Prison Health Care System Research Articles

From the Editors’ Desk: Valuing Health and Primary Care

In June 2011, James Verone walked into a bank in North Carolina and attempted to rob it for a single dollar. Three years previously, he had been laid off from his 17-year job as a Coca-Cola deliveryman and, unable to find permanent alternative employment, had depleted his life savings. Unlike most bank robbers in this predicament, his goal was not pecuniary, though he certainly could use more money. Instead, his objective was to be apprehended and eventually imprisoned for robbery in order to obtain free health care from within the prison system. Unarmed, he was taken into custody. Sadly, Mr. Verone felt that the prison health care system was his best option for having access to medical care for his chronic medical conditions. Mr. Verone’s actions, while extreme, highlight the continuing problem of access to health care faced by over 50 million people in the US. The 2010 Patient Protection and Affordable Care Act health reform bill is poised to decrease that number dramatically, by increasing health care access through taxes, offsets, and negotiated deals—for an estimated $900B invested over 10 years. Among other measures, the PPACA enacted provisions to mandate most legal US residents to buy or continue health insurance (through subsidies, health insurance exchanges, penalties and employer mandates), and prohibits discrimination by insurance companies based on pre-existing conditions. Additionally, the provisions of the 2009 American Recovery and Reinvestment Act (ARRA) provided $90B to states to strengthen Medicaid, $2B for community health care centers, and more. These progressive acts of legislation have an underlying assumption—that increased demand for medical care can be accommodated by our current system of medical care. However, as most patients know, primary care practices are full. The 350,000 US primary care physicians are unlikely to have the capacity to provide care for the PPACA-subsidized newly insured. The AAMC estimates a 150,000 physician shortfall within 15 years. In this issue of JGIM, several papers explore the value of primary care access and patient empowerment. DeVoe addresses the need for insured patients to obtain access to a usual source of care. In her cohort of 62,000 Medical Expenditure Panel Survey (MEPS) adults, insured patients without a usual source of care were significantly more likely to have problems obtaining primary care. Using a nationally representative sample of 1,000 US primary care physicians, Carrier studied the relationship between quality of care delivered and socio-economic characteristics of their Medicare patients. Her findings of a significant but inconsistent relationship between lower quality of care and lower income and education, black race and Medicaid eligibility are important to consider as we re-consider methods to provide equitable care using ARRA stimulus funds. In addition to measures used to improve access to care, innovative solutions must be found to help patients maintain or improve their health. For instance, in this issue of JGIM, Hill-Briggs and colleagues randomized 56 urban African-Americans with poorly controlled diabetes and hypercholesterolemia to an intensive and condensed literacy-adapted self-management course. Her patients underwent health problem-solving training. While all patients had an improvement in knowledge, at 3 months the intensive education group decreased their HbA1c by 0.71%. James Verone took extreme and unusual measures to gain access to medical care. While access to primary care is a necessary first step to improve health outcomes, access alone will not ensure high quality medical care. As we confront the urgent need for health care reform in the US, we must consider new models to engage our patients in their own health care for chronic disease management—keeping in mind current variations in health care outcomes across education, income and race.

A Study of Women Prisoners' Use of Co-Payments for Health Care: Issues of Access

We sought to analyze women prisoners' use of co-payments for health care; how co-payments affect their access to health care; and how they view the impact of co-payments on their health. Using a community-based participatory research approach, we conducted six focus groups with 31 previously incarcerated women. Data were analyzed using qualitative field research methods, grounded theory, and consensual qualitative research strategies to construct a shared understanding of the data. Co-payments hindered women prisoners' access to health care. Women reported inequitable implementation of the policy and foregoing care because of the financial burden of the co-payment. Co-payments contributed to delays in treatment, avoidance of health care professionals, unnecessary suffering, and poor health outcomes. In response, women used self-advocacy skills to manage their health care needs and deal with the prison health care system. Co-payments place an unfair burden on prisoners who are poor, limit access to health care, and contribute to needless suffering and potentially to preventable deaths.

Fixing the Prison Health Care System Through Changes in Punishment

Something must be done to improve access to health care in America’s prisons. A prison sentence today imposes an illegitimate burden of poor quality medical care on prisoners. The prison system neither treats inmate fairly nor effectively, and exacerbates and spreads disease. Existing pathways to reform have failed. Legislative fixes have been mired in losing political battles. Efforts at litigating for change have been derailed by hostility both from the judiciary and legislatures. Finally, common-sense prison based remedies have been stymied by extraordinarily rare application. The best hope for improving conditions comes through a radical expansion of sentencing and early-release initiatives. These proposals limit the sentences of sick inmates at the outset, and provide for early release of sick inmates who are already incarcerated. These measures serve as a safety-valve for the overburdened prison health-care system, while avoiding the problems of other measures.

