Health care needs and service use among male prison inmates in the United States: A multi-level behavioral model of prison health service utilization

Understanding and improving the quality of primary care for people in prison: a mixed-methods study

Background

People in prison are generally in poorer health than their peers in the community, often living with chronic illness and multimorbidity. Healthcare research in prisons has largely focused on specific problems, such as substance use; less attention has been paid to conditions routinely managed in primary care, such as diabetes or hypertension. It is important to understand how primary care in prisons is currently delivered in the United Kingdom and how it can be improved, in order to reduce health inequalities.

Objective

To understand the quality of primary care in prison, including gaps and variations in care, in order to recommend how quality of prison health care can be improved.

Design

A mixed-methods study with six interlinked work packages.

Setting

Predominantly the North of England.

Methods

Between August 2019 and June 2022, we undertook the following work packages: (1) International scoping review of prison healthcare quality indicators. (2) Stakeholder consensus process to identify United Kingdom focused prison healthcare quality indicators. (3) Qualitative interview study with 21 people who had been in prison and 22 prison healthcare staff. (4) Quantitative analysis of anonymised, routinely collected data derived from prison healthcare records (~ 25,000 records across 13 prisons). (5) Stakeholder deliberation process to identify interventions to improve prison health care. (6a) Secondary analysis of the qualitative data set, focusing on mental health and (6b) analysis of the quantitative data set, focusing on health care of three mental health subgroups.

Findings

Our scoping review found predominantly only papers from the United States of America and of variable rigour with the main finding being that performance measurement is very challenging in the prison healthcare setting. In collaboration with stakeholders, we prioritised, refined and applied a suite of 30 quality indicators across several healthcare domains. We found considerable scope for improvement in several indicators and wide variations in indicator achievement that could not be attributed to differences in prison population characteristics. Examples of indicators with scope for improvement included: diabetes care, medicines reconciliation and epilepsy review and control. Longer length of stay in prison was generally associated with higher achievement than shorter stays. Indicator achievement was generally low compared to that of community general practice. We found some encouraging trends and relatively good performance for a minority of indicators. Our qualitative interviews found that quality of health care is related to factors that exist at several levels but is heavily influenced by organisational factors, such as understaffing, leading to a reactive and sometimes crisis-led service. Our stakeholder deliberations suggested opportunities for improvement, ideally drawing on data to assess and drive improvement. Our mental health work package found that coded mental illness had mixed associations with indicator achievement, while the interviews revealed that mental distress is viewed by many as an inevitable facet of imprisonment.

Limitations

Our analyses of indicator achievement were limited by the quality and coverage of available data. Most study findings are localised to England so international applicability may differ.

Conclusions

Marked variations in the quality of primary care in prisons are likely to be attributable to the local organisation and conditions of care delivery. Routinely collected data may offer a credible driver for change.

Study registration

This study is registered at researchregistry.com (Ref: 5098).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/26) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 46. See the NIHR Funding and Awards website for further award information.

Opioid use, prescribing and fatal overdose patterns among racial/ethnic minorities in the United States: A scoping review and conceptual risk environment model

ISSUES

To date, there has been no synthesis of research addressing the scale and nuances of the opioid epidemic in racial/ethnic minority populations in the United States that considers the independent and joint impacts of dynamics such as structural disadvantage, provider bias, health literacy, cultural norms and various other risk factors.

APPROACH

Using the "risk environment" framework, we conducted a scoping review on PubMed, Embase and Google Scholar of peer-reviewed literature and governmental reports published between January 2000 and February 2024 on the nature and scale of opioid use, opioid prescribing patterns, and fatal overdoses among racial/ethnic minorities in the United States, while also examining macro, meso and individual-level risk factors.

KEY FINDINGS

Results from this review illuminate a growing, but fragmented, literature lacking standardisation in racial/ethnic classification and case reporting, specifically in regards to Indigenous and Asian subpopulations. This literature broadly illustrates racial/ethnic minorities' increasing nonmedical use of opioids, heightened burdens of fatal overdoses, specifically in relation to polydrug use and synthetic opioids, with notable elevations among Black/Latino subgroups, in addition uneven opioid prescribing patterns. Moreover, the literature implicates a variety of unique risk environments corresponding to dynamics such as residential segregation, provider bias, overpolicing, acculturative stress, patient distrust, and limited access to mental health care services and drug treatment resources, including medications for opioid use disorder.

