Health-care needs of older women prisoners: Perspectives of the health-care workers who care for them

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.

"Equipping and enabling" health literacy during a "time of change": understanding health literacy and organisational health literacy responsiveness for people leaving prison in later life

BACKGROUND

This qualitative study investigated experiences and understandings of health literacy for those released from prison in later life. The global rise in older incarcerated individuals-defined as those aged 50 and above-poses significant public health and health equity challenges. With up to one in four prisoners being categorized as "older," their complex health needs often exceed those of younger inmates and the general community. An important but under-investigated challenge for this older population is navigating health care systems and self-management of health after release. Research evidence, albeit limited, has consistently identified health literacy deficits in this this population, complicating their health outcomes and reintegration more generally. This study fills a gap in the experience of health literacy for older people leaving prison, thus contributing to conceptual understandings and guiding targeted intervention development for this marginalised population.

RESULTS

Fifteen people with lived experience of release from prison in older age (mean age = 57) and thirteen staff or stakeholders with relevant professional experience from Australia participated in workshops and interviews exploring health literacy during the post-release period. An abductive thematic analysis was applied to the data, guided by the concept of health literacy and organisational health literacy responsiveness. The analysis produced two global themes ("Change" and "Equipped and Enabled") and seven subthemes ("A demanding time of change", "Braving a new world", "Leaving prison care", "I can only do what I can", "Help me help myself", "Others are key", "Everybody's problem, nobody's job"). Together, these themes indicated these individuals are the subject of complex and overlapping life circumstances, with limited resources and support currently available for health literacy both during and after release.

CONCLUSION

This population are mostly passive health care and information 'receivers' as a result of their imprisonment, who must be equipped and enabled to become more active health literacy 'doers'. This can be achieved through interventions that prepare the person better for life in community, and improve positive self-concept. Health and custodial organisations have an important role to play, with opportunities for improvement apparent across areas such as communication, focused health literacy policies, and collaboration with community partners.

Older women in the criminal justice system: a brief report from a nominal group

There are increasing numbers of older women in prison in England and Wales. The needs of older women in prison have been under researched and are often unmet. This paper explores staff and expert perspectives on the needs of older women in prison through a nominal group attended by six participants, including a consultant at the UK Health Security Agency; a General Practitioner; a postgraduate student completing a project on older women in prison; an academic researcher with expertise on older women in prison; a National Women's Health, Social Care, and Environment Review Group lead; and a HMMPS Diversity and Inclusion Lead. Six key themes were identified: 1) health screening; 2) health services and unmet health needs; 3) emotional wellbeing; 4) social and family connections; 5) the need for a professional's forum; and 6) limited data and research. Participants agreed that this population's needs are not adequately met. Moving forward, structures must be put in place to ensure that older women's needs are understood and met, and their voices heard.

Population ageing, incarceration and the growing digital divide: Understanding the effects of digital literacy inequity experienced by older people leaving prison

BACKGROUND

Digital inequity refers to the inequality and exclusion experienced by those who lack the same opportunities or circumstances to support the development of digital skills as the rest of modern society. One rapidly growing and highly vulnerable group to digital inequity is older people attempting to reintegrate into society after release from prison, where technology access is limited. Inadequate support for digital skills in this population entails widespread consequences for public health, human rights, social welfare and recidivism. This qualitative study is the first to: examine digital inequity experienced by older people who have been incarcerated, understand the effects of this on reintegration to society, and begin informing appropriate solutions.

METHOD

Semi-structured interviews were conducted with N = 15 older people (mean age = 57) who had been released from an Australian prison in the last two years, regarding their experiences of digital literacy since leaving prison. Reflexive thematic analysis was conducted under a critical realist lens.

RESULTS

The analysis resulted in six themes that illustrated the extent of digital inequity experienced by this population, and key challenges for improving digital literacy: 'surviving in a digital world', 'stranger in a foreign world', 'questioning the digital divide', 'overcoming your "old" self', 'don't like what you don't know', and 'seeking versus finding help'.