The Effect of Health and Penal Harm on Aging Female Prisoners' Views of Dying in Prison

With tougher sentencing laws, an increasing number of individuals are finding themselves spending their final years of life in prison. Drawing on a sample of 327 women over the age of 50 incarcerated in five Southern states, the present study investigates the relationship between numerous health variables and the Templer Death Anxiety Scale (TDAS). Qualitatively, the article also provides personal accounts from inmates that serve to reinforce death fears when engaging the prison health care system. Participants reported a mean of 6.40 on the TDAS indicating a substantial degree of death anxiety when compared to community samples. Both mental and physical health measures were important indicators of death anxiety. Qualitative information discovered that respondents' concerns about dying in prison were often influenced by the perceived lack of adequate health care and the indifference of prison staff and other instances of penal harm.

No Real Release

Media attention to the inadequacies of the prison health care system, often reported in vivid detail, has had real implications for prison policies and management. There's now growing recognition of the role prisons play in the spread of infectious disease and serious efforts to curtail infection among prisoners.

Prison health care: is contracting out healthy?

US prison health care has recently been in the news and in the courts. A particular issue is whether prisons should contract out for health care. Contracting out has been growing over the past few decades. The stated motivation for this change ranges from a desire to improve the prison healthcare system, sometimes in response to a court mandate, to a desire to reduce costs. This study is a first attempt to quantify the impact of this change on inmate health. As morbidity measures are not readily obtainable, we focus on mortality. More specifically, we use a panel of state prisons from 1979 to 1990 and a fixed effects Poisson model to estimate the change in mortality associated with increase in the percentage of medical personnel employed under contract. In contrast to the first stated aim of contracting, we find that a 13% increase in percentage of medical personnel employed under contract increases mortality by 1.3%.

Health Issues in Prisons and Jails

Health Issues in Prisons and Jails

A review of prison health and its implications for primary care nursing in England and Wales: the research evidence

To provide a systematic overview of the policy and practice literature concerned with the primary healthcare needs of prisoners in England and Wales and to address the implications of these health needs for nurses working in prisons. The recent reorganization of the prison healthcare system, which has brought prison health services in England and Wales within the National Health Service, has major implications for the role of prison nurses. Nurses in prisons are increasingly providing services to promote the health of prisoners, in addition to making assessments of health need and treating health problems. The review examined literature from 1995 to date using standard review techniques adapted to be both sensitive and inclusive and with high recall because of the unexplored nature of primary health care in prisons. Findings are identified in three main areas: the general health needs of prisoners, health promotion and chronic disease management. In all these areas, the health needs of the prison population are much greater than the community as a whole, resulting in a high demand for primary care services in prison. However, the prison setting can militate against providing good primary care services in prison. More research has been carried out into the health needs of prisoners than into the provision of primary care nursing services in prisons. Further research is needed into primary care nursing in prison to meet the health needs of prisoners effectively. With the reorganization of prison health services, health provision in prisons is increasingly primary care focused. This presents new challenges to nurses working in prison to provide a primary care service, which meets the identified health needs of prisoners.

Users’ views of prison health services: a qualitative study

This paper is a report of a study of the views of prisoners about health services provided in prisons. Prison provides an opportunity for a 'hard to reach' group to access health services, primarily those provided by nurses. Prisoners typically have high health and social needs, but the views and experiences of prisoners about health services in prison have not been widely researched. Semi-structured interviews were carried out with 111 prisoners in purposively selected 12 prisons in England in 2005. Interviews covered both prisoners' views of health services and their own ways of caring for their health in prison. Interviews were analysed to develop a conceptual framework and identify dominant themes. Prisoners considered health services part of a personal prison journey, which began at imprisonment and ended on release. For those who did not access health services outside prison, imprisonment improved access to both mental and physical health services. Prisoners identified accessing services, including those provided by nurses, confidentiality, being seen as a 'legitimate' patient and living with a chronic condition as problems within the prison healthcare system. At all points along the prison healthcare journey, the prison regime could conflict with optimal health care. Lack of autonomy is a major obstacle to ensuring that prisoners' health needs are fully met. Their views should be considered when planning, organizing and delivering prison health services. Further research is needed to examine how nurses can ensure a smooth journey through health care for prisoners.

