Access to healthcare services during incarceration among female inmates

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International Journal of Prisoner Health
Access to healthcare services during incarceration among female inmates
Rabia Ahmed, Cybele Angel, Rebecca Martel, Diane Pyne, Louanne Keenan,
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during incarceration among female inmates", International Journal of Prisoner Health, Vol. 12 Issue: 4, pp.204-215, https://
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Access to healthcare services during
incarceration among female inmates
Rabia Ahmed, Cybele Angel, Rebecca Martel, Diane Pyne and Louanne Keenan
RabiaAhmedisanAssociate Abstract
ProfessorattheDepartmentof Purpose – Incarcerated women have a disproportionate burden of infectious and chronic disease, in
T) Medicine,UniversityofAlberta, additionto substanceuse disorderand mental health illness, when compared to the general population
P
8 ( Edmonton,Canada. (Binswangeretal.,2009;Fazeletal.,2006;Fuentes,2013;Kouyoumdjianetal.,2012).Womenoftenenter
01 CybeleAngelisaRegistered thecorrectionalsysteminpoorhealth,makingincarcerationanopportunitytoaddresshealthissues.The
2
e NurseatCorrectionsHealth, purposeofthispaperistoexplorethebarrierstoaccessinghealthservicesthatfemaleinmatesfaceduring
n
u incarceration,theconsequencestotheirhealth,andimplicationsforcorrectionalhealthservicesdelivery.
J AlbertaHealthServices,
4 Design/methodology/approach – Focus groups were conducted in Canadian correctional center
1 2 Edmonton,Canada. with female inmates. Focus groups explored women’s experiences with accessing health services while
9:2 RebeccaMartelisbasedatthe incarcerated;theimpactofaccesstohealthservicesonhealthduringincarcerationandinthecommunity;and
At 0 OccupationalTherapy, recommendationsforimprovingaccesstohealthservices.ThematicanalysiswascompletedusingN-vivo10.
n UniversityofAlberta, Findings – The women described multiple barriers to accessing health services that resulted in negative
o
ust Edmonton,Canada. consequencestotheirhealth:treatmentinterruption;healthdisempowerment;poormentalandphysicalhealth;
Ho DianePyneisbasedat andrecidivismintoaddictionandcrimeuponrelease.Womenmadethreeimportantrecommendationsfor
of CorrectionsHealth,Alberta correctional health service delivery: provision of comprehensive health entry and exit assessments;
versity HCeaanlathdaS.ervices,Edmonton, iomrgparonvizeemdeinnttooafnh“eAaclthcelsitseirnagcyH;eaanltdheSsetravbiclieshsmReenstouorfcheeMaltahnusaulp”pfoorrtinnceatrwceorrakste.dTwheomreecno.mmendationswere
Uni LouanneKeenanisthe Originality/value–Thereisapaucityofexistingliteratureexaminingprovisionofhealthservicesforfemale
oaded by DRPreiroesfeceatsorscro,hrCaaontmdFmaamnuinlAyitsyMsEoencdgiiacatiengee,d ioKnremgyaawnteiozsar.dtiosTnhPserstehe-atrtifaipnlrddoinevtgidesnethihoeanav,letChorsererleervvciatcinoecnsyaflohfroetrhailstchovrcuraelnrceet,rioaPnboalesltp-aronepdleualacsteoiomcnam.reu,nWityomheeanl’tshhceaarlteh,providers and
wnl UniversityofAlberta, Healthpromotion,Womenprisoners
o PapertypeResearchpaper
D Edmonton,Canada.
1. Background
Morethan625,000womenandgirlsareheldinremand(“pre-sentence”or“detentioncenters”)
and sentenced correctional facilities throughout the world (Walmsley, 2012). The female
incarceratedpopulationhasgrownby16percentoverthelastdecade.However,femalescontinue
tomakeupasmallproportionofthetotalglobalincarceratedpopulation,accountingforjust2-9
percent (Walmsley, 2012). In Canada, women make up approximately 5.1 percent of the
incarcerated population (Walmsley, 2012). In keeping with global trends, the Canadian female
incarceratedpopulationhasalsogrowninsize:remandandprovincialfacilities(sentencesoftwo
yearsorless)increasedfrom9percentbetween1999and2000to12percentbetween2008and
2009; and federally (sentences of two years or more) the female incarcerated population has
increasedfrom5to6percentforthesametimeperiod(Dauvergne,2012).