CONCLUSIONS

The digital inequity that older people experience during and after incarceration creates additional challenges for a growing group who are already medically and socially marginalised. Prioritisation of this group for digital literacy initiatives both during incarceration and in the community will have benefits for their health, social and financial reintegration. Their unique life experiences should be considered in designing and delivering these programs. Simultaneously, prisons should be cognizant of the potential detrimental effects of technology restriction on reintegration and criminogenic outcomes.

Sex and aging: Perspectives of older adult women with experience of incarceration

To explore perspectives on sexuality, sexual health, and sexual health care of older adult women with a history of criminal legal system involvement, we conducted phone interviews with women aged 50 years or older who were living in the community but had a history of jail and/or prison incarceration. Interview questions and initial analysis were guided by the sexual health framework for public health and Mitchell's sexual wellness model. Data analysis followed a framework method. Nine women, aged 53-66, participated in phone interviews between December 2020 and December 2021. Slightly over half the participants were Black; none were Hispanic. Most were single. We formulated a sex-in-aging (SAGE) framework comprising three categories and two overarching themes. Women with a history of criminal-legal system involvement have heterogeneous views on sex and sexual health and describe a range of desire and sexual activity as they age, including shifting ideas about what they expect from partners, how they keep themselves safe in sexual and intimate relationships, and how life circumstances that are often associated with criminal legal system involvement (substance use, trauma) impact their interest in sex as they age. The SAGE framework integrates these categories and themes and offers a starting point for further research and intervention development.

The use of benzodiazepines and the mental health of women in prison: a cross-sectional study

In this article we assessed the prevalence of benzodiazepine (BZD) use in women before and during imprisonment, as well as its related factors and association with symptoms of anxiety, depression, and posttraumatic stress disorder in a quantitative, cross-sectional, analytical study of regional scope. Two female prisons in the Brazilian Prison System were included. Seventy-four women participated by completing questionnaires about their sociodemographic data, BZD use and use of other substances. These questionnaires included the Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), and Posttraumatic Stress Disorder Checklist-Civilian Version (PCL-C). Of the 46 women who reported no BZDs use before arrest, 29 (63%) began using BZDs during imprisonment (p < 0.001). Positive scores for PTSD, anxiety, and depression, as well as associations between BZD use during imprisonment and anxiety (p = 0.028), depression (p = 0.001) and comorbid anxiety and depression (p = 0.003) were found when a bivariate Poisson regression was performed. When a multivariate Poisson regression was performed for tobacco use, the PHQ-9 and GAD-7 scales, BZD use was associated with depression (p = p = 0.008), with tobacco use (p = 0.012), but not with anxiety (p = 0.325). Imprisonment increases the psychological suffering of women, consequently increasing BZD use. Nonpharmacological measures need to be considered in the health care of incarcerated women.

Women Behind Bars: A Scoping Review of Mental Health Needs in Prison

Background

Women prisoners are a population that is vulnerable to mental health problems. Women prisoners have a higher risk of mental health problems than women in the general population. So far, there have been very few studies with specific on women prisoner populations discussing mental health needs in prisons. The high prevalence of mental health problems in women prisoners is inseparable from meeting the mental health needs of women prisoners in prison. This review aimed to identify the mental health needs of women prisoners.

Methods

A scoping review was used, a systematic search of the articles on Oxford Academic Journals, Emerald Insight, Science Direct, PubMed, and Google Scholar using the keywords "Mental Health" OR "Health" AND "Needs" OR "Needs Assessment" OR "Addressing Needs" AND "Female" OR "Woman" OR "Women" AND "Inmates" OR "Prisoners" OR "Offenders" OR "Convicts".

Results

A total of 10 out of 254 selected, were considered eligible for inclusion and the results showed that the six major themes of mental health needs of women prisoners were treatment of substance, drug, and alcohol abuse, support system, empathy, training, mental illness treatment and access to health services, and health intervention: therapy and counselling.