IMPLICATIONS

There has been a lack of rigorous, targeted study on racial/ethnic minorities who use opioids, but evidence highlights burgeoning increases in usage, especially polydrug/synthetic opioid use, and disparities in prescriptions and fatal overdose risk-phenomena tied to multi-level forms of entrenched disenfranchisement.

CONCLUSION

There is a need for further research on the complex, overlapping risk environments of racial/ethnic minorities who use opioids, including deeper inclusion of Indigenous and Asian individuals, and efforts to generate greater methodological synergies in population classification and reporting guidelines.

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

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

COVID-related disruptions and adaptations to prison-based mental health and substance use services: a narrative review

PURPOSE

Public health experts and advocates have long raised concerns about the pandemic preparedness of prison systems worldwide - an issue that became increasingly salient at the start of the COVID-19 pandemic. People in prison experience poorer health outcomes compared to the general population, making timely access to adequate health services in prison critical for their health and wellbeing. This study aims to identify the extent of the literature on initial changes in mental health and substance use services for people in prison during the COVID-19 pandemic, summarize and synthesize the findings and identify areas in need of further study.

DESIGN/METHODOLOGY/APPROACH

The authors conducted a review of the academic literature published internationally in English between 2019 and December 1, 2020 to describe the disruptions and adaptations to mental health and substance use services in prisons during the onset of the COVID-19 pandemic.

FINDINGS

The authors found that mental health and substance use services in prisons around the world were widely disrupted due to the COVID-19 pandemic - predominantly consisting of the complete suspension of services, discontinuation of transfers to off-site treatment sites and limitations on service capacity. Adaptations ranged from virtual service delivery and changes to treatment dispensation processes to information sessions on overdose prevention.

ORIGINALITY/VALUE

To the best of the authors' knowledge, this is the first review to examine the nature and extent of the literature on delivery of mental health and substance use services in prisons during the COVID-19 pandemic.

Collaborative Healthcare in Incarcerated Settings

A total of 2,162,400 adults were incarcerated in the United States in 2016. Sub-optimal health status, existing healthcare disparities, and fragmented healthcare delivery among incarcerated populations are concerning and warrant redress. This article highlights the need for and discusses the benefits of collaboration between healthcare professionals in incarcerated settings. The roles of primary care health professionals, pharmacists, and medical family therapists (MedFTs) in correctional facilities are outlined. Through integrated healthcare models, enhanced communication, improved continuity of care, and holistic treatment plans, existing gaps in healthcare delivery in correctional facilities can be filled. By working together and assuming nontraditional roles, medical professionals can help improve health outcomes of incarcerated individuals. Collaborative healthcare models in incarcerated settings can elevate public health in a cost-effective, yet positive manner.

Carceral Amplification of COVID-19: Impacts for Community, Corrections Officer, and Incarcerated Population Risks

COVID-19 is challenging many societal institutions, including our criminal justice systems. Some have proposed or enacted (e.g., the State of New Jersey) reductions in the jail and/or prison populations. We present a mathematical model to explore the epidemiologic impact of such interventions in jails and contrast them with the consequences of maintaining unaltered practices. We consider infection risk and likely in-custody deaths, and estimate how within-jail dynamics lead to spill-over risks, not only affecting incarcerated people but increasing exposure, infection, and death rates for both corrections officers and the broader community beyond the justice system. We show that, given a typical jail-community dynamic, operating in a business-as-usual way results in substantial, rapid, and ongoing loss of life. Our results are consistent with the hypothesis that large-scale reductions in arrest and speeding of releases are likely to save the lives of incarcerated people, jail staff, and the wider community.

Hospitalisation following therapeutic community drug and alcohol treatment for young people with and without a history of criminal conviction

INTRODUCTION

This study examines the association between treatment in a therapeutic community for adolescents with drug and alcohol problems on hospitalisation outcomes up to 15 years later for all clients, and separately for those with and without a history of criminal conviction.

METHOD

A quasi-experimental design was used to examine the linked administrative health and criminal justice records for all adolescents admitted to the Program for Adolescent Life Management (PALM) from January 2001 to December 2016 (n = 3059) in Sydney, Australia. ICD-10AM codes were used to designate hospitalisation outcomes as either physical injury, mental health problems, substance use disorders, or organic illness. The treatment and comparison groups were matched on factors associated with program retention, resulting in a final sample of 1266 clients. We examined the rate of hospitalisation up to 15 years posttreatment for all clients and stratified by prior conviction status using Cox regression analyses.

