Correctional Health Care System Research Articles

Gambling Behaviors and Perceived Health Among Incarcerated Older Adults

The proliferation of lotteries and casinos has led to increased participation in gambling. Older adults who have opportunities to gamble may be vulnerable to gambling problems, and incarcerated older adults may be the most vulnerable. Furthermore, research has linked decreased health to gambling problems. This study compared perceived health and gambling problems among 43 incarcerated older adults from two county jails in the midwestern United States. Results from the South Oaks Gambling Screen indicated 48.83% of the sample scored in the problem or pathological range. Short Form-36 results were compared with U.S. norms for ages 55 to 64 and showed significantly lower perceived health scores on Role-Physical, Bodily Pain, Mental Health, Social Functioning, and Role-Emotional subscales. The problem and pathological gamblers showed significantly lower social functioning than the recreational gamblers. Assessment of health conditions and gambling behaviors is important for quantifying current and anticipated burdens of these conditions on correctional health care systems and the community.

Commentary: Treatment for Prisoners: A U.S. Perspective

Commentary: Treatment for Prisoners: A U.S. Perspective

Studying health disparities by including incarcerated and formerly incarcerated individuals.

IN SEPTEMBER 2010, THE NATIONAL INSTITUTES OF HEALTH formalized a commitment to ending health disparities by establishing a 27th institute, the National Institute on Minority Health and Health Disparities, with priorities that include “improving the participation of health disparity populations in clinical research.” Accomplishment of this important goal will require recognition of the disproportionate incarceration of individuals from racial/ ethnic minority populations and reassessment of the federal near prohibition on the participation of current and former prisoners in clinical research. Currently, more than 2.3 million individuals are incarcerated in the United States. It is estimated that on any given day, 1 in 9 US black men aged 20 to 34 years is incarcerated, and 1 in 3 black men are expected to be imprisoned at some point in their lives if rates of incarceration stay the same. Ninety-five percent of these individuals are ultimately released back into society but most continue to cycle through the legal system throughout their lives. These numbers have direct bearing on the ability to design and implement studies of health disparity populations and thereby undermine the ability to understand and mitigate the racial/ ethnic health disparities such studies seek to diminish. For example, cardiovascular disease mortality is 20% higher in black men than in white men. Similarly, hypertension, a risk factor for cardiovascular disease, tends to be more common, develops at an earlier age, and is more severe for black than white individuals. Much of what is known about these disparities has been derived from federally funded cross-sectional studies such as the National Health and Nutrition Examination Studies, which sample noninstitutionalized, community-dwelling adults. However, if 1 in 9 young black men is currently incarcerated, how accurate can the surveillance of racial disparities be—especially since incarceration may be associated with an increased risk of developing cardiovascular disease? For comparison, if 1 in 9 of these black men were a current smoker (and given that such rates of smoking were exceptionally high), but these men could not be included in national surveys, estimates of smoking prevalence might be inaccurate. By not including the 2.3 million currently incarcerated individuals in national surveys, the surveillance systems might provide flawed estimates of racial/ethnic disparities in cardiovascular risk factors and miss opportunities to understand how incarceration and the correctional health care system affect cardiovascular risk factors and disease. Mass incarceration affects not only disease surveillance but also studies of risk factors for the development of cardiovascular disease or tests of interventions to reduce disease in minority populations. The National Heart, Lung, and Blood Institute spends hundreds of millions of dollars on prospective cohort studies and randomized controlled trials such as the Atherosclerosis Risk in Communities study, the Jackson Heart Study, the Multiethnic Study of Atherosclerosis, and the Coronary Artery Risk Development in Young Adults (CARDIA) study, all of which are focused on improving the health of minority populations. Of critical importance to the validity of these studies is participant follow-up over time. However, in all of the aforementioned studies, observing young black men over time has proven to be challenging. In CARDIA, for example, only 56% of black men remained in the study at the year 20 examination in 2005, compared with 75% of white men, 68% of black women, and 77% of white women. It is likely that at least some of the black men who dropped out of CARDIA did so because of incarceration. What are the potential implications if a disproportionate number of black men are being excluded from crosssectional and prospective cohort studies due to incarceration? Only 2 potential implications, power and precision, are considered in this Commentary. If a significant proportion of black men are lost to follow-up or excluded, statistical power for that group may be reduced, impeding efforts to identify significant associations. Furthermore, if data are not missing at random, which they are not if imprisonment disproportionately affects black men, the estimated effects may be biased for black men (assuming the dependent and explanatory variables are associated with incarceration). Thus, the loss of black men from medical research due to incarceration may produce biased, underpowered estimates in studies of health disparities.