Conclusion

It is recommended for further research to focus more on the problem of access to gender-based mental health services in prisons.

Structural racism and the impact on incarcerated midlife women

High recidivism rates indicate that current forms of imprisonment may be an ineffective response to problems that mainly burden those ensconced in poverty and marginalization. Homelessness, unemployment, racial disparities, drug use, and mental illness, disappear from public view when the afflicted individuals are relegated to a life behind bars. Women are the fastest growing prison population and most incarcerated women are from Black and Latinx groups. Structural racism encompasses the many ways in which society fosters racial discrimination through mutually reinforcing unfair systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice. In turn, this behavior reinforces discriminatory beliefs, values, and distribution of resources. Structural racism pervades every aspect of society, including the carceral system, from policing to prosecutorial decisions, pretrial release processes, sentencing, correctional discipline, and even reentry. Women constitute a minority within the carceral system, and as a result, their unique health care needs, especially during the midlife period, are inadequately addressed and often overlooked. There is also a general lack of gender sensitivity and special considerations in existing jail and prison policies and practices. This commentary highlights the impact of structural racism on the arrests and incarceration of women, and discusses their special health and wellness needs, with emphasis on midlife women. It also illuminates the need to address structural racism and its ripple effects within the carceral system.

A human rights assessment of menopausal women's access to age- and gender-sensitive nondiscriminatory health care in prison

IMPORTANCE AND OBJECTIVE

Women represent about 6% of the global prison population of 11 million. The female prison population has increased significantly in the past decade. Where attention is devoted to women's unique sexual and reproductive health needs in prison, this is largely focused on menstruation management and ante/postnatal care. There is no explicit guidance regarding imprisoned menopausal women's health care in the United Nations normative standards of detention (Mandela Rules, Bangkok Rules). A human rights assessment of menopausal women's access to age- and gender-sensitive nondiscriminatory health care in prison since 2010 was conducted.

METHODS

Arksey and O'Malley's scoping review methodology was adhered to. A systematic search was conducted using detailed MeSH terms on CINAHL, MEDLINE, PubMed, ProQuest Central, PsycInfo, Scopus, and the Web of Science. All published materials in the English language in the time frame of 2010-2022 were collated (n = 268). Fourteen duplicates were removed. Two hundred thirty-four were excluded after title and abstract screening, with five records remaining. Hand searching yielded an additional 11 records. Sixteen records were charted and analyzed thematically using a human rights lens. Themes were the following: environmental conditions and menopausal sequelae, gender-sensitive nondiscriminatory free health care, evidence-based age/gender-sensitive prison health policies, and medical insensitivity and incompetencies in menopausal care.

DISCUSSION AND CONCLUSION

Menopausal women have the right to the underlying environmental determinants of health in prison and rights to nondiscrimination and equivalence of care, essential medicines, medical care and treatment, preventive health services, and participation in the generation of prison policies and support initiatives. The lack of visibility regarding their health needs in policies and healthcare provisions is reflected in the realities of life in prison, with glaring gaps in the practical medical and lifestyle supports of menopause. Further research is warranted to inform evidence-based prison reforms to improve the quality of life of older women in prison.

'You're setting a lot of people up for failure': what formerly incarcerated women would tell healthcare decision makers

BACKGROUND

Incarcerated women have a higher prevalence of health problems than the general population; however, little is known about their perspectives on the healthcare they receive. Here, we conducted semi-structured interviews with women who had been incarcerated (n = 63) which asked what they would tell healthcare decision-makers about their experiences of healthcare in prisons and the community post-incarceration if provided the opportunity. All participants had a history of sexual violence victimization and had at least one period of incarceration in a community corrections center in Arkansas due to the goals of the larger study from which data were drawn.