Received8April2016 Itiswelldocumentedintheexistingliteraturethatincarceratedwomensufferadisproportionate
Revised16July2016
Accepted25July2016 burden of HIV and other sexually transmitted infections (STI), chronic medical conditions,
j j
PAGE204 INTERNATIONALJOURNALOFPRISONERHEALTH VOL.12NO.42016,pp.204-215, ©EmeraldGroupPublishingLimited,ISSN1744-9200 DOI10.1108/IJPH-04-2016-0009
mentalhealthillness,andsubstanceusedisordercomparedtothegeneralfemalepopulationand
incarcerated men (Binswanger et al., 2009, 2010; Fuentes, 2013; Kouyoumdjain et al., 2012;
Fazeletal.,2006;Freudenburgetal.,2007;Alticeetal.,2005).Thusincarceratedwomenarein
particularneedofseamless,coordinatedhealthcareastheytransitionbetweenincarcerationand
thecommunity.Yettheyoftenexperience“fragmented”healthservicesastheycyclebetween
community and incarceration (Sered and Norton-Hawk, 2013; Eliason et al., 2004; National
Commission on Correctional Health Care, 2002). The concept of fragmentation of health care
servicesamongincarceratedwomenhasbeendescribedbySeredandNorton-Hawk(2013)in
detailandincludesuchcontributingfactorsofbureaucraticchallengesrelatedtohealthinsurance
networks,providerdisruptions,short-termfacilitiesandprograms,lackofco-ordinationamong
facilities, and a sense of being an “unwanted patient” (Sered and Norton-Hawk, 2013). In the
community,careisoftennotlimitedtoasingleprimarycareproviderandconsequentlywomen
with a history of incarceration often make use of emergency departments (Ramaswamy et al.,
2015;SeredandNorton-Hawk,2013;Statonetal.,2003).Emergencydepartmentsoftenurgent
health issues and may not provide comprehensive management of chronic medical, mental
health,andsocialconditions.Likewisehealthcareservicesduringshort-termincarcerationare
focusedon“crisismanagement”ofmedicalandmentalhealthneeds,andaretypicallynotlinked
with community-based health care providers. In contrast, while long-term incarceration facilities
mayprovidemorecomprehensiveprimarycareandpreventivehealthservices,byfarthemajorityof
femaleinmatesareremandedorserveshortsentences,makingthisacriticalpopulationtotarget
forsuchhealthinterventions(QuakerCouncilforEuropeanAffairs,2007;Trevethan,2000).Infact
T) giventhevolumeofwomencyclingbetweenshort-termincarcerationandthecommunity,short-term
8 (P incarcerationmayinfactbethemostconsistentsourceofhealthcareforthesewomen.
1
20 Incarcerationdoesprovideabriefperiodofstabilityfromoftenchaoticlifestylescharacterizedby
e
n housinginstability,foodinsecurity,substanceabuse,andlackoffinancialsecurity.Recognizing
u
J
4 theirunaddressedhealthneedsinthecommunityandthebriefopportunitytheyhavetoaccess
2
1 healthcareservicesduringincarceration,healthconcernsoftencometotheforefront.Assuch,
2
09: incarcerated women serving short sentences have been shown to make more healthcare
At requestsandaccessmorehealthcareservicesthanthosewithprolongedincarceration(Hydeetal.,
n
o 2000).Unfortunately,femaleinmateshavecitedanumberofbarrierswhenaccessinghealthcare
st
ou services during incarceration including: long waitinglists,difficulty accessingmedications,under-
H
of skilledornon-empathetichealthcarestaff,lackofcontinuityofcare,lackofhealthliteracy,andpoor
y transitionalplanning(Pluggeetal.,2008;HarnerandRiley,2013;Hattonetal.,2006;Donelleand
sit
er Hall,2014).Ultimatelythesebarrierscontributedtotheoverallsensethatincarcerationnegatively
v
ni impacted health. Harner and Riley (2013) found that these barriers culminated in “limited and
U
y complicatedaccess to health care,” which resultedin the non-resolution of healthcare concerns
b
d duringincarceration.Further,Pluggeetal.(2008)describedtheresultingsenseofdisempowerment
e
d
oa amongfemaleinmatesduetolossofautonomyinhealthmaintenance.Thereishoweverapaucityof
wnl literature regarding how to best provide gender sensitive health care services for incarcerated
o
D womendespiterecommendationsfromtheWorldHealthOrganization(WHO)andfurtherevidence
suggestingthatmaleandfemaleinmatesresponddifferentlytohealthcareservices(WorldHealth
Organization(WHO),2009;Sacks,2004;Lewis,2006).
Health literacy of incarcerated women may contribute to overall poor health and health care
access during incarceration and the transition to the community. In Canada, health literacy is
definedasthe“abilitytoaccess,understand,evaluateandcommunicateinformationasawayto
promote,maintainandimprovehealthinavarietyofsettingsacrossthelife-course”(Rootman
andGordon-El-Bihbety,2008).Healthliteracycontributestohealthbyaffectingone’sabilityto
makeinformedchoices,reduceriskstohealth,navigatethehealthcaresystem,enhancequality
of life, and reduce health inequities (Donelle and Hall, 2014), Rootman, 2003; Rootman and
Ronson, 2005). Nutbeam (2000) conceptualized health literacy as a hierarchy: ability to
communicatehealthinformation,awarenessofhealthservices,andtheabilitytousethehealth
care system (functional health literacy); development of personal skills in a supportive
environment to improve individual motivation and self-confidence to act in ways that enhance
health (interactive health literacy); and personal and community health empowerment through
recognizing and responding to the role that social determinants play in health (critical health
literacy) (Nutbeam, 2000). Donelle and Hall (2014) examined health literacy amongst female
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VOL.12NO.42016 INTERNATIONALJOURNALOFPRISONERHEALTH PAGE205
inmatesonprobationwithinthishierarchyanddescribedsignificanthealthliteracychallengesin
keeping with low levels of health literacy. As health literacy is closely linked with health service
accessandutilization,improvingfemaleinmates’healthliteracyacrossallthreelevelsmayresult
inimprovedhealthoutcomes.