Psychiatric problems of detainees under the Anti-Terrorism Crime and Security Act 2001

Aims and MethodTo provide a composite view of the impact of indefinite detention under the Anti-Terrorism Crime and Security Act 2001. Until recently, a number of detainees had been detained under this legislation since December 2001. The impact of this on eight detainees and three of their spouses is examined through qualitative analysis of 48 reports and documents compiled by 11 psychiatrists and 1 psychologist.ResultsDetention has had a severe adverse impact on the mental health of all detainees and the spouses interviewed. All were clinically depressed and a number had post-traumatic stress disorder. The indefinite nature of detention was a major factor in their deterioration.Clinical ImplicationsThe use of indefinite detention without trial has severe adverse consequences that may pose insurmountable problems for the prison healthcare system.

The development and evaluation of a telepsychiatry service for prisoners.

The introduction of increasingly sophisticated telecommunication systems seems to offer opportunities to respond to some of the key problems around structural and spatial inequalities in access to health care. There is evidence which suggests that serious mental health problems are common among prisoners and psychiatric comorbidity is the norm. Many prisoners have complex mental health needs, but more often than not these remain unaddressed. Telepsychiatry is one strategy to improve the accessibility and quality of mental health care in the prison setting. This paper firstly reviews the current prison health care system and then describes a research study which is focused on the development and evaluation of a telepsychiatry service for prisoners. This study has investigated what is lost or gained in a psychiatric assessment when it is conducted via telepsychiatry. The researcher compared the inter-rater reliability between two raters interviewing 80 participants in an observer/interviewer split configuration in telepsychiatry and same room settings. The measure used was the Comprehensive Psychopathology Rating Scale. Prisoners and prison staff also took part in semi-structured interviews which focused on their satisfaction and acceptability of the telepsychiatry service. A cost comparison of the telepsychiatry service with the existing visiting service was conducted. This paper outlines the study design and focuses on the potential impact that telepsychiatry may have upon the practice setting.

Prisons and prisoners: some observations, comments and ethical reflections based on a visit to a prison hospital in the Ukrainian Republic.

The Republic of the Ukraine has a huge prison population and a large prison health care system. Like all other public services in that country it is lacking in sufficient funds to operate adequately and with due respect to the human rights of the prisoners and its health care employees. This report and observations are based on my knowledge of the Ukrainian health care system and a visit to a Ukrainian prison hospital. It includes some ethical reflections stemming from this experience. Although problem-solving exercises can often help to point to areas of potential intervention that could ameliorate a troublesome situation, in this case prison health care conditions cannot be substituted for economic growth, political stability or increased awareness of societal moral obligations.

Shared Values In A Prison Health Care System

In the first of a new series, Ann Norman and Alan Parrish call for leadership in prison nursing.

Cruel and Unusual Punishment

Nationally, the number of female prison inmates--although small compared with the number of male inmates--is on the upswing. Since correctional facilities are legally mandated under the eighth amendment to provide inmates with their constitutional right to health care, innovative methods of delivering that care will have to be devised within a current system that is neither funded nor prepared to design and dispense such programs. The most frequent medical problems among incarcerated women are drug/alcohol addiction, gynecological diseases, and exacerbation of chronic health problems, particularly hypertension, diabetes and epilepsy. The prison health care system is also being faced with management of an increasing number of pregnant and postpartal inmates. Health needs of this group include basic health care, teaching, counseling and supportive care--services that can be appropriately provided by nurse practitioners and other health care providers.

Acquired immunodeficiency syndrome in male prisoners. New insights into an emerging syndrome.

Between September 1981 and June 1982, the acquired immunodeficiency syndrome and Pneumocystis carinii pneumonia were diagnosed in seven previously healthy young men incarcerated for 5 to 38 months in New York State correctional facilities. All seven patients were anergic, six were lymphopenic, and all developed oral candidiasis. Immunologic evaluation in vitro showed profound defects in cellular immune function in patients tested, with inversion of the normal ratio of helper to suppressor T-cell populations in four of five patients studied. No underlying immunosuppressive disorder was found in any patient, including three patients who had postmortem examinations. Based on these cases, the incidence of this syndrome among inmates of New York State correctional facilities is estimated to be at least 20 out of 100 000 per year. None of the inmates was homosexual but all had used intravenous drugs extensively before incarceration. If intravenous drug use is a cause of the syndrome, then the epidemiologic findings of this study suggest a prolonged incubation period (mean, 14.6 months) before development of serious opportunistic infection. Recognition that certain prisoners are at high risk for the acquired immunodeficiency syndrome has important implications for the prison health-care system.