RESULTS

Four themes arose when participants were asked what they would tell people who make decisions about community healthcare: 1) the healthcare system is not working (52%; n = 33), 2) have compassion for us (27%; n = 17), 3) recognize that we have specific and unique needs (17%; n = 11), and 4) the transition from incarceration is challenging and requires more support (22%; n = 14). Three themes arose when we asked participants what they would tell people who make decisions about healthcare in prisons: 1) we had experiences of poor physical healthcare in prison (44%; n = 28), 2) more specialty care is needed in prison (49%; n = 31), and 3) healthcare providers treat women in prison poorly (37%; n = 23).

CONCLUSIONS

Our findings underscore the need for systemic changes including greater oversight of prison-based healthcare services, enhanced access to medical subspecialties in prisons, and healthcare provider training on the unique needs of incarcerated and previously incarcerated women. Polices that expand healthcare access are also likely to benefit formerly incarcerated women given the challenges they experience seeking community-based care.

Challenges in providing ethically competent health care to incarcerated older adults with mental illness: a qualitative study exploring mental health professionals' perspectives in Canada

BACKGROUND

The population of incarcerated older adults is the fastest growing demographic in prisons. Older persons in custody have poorer health as compared with those in the community. The unmet and complex health care needs of incarcerated older adults with mental illness raise justice, safety, dignity and fairness in care as ethical concerns. As there exists research gap to better understand these concerns, the current study aimed at exploring the perspectives of mental health professionals on challenges in delivering ethically competent care to mentally ill incarcerated older adults in Canada.

METHODS

Thirty-four semi-structured interviews were conducted between August 2017 and November 2018 with prison mental health professionals in Canada who were selected using purposive and convenience sampling techniques. The audio recorded interviews were transcribed verbatim and analysed inductively to generate themes.

RESULTS

The results were distilled into three main categories and seven subcategories that related to ethical issues in the provision of health care for mentally ill incarcerated older adults. The main categories included imprisoned older persons with special care needs, lack of resources, and the peer-support program.

CONCLUSIONS

Results of this study showed that existing practices of care of mentally ill incarcerated older adults are characterised by challenges that increase their vulnerability to worse health conditions. It is imperative for local authorities, policy makers and representatives to prepare for and respond to the challenges that compromise ethically competent health care for, and healthy ageing of, mentally ill incarcerated older adults.

Health and Health Service Needs: Comparison of Older and Younger Women with Criminal-Legal Involvement in Three Cities

Objectives: We profiled the health and health services needs of a sample of older adult women (age 50+) with criminal-legal system (CLS) involvement and compared them with younger women (age 18-49), also CLS-involved. Methods: Using survey data collected from January to June 2020 from adult women with CLS involvement in three US cities, we profiled and compared the older adult women with younger women on behavioral and structural risk factors, health conditions, and health services access and use. Results: One-third (157/510) were age 50+. We found significant differences (p < .05) in health conditions and health services use: older women had more chronic conditions (e.g., hypertension and stroke) and more multimorbidity and reported more use of personalized care (e.g., private doctor, medical home, and health insurance). Discussion: Although older women with CLS involvement reported good access to health services compared with younger women, their chronic health conditions, multimorbidity, and functional declines merit attention.

Symptomatic menopause: Additional challenges for incarcerated women

Menopause is an age-associated physiological transition in women, usually occurring between the ages of 40 and 58 years, with an average of 51 years. As the age of women residing in the prison system is increasing globally, it becomes increasingly important for older female inmates to be assessed for menopausal symptoms and offered effective, personalized management. Middle-aged and older women, regardless of their living situation, are at increased risk of experiencing vasomotor symptoms and developing pelvic floor problems, bladder dysfunction and osteoporosis. However, all of these menopausal sequelae are typically exacerbated by prison conditions and by a lack of health support. Therefore, it is critical to implement prison programs and to create gender-specific training to aid in the health care needs of aging female inmates. Addressing this growing population of incarcerated women and attending to their menopausal needs require advocacy and active monitoring of prison-specific templates of care to ensure quality care. One such initiative legislated to address the health care needs of incarcerated women was commenced in New Jersey, USA. This entity, the NJ Commission on Women's Reentry, is addressing the unique health care needs of women, including menopausal ones, while incarcerated and then upon reentry into their community.