RESULTS

The treatment group had significantly lower rates of hospitalisation for a physical injury (HR = 0.77 [95% CI = 0.61-0.98]), mental health problem (HR = 0.62 [95% CI = 0.47-0.81]), substance use disorder (HR = 0.59 [95% CI = 0.47-0.75]), and organic illness (HR = 0.71 [95% CI = 0.55-0.92]). There was a significant interaction between treatment and prior criminal conviction status on rate of hospitalisation for physical injury, suggesting that the effect of treatment on physical injury was significantly greater for clients with a prior criminal conviction.

CONCLUSIONS

Adolescents who engage in a therapeutic community treatment program may have a long-lasting reduction in the risk of subsequent hospitalisation. This also appears to apply to those with a history of criminal conviction.

Can Viewing Nature Through Windows Improve Isolated Living? A Pathway Analysis on Chinese Male Prisoners During the COVID-19 Epidemic

Nature exposure is known to promote life satisfaction and well-being, and indirect exposure through windows is likely to benefit isolated populations. However, whether such type of exposure can benefit prisoners, the extremely isolated population, is unknown. In the current study, we investigated 326 male prisoners from three prisons in southwest China. Psychological variables including depression, anxiety, loneliness, distress tolerance, life satisfaction, and well-being were measured using the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder Scale (GAD-7), short-form UCLA Loneliness Scale (ULS-6), Distress Tolerance Scale (DTS), Satisfaction with Life Scale (SWLS), and 5-item World Health Organization Well-Being Index (WHO-5), respectively. Structural equation modeling was employed to identify the pathways from the visibility of nature through windows to prisoners' life satisfaction and well-being. Our results demonstrated that visibility of nature promoted the frequency and duration of viewing nature through windows. The frequency directly affected well-being, but the duration did not effectively affect any measured variables. The visibility of nature enhanced life satisfaction mainly via direct effects but enhanced well-being mainly via indirect effects. Regarding the indirect pathways, the visibility of nature increased distress tolerance and thus reduced loneliness and mental health problems. The reduced mental health problem, in turn, promoted life satisfaction and well-being. Our findings suggest that nature exposure through windows is effective in enhancing prisoners' life satisfaction and well-being. The policymaker may need to consider nature-based solutions such as indirect nature exposure in prions to benefit isolated populations.

Kidney Disease among People Who Are Incarcerated

CKD affects 15% of US adults and is associated with higher morbidity and mortality. CKD disproportionately affects certain populations, including racial and ethnic minorities and individuals from disadvantaged socioeconomic backgrounds. These groups are also disproportionately affected by incarceration and barriers to accessing health services. Incarceration represents an opportunity to link marginalized individuals to CKD care. Despite a legal obligation to provide a community standard of care including the screening and treatment of individuals with CKD, there is little evidence to suggest systematic efforts are in place to address this prevalent, costly, and ultimately fatal condition. This review highlights unrealized opportunities to connect individuals with CKD to care within the criminal justice system and as they transition to the community, and it underscores the need for more evidence-based strategies to address the health effect of CKD on over-represented communities in the criminal justice system.

A Scoping Review of Current Social Emergency Medicine Research

INTRODUCTION

Social emergency medicine (EM) is an emerging field that examines the intersection of emergency care and social factors that influence health outcomes. We conducted a scoping review to explore the breadth and content of existing research pertaining to social EM to identify potential areas where future social EM research efforts should be directed.

METHODS

We conducted a comprehensive PubMed search using Medical Subject Heading terms and phrases pertaining to social EM topic areas (e.g., "homelessness," "housing instability") based on previously published expert consensus. For searches that yielded fewer than 100 total publications, we used the PubMed "similar publications" tool to expand the search and ensure no relevant publications were missed. Studies were independently abstracted by two investigators and classified as relevant if they were conducted in US or Canadian emergency departments (ED). We classified relevant publications by study design type (observational or interventional research, systematic review, or commentary), publication site, and year. Discrepancies in relevant publications or classification were reviewed by a third investigator.

RESULTS

Our search strategy yielded 1,571 publications, of which 590 (38%) were relevant to social EM; among relevant publications, 58 (10%) were interventional studies, 410 (69%) were observational studies, 26 (4%) were systematic reviews, and 96 (16%) were commentaries. The majority (68%) of studies were published between 2010-2020. Firearm research and lesbian, gay, bisexual, transgender, and queer (LGBTQ) health research in particular grew rapidly over the last five years. The human trafficking topic area had the highest percentage (21%) of interventional studies. A significant portion of publications -- as high as 42% in the firearm violence topic area - included observational data or interventions related to children or the pediatric ED. Areas with more search results often included many publications describing disparities known to predispose ED patients to adverse outcomes (e.g., socioeconomic or racial disparities), or the influence of social determinants on ED utilization.