Correctionalfacilitiesofferauniqueopportunitytoreachavulnerablepopulationofwomenwho
areatriskforpoorhealthoutcomes.Screeningforinfectiousdiseases,provisionofprimarycare,
substance abuse treatment, and access to mental health services along with linkages to
community-basedhealthservicescouldhelpdecreasehealthdisparities.InkeepingwithWHO
recommendations for correctional health, provincial correctional facilities healthcare services in
theprovinceinwhichthisstudywasconductedinweretransitionedtothepublichealthauthority
in 2010-2011. This model of health care delivery is in its early stages and requires formal
evaluationbuthasresultedingreateraccesstoresourcesforhealthcareserviceprovisionaswell
ascreatedtheopportunitytoimproveservicedelivery.However,littleisknownregardinghowto
improveaccesstocorrectionalfacilityhealthcareservicesforincarceratedwomen.Theaimofthis
paperistoreportonfemaleinmates’perceptionsofthebarrierstheyfacewhenaccessinghealth
careduringincarceration,theimpactthatthishasontheirhealthduringincarcerationandinthe
community,andimplicationsforcorrectionalhealthcarepractice,andtoshowhowthesewere
usedtoinformthedevelopmentofaresourceforfemaleinmatesaimedatimprovingfunctional
healthliteracyregardingaccessingcorrectionalhealthcareservices.
T) 2. Methods
P
8 ( 2.1 Settingandparticipants
1
0
2
e This study was conducted in a large maximum-security provincial remand facility in Canada.
n
Ju Thisfacilityhasthecapacitytohouseapproximately1,900inmates,includingupto500females.
4
2 In2011-2012,atotalof2,705femaleinmateswerehousedinthisfacilityforanaveragelengthof
1
9:2 stay of 17.2 days. As of 2010, healthcare for all provincial correctional facilities (remanded
0
At orsentencesoftwoyearsorless)intheprovincetransitionedtothepublichealthauthority.
n
o Femaleinmateswereconsideredeligibleforstudyparticipationiftheywere18yearsofageor
st
ou older,abletospeakEnglish,hadthecapacitytocomprehendandconsenttostudyprocedures,
H
of andwerehousedwithinthegeneralfemalepopulation.Writteninformedconsentwasobtained
y from participants that met eligibility criteria. Two 60-minute focus groups were conducted in
sit
er March2015consistingofsixwomenpergroup.Participantswereprovidedwithanequivalentof
v
ni $10.00worthofediblecanteenitempurchases.
U
y
b
d 2.2 Focusgroups
e
d
a
nlo Two experienced qualitative interviewers conducted the focus groups. Focus groups were
w
o guided by a semi-structured guide that was developed and revised by members of the
D
multi-disciplinary study team and informed by previous focus groups conducted with this
population(Ahmedetal.,2016).Focusgroupsexploredwomen’sexperienceswithaccessing
health services while incarcerated; the impact of access to health services on health during
incarceration and in the community; and recommendations for improving access to health
services.Sinceouraimwastousethedatafromthefocusgroupstoinformthedevelopmentofa
resourcetoimproveaccesstocorrectionalhealthservices,questionsalsofocusedonhowbest
toprovideinformationonaccessinghealthservicestofemaleinmates.
2.3 Dataanalysis
Focusgroupinterviewsweredigitallyrecordedanduploadedontoanencryptedsecuredriveand
fully transcribed. Transcripts were checked by a study team member against the original
audiotapestoensureaccuracy.Focusgrouptranscriptsservedastheprimarysourceofdata.
Secondary data sources included a short demographic survey and interviewer notes and
summaries.TranscriptswereenteredintoN-vivo10qualitativedataanalysissoftware.
Two study team members conducted thematic analysis of the transcripts independently.
Transcripts were coded line-by-line, and categorized into initial themes and then subthemes,
j j
PAGE206 INTERNATIONALJOURNALOFPRISONERHEALTH VOL.12NO.42016
which were verified through regular meetings. Once emerging themes and subthemes
were finalized, participant verbalizations were categorized into each domain as applicable.
Toensurevalidityofouranalysis,themesandsubthemeswerepresentedtotwofemaleinmates
thatwerenotinvolvedintheoriginalfocusgroupstoprovide“memberchecking.”Thisstepalso
acknowledged that the participants are the “knowers” of their contexts and environments
(Tuhiwai,1999).