Legal Issues Regarding Medical Care for Pregnant Inmates

This article examines mothers in prison, highlighting the complexity and detrimental consequences incarceration has for their families and children. It documents the legal remedies available to pregnant prisoners, focusing on their unique medical needs. After reviewing the U.S. Supreme Court’s standard for liability, the article explores lower court case law to establish the legal parameters of pregnant prisoners’ health care needs. The article concludes that although correctional health care systems have made strides in bringing appropriate medical care to pregnant prisoners, more remains to be done to raise the quality of care to those similarly situated in the free-world.

Prevalence of chronic medical conditions among inmates in the Texas prison system.

Given the rapid growth and aging of the US prison population in recent years, the disease profile and health care needs of inmates portend to have far-reaching public health implications. Although numerous studies have examined infectious disease prevalence and treatment in incarcerated populations, little is known about the prevalence of non-infectious chronic medical conditions in US prison populations. The purpose of this study was to estimate the prevalence of selected non-infectious chronic medical conditions among inmates in the Texas prison system. The study population consisted of the total census of inmates who were incarcerated in the Texas Department of Criminal Justice for any duration from September 1, 2006 through August 31, 2007 (N=234,031). Information on medical diagnoses was obtained from a system-wide electronic medical record system. Overall crude prevalence estimates for the selected conditions were as follows: hypertension, 18.8%; asthma, 5.4%; diabetes, 4.2%; ischemic heart disease, 1.7%; chronic obstructive pulmonary disease, 0.96%; and cerebrovascular disease, 0.23%. Nearly one quarter (24.5%) of the study population had at least one of the selected conditions. Except for asthma, crude prevalence estimates of the selected conditions increased monotonically with age. Nearly two thirds (64.6%) of inmates who were >or=55 years of age had at least one of the selected conditions. Except for diabetes, crude prevalence estimates for the selected conditions were lower among Hispanic inmates than among non-Hispanic White inmates and African American inmates. Although age-standardized prevalence estimates for the selected conditions did not appear to exceed age-standardized estimates from the US general population, a large number of inmates were affected by one or more of these conditions. As the prison population continues to grow and to age, the burden of these conditions on correctional and community health care systems can be expected to increase.

Heterogeneity in Hepatitis B Virus (HBV) Seroprevalence Estimates from U.S. Adult Incarcerated Populations

Despite substantial declines over the past two decades in U.S. incidence rates for hepatitis B virus (HBV) infection, chronic HBV infection and its sequelae—chronic liver disease/cirrhosis and primary liver cancer—remain significant public health problems (1–7). These conditions may have a particularly strong impact on correctional health-care systems in the United States, as studies suggest that the prevalence of current or past HBV infection in incarcerated populations may be four to five times greater than that in the U.S. general population (6, 8–30). However, HBV seroprevalence estimates from U.S. incarcerated populations appear to vary widely across studies, with prevalence estimates for HBV surface antigen (HBsAg) (current infection) ranging from 0.9% to 11.4% (12, 28) and HBV core antibody (anti-HBc) (past or current infection) estimates ranging from 6.5% to 42.6% (12, 19). Variation in HBV seroprevalence estimates across incarcerated populations has received limited attention in the literature (12–14), and several authors have suggested that HBV seroprevalence estimates reported in their studies were consistent with previous estimates (15, 17, 19, 21, 27–29). We conducted a systematic review of studies reporting HBV seroprevalence estimates from U.S. adult incarcerated populations to describe variation in these estimates across studies.