CONCLUSION

Social emergency medicine research has been growing over the past 10 years, although areas such as firearm violence and LGBTQ health have had more research activity than other topics. The field would benefit from a consensus-driven research agenda.

Healthcare in a pure gatekeeping system: utilization of primary, mental and emergency care in the prison population over time

BACKGROUND

This study investigates the prisoner and prison-level factors associated with healthcare utilization (HCU) and the dynamic effects of previous HCU and health events. We analyze administrative data collected on annual adult prisoner-stay HCU (n = 10,136) including physical and mental chronic disease diagnoses, acute health events, penal circumstances and prison-level factors between 2013 and 2017 in 4 prisons of Canton of Vaud, Switzerland. Utilization of four types of health services: primary, nursing, mental and emergency care; are assessed using multivariate and multi-level negative binomial regressions with fixed/random effects and dynamic models conditional on prior HCU and lagged health events.

RESULTS

In a prison setting with health screening on detention, removal of financial barriers to care and a nurse-led gatekeeping system, we find that health status, socio-demographic characteristics, penal history, and the prison environment are associated with HCU overtime. After controlling for chronic and past acute illnesses, female prisoners have higher HCU, younger adults more emergencies, and prisoners from Africa, Eastern Europe, and the Americas lower HCU. New prisoners, pretrial detainees or repeat offenders utilize more all types of care. Overcrowding increases primary care but reduces utilization of mental and emergency services. Higher expenditure on medical staff resources is associated with more primary care visits and less emergency visits. The dynamics of HCU across types of care shows persistence over time related to emergency use, previous somatic acute illnesses, and acting out events. There is also evidence of substitution between psychiatric and primary care.

CONCLUSIONS

The prison healthcare system provides an opportunity to diagnose and treat unmet health needs for a marginalized population. Access to psychiatric and chronic disease management during incarceration and prevention of emergency or acute events can reduce future demand for care. Prioritization of high-risk patients and continuity of care inside and outside of prisons may reduce public health pressures in the criminal system. The prison environment and prisoners' penal circumstances impacts healthcare utilization, suggesting better coordination between the criminal justice and prison health systems is required.

Barriers to access and utilisation of HIV/STIs prevention and care services among trans-women sex workers in the greater Kampala metropolitan area, Uganda

BACKGROUND

Trans-women sex workers bear the greatest brunt of HIV and other sexually transmitted infections (STI). Trans-women are 49 times more at risk of HIV infections compared to the general population. However, they remain underserved and continue to grapple with access to and utilisation of HIV/STI prevention services. This study explored barriers to access and utilisation of HIV/STI prevention services and associated coping mechanisms.

METHODS

This exploratory qualitative study was conducted among trans-women sex workers in the Greater Kampala Metropolitan area, Uganda. A total of 22 in-depth interviews, 6 key informant interviews and 9 focus group discussions were conducted to obtain data on barriers to access and utilisation of HIV and other STI prevention and care services, and coping strategies of trans-women sex workers. Data were analysed through thematic analysis using a hybrid of inductive and deductive approaches.

RESULTS

Individual level barriers to access and utilisation of HIV/STI prevention and care services included internalised stigma and low socio-economic status. Healthcare system barriers included social exclusion and lack of recognition by other key population groups; stigmatisation by some healthcare providers; breach of confidentiality by some healthcare providers; limited hours of operation of some key population-friendly healthcare facilities; discrimination by straight patients and healthcare providers; stockout of STI drugs; inadequate access to well-equipped treatment centres and high cost of drugs. At community level, transphobia hindered access and utilisation of HIV/STI prevention and care services. The coping strategies included use of substitutes such as lotions, avocado or yoghurt to cope with a lack of lubricants. Herbs were used as substitutes for STI drugs, while psychoactive substances were used to cope with stigma and discrimination, and changing the dress code to hide their preferred gender identity.

CONCLUSIONS

Individual, community and healthcare system barriers hindered access and utilisation of HIV/STI prevention and care services among the trans-women sex workers. There is a need to create an enabling environment in order to enhance access to and utilisation of HIV/STI prevention and care services for trans-women sex workers through sensitisation of healthcare providers, other key population groups and the community at large on the transgender identity.