2.4 Developmentofhealthservicesresource
Themes and subthemes identified during data analysis were collated to form categories that
represented core areas in poor functional health literacy that impacted accessing health care
services.Categorieswerecheckedsystematicallyagainsttherawdatatoensureaccuracy.Once
categorieswerefinalized,weconductedaninformalenvironmentalscanofhealthserviceswithin
thecorrectionalfacilityandmechanismsforaccessingthem.Healthservicesincluded:women’s
health, STI, HIV, mental health and addictions, social work, pharmacy, primary care, case
workers, and community transitions team. Key informants from each of these health services
wereaskedtovoluntarilycompleteastructuredopen-endedquestionnaireoutliningtheservices
offeredandthebestmethodtoaccesstheservice.Questionsincluded:howtobestaccessthe
healthserviceduringincarcerationandinthecommunity;whattheservicecouldandcouldnot
provide during incarceration; and suggestions for preparing for release. Based on themes
identified regarding content and layout from focus group analysis, the information was then
organizedintoahealthservicesresourcemanualforincarceratedwomen.Themanualwasthen
T)
P reviewedduringmembercheckingbytwofemaleinmates.Activeinvolvementoffemaleinmates
18 ( inthedevelopmentprocesshelpedtoensurethatthefinalproductwouldmeettheneedsofthe
0
e 2 target population. Input was requested regarding readability, relevancy of content, and layout.
n
u The manualwasalsocritically reviewed bya multi-disciplinary teamof correctional healthcare
J
24 providersandadministratorstoensurecontentaccuracyandvalidity.Thisincludedthemanagers
1
2 for health care, mental health, social work, addictions, and pharmacy. The draft was then
9:
At 0 modifiedaccordinglyandfinalized.
n
o
ust 2.5 Ethics
o
H
of This study received ethical approval through the University of Alberta Health Ethics Research
sity Board.AdditionaloperationalandadministrativeapprovalwasreceivedthroughAlbertaJustice
er andSolicitorGeneralandAlbertaHealthServices.
v
ni
U
y
d b 3. Results
e
d
oa The12femaleinmateswerepurposivelyselectedfromthegeneralcorrectionalfacilitypopulationto
nl
w meettheliteracycriteriarequiredtoparticipateinthefocusgroups.Theparticipantswereableto
o
D describeandillustratewhatistypicalinthetransientremandcentersetting;theirexplanationswere
not requested toprovide generalizedstatements about the experiences of all female inmates in
correctionalfacilities(Patton,2002).Saturationwasestablishedthroughconstantcomparisonof
commonalitiesandsimilaritieswithineachfocusgroupandacrossbothfocusgroups.
ParticipantdemographicsareshowninTableI.Thefemaleinmatesself-reportedtheirethnicityas
follows:six(50percent)White,five(42percent)Aboriginal,andone(8percent)reported“Other”
ethnicity. The average age of participants was 33.5 years. Six (50 percent) women reported
having less than a high school education. Seven (58 percent) women each reported having
current stable and secure housing, chronic medical or mental health conditions, and having a
regulardoctororhealthcareprofessionalseeninthecommunity.Allwomenreportedalcoholor
substanceabusepriortoincarceration.
3.1 Accesstohealthcareservicesduringincarceration,andtheconsequencesand
implicationsforcorrectionalhealthcarepractice
This study describes female inmates’ perceptions of correctional health care services
acrossfourbroadthemes.TableIIprovidesaguidetothethemesandsubcategories,which
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VOL.12NO.42016 INTERNATIONALJOURNALOFPRISONERHEALTH PAGE207
TableI Participantdemographicsandcharacteristics
Age(years) 33.5(range23-41)
Race
Aboriginal 5(42%)
White 6(50%)
Other 1(8%)
Highestgradecompleted
Lessthanhighschooleducation 6(50%)
GraduatedhighschoolorGED 3(25%)
Post-secondaryschooleducation 3(25%)
Currentstableandsecurehousing 7(58%)
Chronicmedicalormentalhealthcondition 7(58%)
Currentalcoholordrugaddiction 12(100%)
Hasregularfamilydoctor/healthcareprofessionalseeninthecommunity 7(58%)
Note:n¼12
TableII Access to health care services during incarceration and transition points, impact on health and implications
forcorrectionalhealthcarepractice
Transitioning Implicationsfor
T) Barrierswhenaccessinghealthcare tothecommunity Impactofbarriersonwomen’shealthduring correctionalhealthcare
P
8 ( duringincarceration orotherfacility incarcerationandincommunity policy
1
0
2
e 1.Lackofknowledgeofhealthservices 1.Lackof 1.Notpreparedwhenreleasedintocommunity 1.Comprehensive
n
Ju andbasichealthprinciples ¼ fear, consistencyin 2.Criticalissuesofhousing,socialassistanceand entryandexithealth
4
2 anxiety,frustration healthcare employmentsupersedehealthissuesthathad assessments
1
2 2.ComplicatedHealthServiceRequest services beenaddressedinjail 2.Addresspoorhealth
9:
0 (HSR)formprocess 2.Fragmentationof literacy
At Poorcommunicationwith healthcareat 3.Healthsupport
on healthcare transitionpoints networks(peersand
ust Delaysinaccesstohealthcare professionals)
o
H Lackofconfidentiality
of
y
sit
er
v
ni demonstrates the path that female inmates traveled from entry into the correctional facility,
U
y to accessing healthcare during incarceration, and transitioning back into their communities.