Contraception services for incarcerated women: a national survey of correctional health providers

Background Incarcerated women have had limited access to health care prior to their arrest. Although their incarceration presents an opportunity to provide them with health care, their reproductive health needs have been overlooked. Study Design We performed a cross-sectional study of a nationally representative sample of 950 correctional health providers who are members of the Academy of Correctional Health Providers. Results A total of 405 surveys (43%) were returned, and 286 (30%) were eligible for analysis. Most ineligible surveys were from clinicians at male-only facilities. Of eligible respondents, 70% reported some degree of contraception counseling for women at their facilities. Only 11% provided routine counseling prior to release. Seventy percent said that their institution had no formal policy on contraception. Thirty-eight percent of clinicians provided birth control methods at their facilities. Although the most frequently counseled and prescribed method was oral contraceptive pills, only 50% of providers rated their oral contraceptive counseling ability as good or very good. Contraception counseling was associated with working at a juvenile facility, and with screening for sexually transmitted infections. Conclusions Contraception does not appear to be integrated into the routine delivery of clinical services to incarcerated women. Because the correctional health care system can provide important clinical and public health interventions to traditionally marginalized populations, services for incarcerated women should include access to contraception.

Monitoring a correctional mental health care system: the role of the mental health expert

Class action litigation has been instrumental in jail and prison reform over the past four decades. This article provides a very brief introduction underlying the legal basis for such litigation. It focuses on the role of the mental health expert in monitoring a correctional mental health care system as a result of class action litigation including issues related to selection of the expert, development of the remedial plan, and monitoring of the implementation of the remedial plan. The importance of policies and procedures and a quality improvement process is emphasized. Essential elements of the monitoring process, prior to and during the site assessment, are described. Inmates and correctional staff alike have benefited substantially from such litigation in the form of increased resources and positive changes in institutional culture.

HCV-related mortality among male prison inmates in Texas, 1994-2003

The prevalence of hepatitis C virus (HCV) infection is high among adult incarcerated populations, but HCV-related mortality data are lacking. The study purpose was to assess HCV-related mortality over time and across racial/ethnic categories from 1994 through 2003 among male prisoners in the Texas Department of Criminal Justice (TDCJ). TDCJ decedent data were linked with Texas Vital Statistics multiple-cause-of-death data. Crude annual HCV death rates, age- and race-adjusted summary rates, and average annual percent changes were estimated. The proportion of deaths due to chronic liver disease/cirrhosis, liver cancer, hepatitis B, and HIV for which HCV was identified as an intervening or contributing cause of death was calculated. Among Texas male prisoners, HCV death rates were high and increased over the 10-year study period by an average 21% annually, with the largest increase occurring among Hispanic prisoners. HCV was identified as an intervening or contributing cause of death in 15% of chronic liver disease/cirrhosis deaths, 33% of liver cancer deaths, 81% of hepatitis B deaths, and 7% of HIV deaths. Because HCV-related deaths among Texas male prisoners are high and increasing, particularly among Hispanics, targeted prevention, screening, and treatment of HCV infections should be among the priorities of U.S. correctional healthcare systems.

A Cruel and Unusual System: The Inherent Problems of the Practice of Outsourcing Health Care of Prisons and Jails

The aim of this paper is to show that at a systemic level, the outsourcing of health care in prisons and jails has or will soon provide such a paucity of health care that the level of care could be considered cruel and unusual punishment and thus be unconstitutional. This result is inevitable considering the race to the bottom that occurs when several for-profit companies compete for a correctional system's health care contract, and considering that the prison population has little or no power as a social or political constituency. Section II will examine the legal standards under which inmates may bring actions alleging paucity of health care. Section III will argue that the practice of outsourcing prison and jail health care inexorably leads to a violation of inmates' Constitutional rights. Section IV will suggest ways to improve correctional institutions' health care systems.

