced access and changes to how healthcare was delivered. This affected the health of prisoners by exacerbating existing conditions, new conditions being undiagnosed and mental health needs increasing. Second, the pandemic impacted on healthcare staff through creation of stress, frustration and exhaustion due to minimal staffing levels in an already under-resourced system. Third, an emerging conflict was witnessed. People in prison felt neglected regarding their healthcare needs but staff reported doing the best they could in an unprecedented situation. Healthcare staff and decision makers felt that prison healthcare was seen as a poor relation when compared with healthcare in the community, with no extra resource or staffing for Covid-19 testing or vaccinations.ConclusionThe Covid-19 pandemic has significantly impacted almost all aspects of prison healthcare in the UK. This includes delivery of healthcare by staff, receipt of it by people in prison and the management, planning and commissioning of it by decision makers. These three groups of people were all affected detrimentally but in vastly different ways, with some participants describing a sense of trauma. Health needs that were exacerbated or went unmet during Covid urgently need to be addressed in order to reduce health inequalities. In order for welfare and wellbeing to be maintained, and in some cases repaired, both prisoners and staff need to feel heard and recognised.

The increasing size of the ageing English prison population means that non-communicable diseases such as cancer are being more commonly diagnosed in this setting. Little research has so far considered the incidence of cancer in the English prison population, the treatment patients receive when they are diagnosed in a prison setting, their care costs and outcomes or their experiences of care compared with those of people diagnosed in the general population. This is the first mixed-methods study that has been designed to investigate these issues in order to inform recommendations for cancer practice, policy and research in English prisons. We compared cancer diagnoses made in prison between 1998 and 2017 with those made in the general population using a cohort comparison. We then used a cohort comparison approach to patients' treatment, survival, care experiences and costs of care between 2012 and 2017. We also conducted qualitative interviews with 24 patients diagnosed or treated in prison, and 6 custodial staff, 16 prison health professionals and 9 cancer professionals. Findings were presented to senior prison and cancer stakeholders at a Policy Lab event to agree priority recommendations. By 2017 cancer incidence in prison had increased from lower levels than in the general population to similar levels. Men in prison developed similar cancers to men outside, while women in prison were more likely than women outside to be diagnosed with preinvasive cervical cancer. In the comparative cohort study patients diagnosed in prison were less likely to undergo curative treatment, particularly surgery, and had a small but significantly increased risk of death. They also had fewer but slightly longer emergency hospital admissions, lower outpatient costs and fewer planned inpatient stays. While secondary care costs were lower for patients in prison, when security escorts costs were added, emergency care and total costs were higher. Control and choice, communication, and care and custody emerged as key issues from the qualitative interviews. People in prison followed a similar diagnostic pathway to those in the general population but experienced barriers arising from lower health literacy, a complex process for booking general practitioner appointments, communication issues between prison staff, surgical, radiotherapy and oncology clinicians and a lack of involvement of their family and friends in their care. These issues were reflected in patient experience survey results routinely collected as part of the annual National Cancer Patient Experience Survey. The four priorities developed and agreed at the Policy Lab event were giving clinical teams a better understanding of the prison system, co-ordinating and promoting national cancer screening programmes, developing 'health champions' in prison and raising health literacy and awareness of cancer symptoms among people in prison. We could not identify patients who had been diagnosed with cancer before entering prison. Healthcare practices and policies both within prisons and between prisons and NHS hospitals need to be improved in a range of ways if the cancer care received by people in prison is to match that received by the general population. Evaluating new policy priorities. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/52/53) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 3. See the NIHR Funding and Awards website for further award information.