b
d The resultingHealthCareResourceManual providedfemale inmates with a map to navigate
e
d
oa thisprocess.
nl
w
o 3.1.1 Barriers to accessing to health services. The women identified three points where their
D
access to healthcare during incarceration was hindered. First, women described a lack of
knowledge around existing healthcare services and how to gain knowledge regarding these
services.Thislackofknowledgewasviewedasabarriertoaccessinghealthaswomenoftenfelt
“embarrassed”or“afraid”toaskforinformationorthatitwasdifficulttofind:
Somepeopledon’tevenknowwhattodowhentheyfirstcomein.Theydon’tevenknowabouthalf
thestuffthattheyofferhereandsomepeoplearetooafraidtoask.Butiftheinformationwasoutthere,
theneverybodywouldknoweverythingtheyneedtoknow.
Second,womenidentifiedtheHealthServiceRequest(HSR)formprocessitselfasabarrierto
accessinghealthcare.Inordertoaccesshealthcareduringincarceration,inmatesarerequiredto
completeaHSRformwheretheyoutlinethespecifichealthconcern(s)thattheyareexperiencing.
Theformisthenreviewedbycorrectionalnursingstaffandawrittenresponseisprovidedtothe
inmateandmayormaynotresultinfurtherassessment. Iffurtherassessment isrequired, the
processstartsbyseeinganursefollowedbyareferraltoseeaphysician,whichmaymeanfurther
periodsofwaiting.Theyattributedthisprocessasthecauseoflongwaitsanddelaysinaccessto
health care. They acknowledged that their health upon entry into the correctional system was
poorandoftenneglected,thustheneedforaccesstohealthcareservicesuponincarceration
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PAGE208 INTERNATIONALJOURNALOFPRISONERHEALTH VOL.12NO.42016
was imperative. However with these delays in access to health services, the women often
sufferedbothphysicallyandmentally:
Itshouldn’tbesuchawaittogetcheckedoutandeverything.’Causepeopledocomeinherereally
sickandyounevergettoseeadoctorfordayslaterandumm[…]yeahit’snotgoodtoseepeople
reallyillandsufferingeventhoughit’stheirowndecisiontodothestufftheydoonthestreet;butyou
knowsomepeopledocomehereforhelp,toreceivehelpandsomepeopledoleavewiththehelpthey
needandsomepeopledon’tandthere’sstillthatwomanouttheresuffering.
Third,whennotsatisfiedwiththeresponsestheyreceivedfortheirHSRs,theydescribedfeeling
“sloughed off.” They described poor communication with health care staff around the request
formswithunclearorinadequateresponsesaddingtotheirfrustration:
Likeit’sjustajoke[…]likethey’renotaddressinganyoftheissues,theyjustkeepsendingrequests
back[…]it’sjuststupid[…]like[I’ve]givenup,whyshould[I]evenbotherwritinganotherrequestform.
Andit’saseriousissue.
Thisisn’taseriousissuebutIputin[arequestform]becauseofmyacne,likeonmyface,andInever
usedtogetacne,IlikebrokeoutallovermyfaceandlikeitwaslikespreadingdownmyneckandIput
inlikearequestformafterrequestform,andtheyfinallygavemeoneresponsebackandIputin
probablylike6right?Thisislike2½weekslaterandtheysaid,“facewash”that’showitwasworded
“facewash,youcanbuyfromcanteen”Likehowdoyouknowitwasn’tMRSAorsomething?You
knowwhatImean?
Fourth,thewomendescribedalackofconfidentialityaroundtheHSRformprocess,wherethey
T) were uncomfortable in describing sensitive issues on the form, perhaps resulting in barriers to
P
8 ( accessingcarefurther:
1
0
2
e Whentherequestformcomesbackitisleftsittingonthepanelforeverybodytoreadit[…]I’veread
n
Ju lotsofrequestforms(giggle).I’mbadforit,butImeanlike,ifsomegirlhasasensitiveissuewhywould
4
2 shewanttowritethat,andlettheguardsreadit[too].
1
2
9: 3.1.2 Transitioningpoints.The“fragmentation”orinterruptionofhealthcareattransitionpointswas
0
At perceivedasamajorbarrierbythefemaleinmates.Specifically,thewomencitedlackofconsistency
on and fragmentation in care between the community (at entry and release from incarceration) and
st
ou transfers to other correctional facilities as the points where fragmentation in health care occurs.