Managing HIV/AIDS in correctional settings

Approximately one quarter of people living with HIV/AIDS in the United States pass through the correctional system, resulting in a burden of infection on the correctional health care system that has challenged correctional and public health officials. The HIV epidemic behind bars results from the high prevalence of HIV risk behaviors among those incarcerated: illicit drug use, untreated mental illness, prostitution, homelessness, and poverty. Challenges to HIV care in correctional settings include management of comorbid conditions, remoteness from HIV care sites, organizational constraints, and access to effective therapies. Despite these challenges, prisoners with HIV have derived considerable benefit from HIV detection and treatment. In order to achieve parity in HIV outcomes among vulnerable populations, effective prison-release programs that incorporate effective case management with effective drug treatment and adherence strategies are required to extend the benefit of highly active antiretroviral therapy as prisoners transition back to community settings.

Characteristics and trends of newly identified HIV infections among incarcerated populations: CDC HIV voluntary counseling, testing, and referral system, 1992-1998.

Inmate contact with the correctional health care system provides public health professionals an opportunity to offer HIV screening to a population that might prove difficult to reach otherwise. We report on publicly funded human immunodeficiency virus (HIV) voluntary counseling, testing, and referral (VCTR) services provided to incarcerated persons in the United States. Incarcerated persons seeking VCTR services received pretest counseling and gave a blood specimen for HIV antibody testing. Specimens were considered positive if the enzyme immunoassays were repeatedly reactive and the Western blot or immunofluorescent assay was reactive. Demographics, HIV risk information, and laboratory test results were collected from each test episode. Additional counseling sessions provided more data. From 1992 to 1998, there were 527,937 records available from correctional facilities from 48 project areas; 484,277 records included a test result and 459,155 (87.0%) tests came with complete data. Overall, 3.4% (16,797) of all tests were reactive for HIV antibodies. Of reactive tests accompanied by self-reports of previous HIV test results (15,888), previous test results were 44% positive, 23% negative, 6% inconclusive or unspecified, and 27% no previous test. This indicates that 56% of positive tests were newly identified. During the study period, the number of tests per year increased three-fold. Testing increased among all racial/ethnic groups and both sexes. The largest increase was for heterosexuals who reported no other risk, followed by persons with a sex partner at risk. Overall, the greatest number of tests was reported for injection drug users (IDUs) (128,262), followed by men who have sex with men (MSM) (19,928); however, episodes for MSM doubled during the study, while for IDUs, they increased 74%. The absolute number of HIV-positive (HIV+) tests increased 50%; however, the percentage of all tests that were HIV+ decreased nearly 50% due to the increased number of tests performed. HIV+ tests fell 50% among blacks (7.6% to 3.7%), Hispanics (6.7% to 2.5%), and males (5.1% to 2.5%); 33% among females (4.5% to 3.1%); 95% among IDUs (8.6% to 4.4%); and 64% among MSM (19.3% to 11.8%). Among HIV+ episodes, those for IDUs dropped from 61.5% to 36.6%, while episodes for heterosexuals with no reported risk factor increased from 4.3% to 18.2%. The use of VCTR services by incarcerated persons rose steadily from 1992 to 1998, and 56% of HIV+ tests were newly identified. High numbers of tests that recorded risk behaviors for contracting HIV indicate that correctional facilities provide an important access point for prevention efforts.

Impact of automation on pharmacist interventions and medication errors in a correctional health care system.

The implementation and impact of an automated check-and-sortation system in a correctional health care system are described. In February 1998 the Managed Health Care Division of the University of Houston College of Pharmacy submitted a proposal to the Texas State Board of Pharmacy for installing an automated check-and-sortation device in its distributive system serving Texas Department of Criminal Justice offenders. The new system would eliminate final visual verification of medication orders by pharmacists and thereby give them more time for in-depth reviews of patient profiles and for recommending clinical interventions. A vendor interested in developing a prototypic automated system was identified, and a disease management training course was developed to enable staff pharmacists to provide evidence-based pharmacotherapy recommendations. Twelve months of data before automation (February 1997 to January 1998) were compared with 16 months of postautomation data (June 1998 to September 1999). The number of clinical interventions increased from 396 per 100,000 medication orders filled before automation to 1075 per 100,000 orders after automation. Dispensing errors decreased from 6.3 to 4.1 per 100,000 medication orders filled. Identified filling errors increased from 224 to 256 per 100,000 orders. The reliability of the automated system was evidenced by a dispensing error rate of 0.6 per 100,000 orders. Implementation of an automated check-and-sortation device in a correctional health care system appeared to reduce dispensing errors and give pharmacists more time to review patient profiles and recommend clinical interventions.