Inequities in consistent condom use among sexually experienced undergraduates in mainland China: implications for planning interventions

BACKGROUND

Since pre-exposure prophylaxis (PrEP) is mainly prescribed to high-risk uninfected individuals, consistent condom use (CCU) continues to be recommended as an inexpensive, feasible, practical and acceptable way to prevent the general population from acquiring and transmitting HIV through sexual intercourse. The objective of this cross-sectional study was to compare the relative importance of various determinants of CCU among sexually experienced undergraduates in mainland China so as to assess and subsequently to suggest ways to eliminate inequities in its use.

METHOD

From September 10, 2018, to January 9, 2019, an anonymous self-administered online questionnaire was voluntarily completed by 12,750 participants distributed across 30 provinces in mainland China (except for Tibet). The present analysis was restricted to 2054 sexually experienced undergraduates. Pearson's chi-square test and Logistic regression models were chosen to analyze the factors associated with CCU.

RESULTS

The overall rate of CCU was 61.3% [95% confidence interval (CI) = 59.2-63.4%]. CCU was inequitably distributed since enabling factors exerted greater effects than predisposing and need variables. Compared with heterosexual men, heterosexual women [adjusted odds ratio (AOR) = 0.78, 95% confidence interval (CI):0.64-0.96)], non-heterosexuals men (AOR = 0.64, 95% CI:0.45-0.92) and women (AOR = 0.68, 95% CI:0.47-0.99) were less prone to using condoms consistently. Those with more resources [i.e., higher levels of self- efficacy for condom use (AOR = 2.86, 95% CI:2.35-3.49) and being knowledgeable of the national AIDS policy (AOR = 1.50, 95% CI:1.23-1.82)], and those with lower need for condoms [i.e., late initiation of sexual activity (AOR = 1.34, 95% CI:1.09-1.64) and single sexual partner (AOR = 1.68,95% CI:1.21-2.33)] were more likely to be consistent condom users.

CONCLUSIONS

In order to increase consistency of condom use and simultaneously reduce the remaining inequities, a comprehensive intervention measure should be taken to target heterosexual women, non-heterosexual men and women, and those with higher need for condoms, improve their condom use self- efficacy and raise their awareness of the national AIDS policy.

Prisoner exposure to nature: Benefits for wellbeing and citizenship

The direct or indirect experience of crime can cause individuals to feel vengeful against the perpetrator(s). The prison system reflects this sentiment by creating austere environments that are dehumanizing, punitive, and hopeless. Prisons are, therefore, environments in which retribution and punishment take priority over rehabilitation. Frequently, prisoners are believed to be untreatable because of their antisocial orientation. However, several factors influence an antisocial orientation such as socioeconomic status, family of origin, and mental health. The ubiquitous nothing works misbelief has resulted in prisoner marginalization and increased recidivism because of insufficient treatment. In 2015, 10 million individuals were incarcerated worldwide with around 30 million circulating through prisons each year. The prison environment decreases prisoner life expectancy and overall health. Sadly, prisoner benefits from treatment post-incarceration dissipate after 3-6 months and many prisoners die by suicide or drug overdose. Prison overpopulation, as well as poor outcome post-incarceration, requires more effective treatment. We hypothesize that Prisoner Exposure to Nature (PEN) can transform prisons into environments that are conducive to maintaining and improving physical and mental health. In prior work we proposed the continuum Nature Exposure Sufficiency (NES) versus Nature Exposure Insufficiency (NEI). Prisons are impoverished environments that limit Nature Exposure (NE) which results in NEI. Individuals experience fluctuations in mental and physical health as a result of NEI. Numerous studies have shown that direct and indirect NE can improve mood, physical health, and facilitate connectivity with self and society. It is necessary to consider ways in which we can incorporate NE for prisoner wellbeing. Additionally, it is crucial that prison personnel and prisoners develop a therapeutic/helping relationship (i.e., alliance) that is facilitated by friendliness and warmth to foster social change and citizenship. Many prisoners experience isolation and disconnection with society upon reentry. Given that most prisoners are eventually released into the community, we are obligated not to make them worse. Hence, it is important that prisons create programs that develop citizenship to engender prisoner volition to become positive and active citizens. We focus on the prison and prisoners, however our work is relevant to all total institutions (e.g., mental hospitals, nursing homes, schools, etc.). The prison system favors punishment and mass incarceration over treatment and decarceration. The deleterious effects of incarceration are clear and it is time to implement treatments based on the principles of PEN to improve prisoner wellbeing and citizenship.