H
of Prescriptionmedicationsforchronicmedicalandmentalhealthconditions,aswellasdiagnostictests
y mayormaynotbecontinuedorfollowedupuponatanyofthesetransitionpoints.Releasesintothe
sit
er communityareaparticularlyvulnerabletimewhereuninterruptedprescribingofmedicationsand/or
v
ni communicationregardingchangesinmedicationsand/ordosesremainschallenging.Thesamegap
U
y occurs upon transfers to alternate correctional facilities where medical files do not always follow
b
ed patientsandpharmaceuticalformulariesvarybyjurisdiction.Thus,mechanismstomaintainmedical
d
oa and mental health are not put in place in these key transition points resulting in unnecessary
nl
w treatmentinterruptionsandpoorphysicalandmentalhealthacrossthespectrum:
o
D
Andyouhavetobedenied,denied,deniedinonejail[andthen]gotoanotherjailandthey’relike“how
didyounotgethelpforthisbefore?”
Becausewhenyou’veexplainedit[healthconcern]42timesitbecomesalotlessimportanttoyouas
yougoalong“causeyou’rejustlikeblah”.
3.1.3 Impactofthesebarriersonwomen’shealthduringincarcerationandincommunity.When
taken as a whole, the barriers discussed above had profound effects on the women’s health.
Of consequence, a sense of disempowerment emerged. Despite the fact that they valued the
opportunity that incarceration provided to address unmet healthcare needs, the process
itself undermined the women’s engagement in the health care system. Participants used
statements like “I’ve given up, why should I even bother” suggesting that this sense of health
disempowermentduringincarcerationcontinueduponreleaseintothecommunity:
I’msuretherecouldbealotofgreatresourcesforwomanbutwhenyou’reaskingforitandyoudon’t
seeit,it’skindof[…]unbelievable.Yeah,it’sverydiscouragingandtiresome.
Notonlydidtheyfeeltheirphysicalandmentalhealthneedsweregoingunaddressed,butalso
theirsocialneeds.Criticalissuesregardinghousing,employment,orsocialassistancecouldnot
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VOL.12NO.42016 INTERNATIONALJOURNALOFPRISONERHEALTH PAGE209
beguaranteedintheimmediatereleaseperiod.Theunknownreleasedate/timewithinaremand
population only compounded the issues as women have been known to be released in the
middleofthenight.Thesubsequentre-emergenceofcompetingprioritiesuponrelease,suchas
food, housing and finances, made maintaining any positive health changes more challenging.
Thustheyhadincreasedriskforpoorhealth,addictions,homelessness,andcrimeuponrelease,
justastheyhadpriortoincarceration.Ultimately,thewomenfeltillpreparedfortheirreleaseinto
thecommunity:
I’mnotsayinglikepityusorwhatever,butit’stothepointwhere-it’sjustlike,youknowwhat,we’reall
womenwealltakecareofourowns**t.Butwhenit’slikeimportantissueswe’reok,we’reputtingina
medicalformbecausewecan’t,youknow,takeacabtogotoamedi-centredowntheroadandgo,
youknowwhatImean,byourselves.Soweputinarequestformbutitnevergetstakencareof,so
thenpeoplegetsick[or]madandsadortheirmentalhealthissuesgetworse.
Alotofwomangetgreatideasandtheygetfocusedontherightthingsinhere[jail]andthentheyleave
andgobacktotheiroldwaysbecausetheyhaven’tmadeanychangesandtheydon’tknowhowto
makethechangesontheoutside.
3.1.4 Implication for correctional health care delivery services. Despite the perceived barriers
thatfemaleinmatesfacedwhenaccessinghealthcare,theymadeseveralrecommendationsto
improvenavigatingthecorrectionalhealthcaresystem.First,thewomendescribedtheneedfor
comprehensiveentryandexithealthassessments.Atthebaseoftheneedforcomprehensive
assessments was recognition of a lack of basic knowledge regarding not only available
T) correctional health services and processes, but also a lack of factual knowledge regarding
8 (P basichealthprinciples.Womenmostoftendescribedtheneedforcomprehensiveassessmentin
01 termsoftheirsocialcontext.Thisincludedtheuseofgenderspecificterms,inrelationtogender
2
e specifichealthcare:
n
u
J
4 Ibelievethattherearewomenouttherethatmaynothaveeverhadtheopportunitytolearntheproper
2
1 timestogoandgetbreastexaminationsorpregnancytestsortheproperplacesorresources,or
2
9: supportsystemsoutthereinthecommunity.Someofuscomefromreallydifferentwalksoflifethan
0
At whatsocalled“normal”societyexpects,youknow.SoIbelievelotsofthingscanbechanged.
n
sto Next, the women described poor health literacy as a major hurdle to accessing health care
u
o and that this could be addressed within the correctional health care system through
H
of the provision of adequate information and support. The participants revealed a keen
sity awarenessofthelinkbetweenaccesstohealthservices,healthoutcomes,andhealthliteracy.
er Theyfurtherstressedthe importanceof“plain language”literatureforenhancedcomprehen-
v
Uni sion of health information that was relevant to their health, based on their own unique social
by conditions:
d
de Yourhealthislike[…]ok,yourlifeislikeabunchofzerosandyourhealthisa“#1”infrontofallthose
a
o
nl zeros.Sowithoutyourhealth,thatnumberwouldbenothing,youknowwhatImean.Ifgirlsinhere
ow onlyrealizedthat[…].Ifeellikethereshouldalsobemoreinformationabouthowimportantitistotake
D
careofyourhealth.