American Academy of Pediatrics: Health care for children and adolescents in the juvenile correctional care system.

Over the past decade, there has been a dramatic increase in the population of juvenile offenders in the United States. Juveniles detained or confined in correctional care facilities have been shown to have numerous health problems. Such conditions may have existed before incarceration; may be closely associated with legal problems; may have resulted from parental neglect, mental health disorders, or physical, drug, or sexual abuse; or may develop within the institutional environment. Delinquent youths are often disenfranchised from traditional health care services in the community. For these adolescents, health care provided through correctional services may be their major source of health services. Pediatricians and correctional health care systems have an opportunity and responsibility to help improve the health of this underserved and vulnerable group of adolescents.

Standardizing Chronic Illness Care Behind Bars

Correctional health care systems regularly standardize many aspects of patient care. However, the care of those with chronic illnesses seldom is standardized, but is left entirely to the discretion...

Practicing penal harm medicine in the United States: Prisoners' voices from jail*

This article explores how the implementation of the penal harm movement within a correctional health care system can lead to the ill-treatment and torture of prisoners. Through an interpretive/inductive analysis of reports written by a federal court monitor and 103 letters written by prisoners to a federal court monitor overseeing a consent decree of a county mega jail located in the United States, we identify six areas of ill-treatment and torture at the jail's medical facilities: (1) using medical care to humiliate prisoners; (2) withholding medical care from HIV-positive prisoners and those with AIDS; (3) withholding medical care from other prisoners; (4) exposing prisoners to temperature extremes and sleep deprivation; (5) using dental care as a means of ill-treatment and torture; and (6) falsifying prisoners' medical records. Because correctional medical personnel work in a system that subordinates their professional canons to the efficiency-based rationality of the new penology and the ethical relativism of the penal harm movement, we conclude that some correctional health providers sympathetic to the custodial subculture abdicate their ethical obligations, and that the result is ill-treatment and torture of prisoners.

Infectious Diseases of Geriatric Inmates

The number of geriatric inmates is rapidly growing because of more frequent incarceration of older offenders as the number of the elderly in the general population increases nationally. The increase is also due to recent changes in sentencing patterns (e.g., longer sentences and tightened parole) that affect younger, long-term inmates. Geriatric inmates often have chronic medical illnesses that may result in hospitalization for infectious complications. These infectious conditions may be related to factors such as institutionalization (e.g., tuberculosis and influenza), chronic medical illness (e.g., pneumococcal pneumonia), and a history of alcohol or drug use (e.g., hepatitis B virus and retrovirus infection). The epidemiology of these conditions is reviewed. Since infectious complications among geriatric inmates will add stress to a correctional health care system that is already burdened by inmates with AIDS-related illnesses, clinical recognition of these complications and preventive measures are of great importance.

Evaluating correctional health care: The lessons of New York City

New York City's correctional health care system is a complicated one, with many component parts. Correspondingly, the task of developing an evaluation process to assess this system turned out to be complex as well. The major responsibility for developing such a process and for keeping it in motion lies with the Contract Evaluation Unit of the Department of Health. Our experiences in meeting these challenges, as well as the historical and institutional factors that have influenced our efforts, should be of interest to professional groups facing similar tasks in other localities and to readers curious about how particular health service evaluation approaches take form. This article describes our method, how it emerged, and what it entails, with an eye toward identifying what might usefully be applied to the study of other correctional health care services and settings.