Youreallygottobreakdowntheinformationsothatit’seasytoread,’causealotofthesegirlsdon’t
havethetimeorpatienceorarenotabletoread.Youhavetoreallybreakitdowntojustverysimple
[terms]andmakeitreallyefficient.
The final recommendation identified the need for health support networks. The women
acknowledgedthecomplexityoftheirhealthsituationandrightlyidentifiedtheirneedforhealth
supportnetworksthatincludedcorrectionalhealthcareprofessionalsaswellasfemaleinmate
peerstonavigatethecorrectionalhealthcaresystem.Theyfurtheridentifiedthecrucialrolethat
one’shealthsupportsystemplayedinmaintainingtheirhealthoncereleasedduetotheriskof
recidivismintoaddictionandcrime,andcalledattentiontotheneedforongoingsupportthrough
thetransitionperiod:
Justtalkingtosomebody,notevengettinganything,justtalkingliketoaperson[…].Iwasthinking
maybelikewhenyougetoutofjailandhavesomebodycomeseeyourightafteryougetoutofjail,like
1-2weeksafterjusttocheckonyouandtoseehowthingsareandtofollowupwithyou.
Thepersonstillcomesandchecksonyouitshowsthemthatsomebodycaresandmaybethatwould
makethemcareaboutthemselves.
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PAGE210 INTERNATIONALJOURNALOFPRISONERHEALTH VOL.12NO.42016
3.2 Femaleinmate’shealthresourcesmanual
Theresultsofthematicanalysiswereusedtoinformthedevelopmentofaguidetohealthservices
forincarceratedwomen.Themesfellintotwobroadcategories:lackoffactualknowledgeorlack
offunctionalknowledge.TableIIIsummarieskeyfeaturesofthecontentofthemanual.Areasof
poorfunctionalhealthliteracythatimpactedhealthcareaccessincluded:
1. lackofknowledgeofthedailyroutinewithinthecorrectionalfacility;
2. poorbasichealthknowledge(e.g.hygiene,nutrition,exercise);
3. poorgenderspecifichealthknowledge(e.g.paptest,STIs,mammograms);
4. howtoaccesshealthcarethroughtheHSRformprocess;
5. lackofknowledgeregardingexistingcorrectionalhealthservices;
6. howtoprepareforrelease;and
7. resourceswithinthecommunity.
TableIII Summaryofcontentandkeyfeaturesoffemaleinmates’healthservicesresourcemanual
Content Keyfeatures
T)
P
8 ( Introduction Statespurposeofmanual
01 Thefirst24hoursinjail Intakehealthassessments
2
e Processofmedicationcontinuationfromcommunitytoincarceration
n
Ju Accessingsubstanceandalcoholwithdrawalmanagement
24 Mentalhealthandsuicideriskassessments
21 Thedailyroutine Correctionalunitweekdayandweekendschedule
09: Timesofmedicationlines
At Howtostayhealthyinjail Keepingyourbodyclean(personalhygieneroutine)
on Handwashing
ust Incorporatingexerciseintodailyroutine
o
H Howtogethealthservices HowtofilloutaHealthServicesRequest(HSR)
of WhatyoucanexpectonceyousubmitaHealthServicesRequest(HSR)
sity Whattodoifyou’reunhappywiththeresponsetoyourHealthServicesRequest
er (HSR)
v
ni Howtoprepareforyourhealthcareappointment
U
y Women’shealthservices Women’shealthclinicservice
d b Women’shealthfacts(patientinformation)
e
d STI/STDhealthfacts(patientinformation)
a
nlo Healthservicesofferedwithincorrectionalfacility Seeingdoctors,nurses,andnursepractitioners
w (informationoftheservicesprovidedandhow Medication(pharmacy)services
o
D andwhentoaccessit;alsoprovidesinformation HIVClinic
whattheservicecanandcannotprovideduring STI/STDclinic
incarceration) Mentalhealthteam
Socialwork
Addictionservices
Dentist
Caseworkers
Correctionstransitionteam
Planningongettingoutofjail(continuityofhealthcare Transferstoanotherfacility
servicesandreleaseplanning) Courtreleases
Knowingwhenyouaregettingout(releasedate)
Stayinghealthyasyouleavejail
Releasechecklist
Communityresources Includesalistofresourcesinthecommunityunderthefollowingheadings:
Medicalandmentalhealthresources
Detoxandaddictiontreatmentandsupport
Housing,andfoodsupport
Personalidentificationandstorageresources
Educationalandemploymenttrainingresources
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VOL.12NO.42016 INTERNATIONALJOURNALOFPRISONERHEALTH PAGE211
Women were enthusiastic about the development of a health resource targeted specifically to
their health needs and felt that this would improve access. However, they consistently
emphasizedtheneedforhealthsystemsthattookintoaccountthesocialfactorsandbroader
issues that affected their health as opposed to just poor health choices. While they called for
“simple terms,”they also cautioned against the use of story-telling or cartoons in terms of the
layoutofinformation,pointingoutthathealthisaseriousmatter:
It’saseriousthingandIknowwithmyhealthI’mserious,I’mseriousaboutstayingoffofdrugs,I’m
seriousaboutallthisstuffandIdon’twanttositthereandreadabout“SallyandJoe”andtheirlittle
problems.IwanttoknowhowI’mgoingtofixit,howI’mgoingtokeepawayfromitandhowI’mgoing
tostayonthatrightpathwiththesupportsystemsthatIhave.Ithinkstraightforwardisthebestway.
4. Discussion
Thefindingsofthisstudydemonstratethatwomenexperiencemanychallengesinnavigatingthe
correctionalhealthcaresystem.Itisimportanttonotethatthesebarriersandtheconsequences
thereofarenotuniquetoourstudyandarecongruentwiththosepreviouslyreportedinstudies
addressingthehealthofincarceratedpopulations(Pluggeetal.,2008;HarnerandRiley,2013;
Hattonetal.,2006).Afterreleasefromincarceration,healthbecomeslessofapriorityandmore
immediate concernsof secure housing, substance abuse, andfinancial supportcompete with
healthneeds(Freudenbergetal.,2007).Thustheperiodofstabilitythatincarcerationprovidesis
a critical opportunity to address longstanding health concerns and preventative care. Further,
T)
P based on high rates of mortality, morbidity, and hospitalization post-release, strengthening
18 ( correctionalhealthsystemsandprimarycaredeliveryduringincarcerationisimperativeinorderto
0
e 2 improvehealthoutcomeswithinthispopulation(Kouyoumdjianetal.,2015).
n
u
4 J Theparticipantsinthisstudyproposedchangestoaddresschallengeswithinthecorrectionalhealth
2
1 care system based on their lived experience and social context. They suggested the need for
2
9: comprehensiveentryandexitincarcerationhealthassessmentsandcalledattentiontothefactthat
0
At theywerefrom“differentwalksoflife”comparedwith“normalsociety,”andthushealthsystems
on needtotakeintoaccounttheirspecifichealthriskswithintheirsocialcontexts.Thisisinkeepingwith
oust theWHOs’declarationofwomen’shealthinprison,whichstressestheimportanceofgenderequity,
of H acceptance of women’s preferences with regard to health care, and that health services for
y incarcerated women should be individualized as far as possible to meet the specific expressed
ersit needsofthewomen(WHO,2009).However,despitetheknownhighprevalenceofchronicdisease
v
ni amongincarceratedwomenandthebarrierstheyfacewhenaccessinghealthcare,littleisknown
U
y about the most effective healthcare delivery models for women. Existing literature suggests that
b
d maleandfemaleinmatesresponddifferentlytoequalservices(Lewis,2006)andgenderspecific
e
d
a programmingisrequired(Sacks,2004).However,asystematicreviewofrandomizedcontroltrials
o
wnl ofinterventionstoimprovethehealthofincarceratedindividualsnotedapaucityofstudiestargeting
Do women(13of83includedstudiestargetedwomenspecifically)(Kouyoumdjianetal.,2015).
One of the most striking findings of this study was the link the women made between health
literacy and health access and outcomes. Participants in our study were able to recognize
deficienciesinallthreelevelsofNutbeam’s(2000)hierarchyofhealthliteracy.Theseincludedthe
lack of factual health knowledge and inability to navigate the correctional healthcare system,
the need for supportive healthcare networks to motivate and maintain health, and finally the
recognitionoftherolethattheirsocialcontextplaysintheirhealthandtheneedforhealthsystems
to adjust to these accordingly. Donelle and Hall (2014) specifically examined health literacy
amongfemalesonprobationwithinNutbeam’sframeworkandidentifiedsimilarthemesoflimited
healthinformationknowledge,andtheneedforsupportivenetworksandhealthcareservicesthat
tailortoindividual’sneeds.Thereislimitedliteratureintheareaofinterventionstargetedtoward
improvinghealthliteracywithinincarceratedwomenandvulnerablepopulationsingeneral.This
studyisuniqueinthesensethatitaddressedfunctionalhealthliteracythroughcommunity-based
participatory methods to create a health resource manual for female inmates. This approach
helpedtoensurethatthefinalproductwasapplicableandvalidtothetargetpopulation.Further
themethodologyusedtodeveloptheproductaswellasthethemesidentifiedtoframethetable
of contents would be transferrable to other correctional facilities, certainly within Canada and
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PAGE212 INTERNATIONALJOURNALOFPRISONERHEALTH VOL.12NO.42016