Medical services policy in respect of detainees: evolution and outstanding issues.

Alleged and confirmed abuse of civilians arrested or detained by the UK Armed Forces has been the subject of four formal enquiries, and all have used medical evidence and/or addressed medical issues. After the first three, robust policies were put in place to ensure that all those arrested had appropriate medical examinations and that healthcare personnel acted appropriately. However, by the time of the Second Gulf War, the training and medical processes had lapsed and were found to be a contributory factor in not preventing abuse. The fourth enquiry has endorsed most of the lapsed policies but is ambiguous in two areas-on medical certification of fitness for interrogation and the timing to the first medical examination. This article summarises the medical aspects of the four enquiries and discusses the two ambiguous areas, arguing that to diverge from the policies eventually put in place in Northern Ireland is a retrograde step. It also discusses how training put in place to avoid the very events which occurred in the Second Gulf was discontinued.

Reframing school-based restorative justice as a structural population health intervention.

School-based restorative justice has gained national prominence as an effective approach to interrupting the school-to-prison pipeline. Remarkably, despite its simultaneous positive association with academic success, school safety, and school connectedness, most scholars and practitioners do not associate restorative justice with health. Using ecosocial theory, we conceptualize school-based restorative justice as a structural population health intervention. Our findings indicate that students attending schools using restorative justice have lower odds of missing school due to adverse health and better academic outcomes compared to students who do not. Restorative justice shows promise as a structural intervention that can contribute to improving population health.

Nursing Leadership Implications for Clinical Placements in Corrections.

Clinical placements in correctional settings offer nursing students unique opportunities for learning mental health and community health concepts, including social justice, restorative justice and the impact of poverty and marginalization on health and life choices. Although there is some evidence to suggest that a small number of nursing programs use clinical placements in correctional settings, relatively little scholarly literature addresses nursing education in such settings, or the implications for nursing leadership when students do have an opportunity to learn in correctional settings. In this paper, we examine the literature that is available on this topic and present the findings of a secondary analysis of interviews with undergraduate nursing students at our nursing program in relation to their clinical placements in correctional settings. Drawing on the students' perspectives, we have found that these placements, in particular, have fostered learning about caring for marginalized populations; themes of hope and restorative justice featured prominently in their descriptions of their learning. Students also emphasized that they learned a great deal about the expanded role of nurses and about caring for marginalized populations. With strong administrative and faculty support, these settings offer students exposure to expert registered nurse mentors who work with clients in an expanded role to facilitate their achievement and stabilization of a broad range of health challenges. They are also role models for students, by showing students that nurses can be agents of hope when working with a diverse client population and their families. We offer recommendations on how to maximize student learning in correctional settings, including a reflection on how to support students' integration of their learning experiences in their nursing practice, with the long-term view that these transformative student experiences have the potential to shape our future nurse leaders.

Freedom-deprived women: social representations of prison, violence, and their consequences.

OBJECTIVE: To understand the social representations that women deprived of their freedom have of imprisonment, violence, and their consequences. METHOD: An exploratory-descriptive qualitative study with 15 women from a female penitentiary in the State of São Paulo, Brazil. Semistructured interview was used. Data submitted to thematic content analysis and interpreted under Social Representations. RESULTS: Categories identified: "Enclosed and abandoned in the prison environment": loss of contact with relatives, difficulties living in prison, and right to be reinserted into society. "Imprisoned in a cycle of social inequality": lack of support, access to education and employment opportunities, leading them to engage in new illicit activities and consequent imprisonment. FINAL CONSIDERATIONS: The social representations of prisoners suggest that they perceive themselves to be doubly "imprisoned", either from the objective point of view, as an individual deprived of freedom; or subjective, as citizens who have their rights disrespected and their possibilities of rehabilitation limited by the prison system.

Freedom-deprived women: social representations of prison, violence, and their consequences / Mujeres privadas de libertad: representaciones sociales de la prisión, la violencia y sus consecuencias / Mulheres privadas de liberdade: representações sociais de prisão, violência e suas consequências

ABSTRACT Objective: To understand the social representations that women deprived of their freedom have of imprisonment, violence, and their consequences. Method: An exploratory-descriptive qualitative study with 15 women from a female penitentiary in the State of São Paulo, Brazil. Semistructured interview was used. Data submitted to thematic content analysis and interpreted under Social Representations. Results: Categories identified: "Enclosed and abandoned in the prison environment": loss of contact with relatives, difficulties living in prison, and right to be reinserted into society. "Imprisoned in a cycle of social inequality": lack of support, access to education and employment opportunities, leading them to engage in new illicit activities and consequent imprisonment. Final considerations: The social representations of prisoners suggest that they perceive themselves to be doubly "imprisoned", either from the objective point of view, as an individual deprived of freedom; or subjective, as citizens who have their rights disrespected and their possibilities of rehabilitation limited by the prison system.

RESUMEN Objetivo: Comprender las representaciones sociales que las mujeres privadas de su libertad tienen sobre la prisión, la violencia y sus consecuencias. Método: Estudio cualitativo exploratorio-descriptivo realizado con 15 mujeres de una cárcel femenina del Estado de São Paulo, Brasil. Se utilizó una entrevista semiestructurada. Los datos se sometieron al análisis de contenido temático y fueron interpretados a la luz de las Representaciones Sociales. Resultados: Categorías identificadas: "Enclaustradas y abandonadas en el ámbito penitenciario": pérdida de contacto con los familiares, dificultades de convivencia en la prisión y en lo que se refiere al derecho a ser reintegradas en la sociedad. "Encarceladas en un ciclo de desigualdad social": falta de apoyo, acceso a la educación y oportunidades de empleo, llevándolas a involucrarse en nuevas actividades ilícitas y por consiguiente volver a ser encarceladas. Consideraciones Finales: Las representaciones sociales de las detenidas sugieren que ellas se sienten doblemente "encarceladas", tanto desde el punto de vista objetivo, como individuo privado de su libertad, como del subjetivo, ciudadanas cuyos derechos no son respetados y sus posibilidades de rehabilitación son limitadas por el sistema penitenciario.

RESUMO Objetivo: Compreender as representações sociais que mulheres privadas de liberdade têm sobre prisão, violência e suas consequências. Método: Estudo qualitativo exploratório-descritivo realizado com 15 mulheres de uma penitenciária feminina do estado de São Paulo, Brasil. Foi utilizada entrevista semiestruturada. Dados submetidos à análise de conteúdo temática e interpretados à luz das Representações Sociais. Resultados: Categorias identificadas: "Enclausuradas e abandonadas no ambiente prisional": perda de contato com familiares, dificuldades de convívio na prisão e direito de serem reinseridas na sociedade. "Aprisionadas em um ciclo de desigualdade social": falta de apoio, acesso à educação e oportunidades de emprego, levando-as ao envolvimento em novas atividades ilícitas e consequente aprisionamento. Considerações finais: As representações sociais das detentas sugerem que elas se percebem duplamente "aprisionadas", seja do ponto de vista objetivo, como indivíduo privado de liberdade; ou subjetivo, como cidadãs que têm seus direitos desrespeitados e suas possibilidades de reabilitação limitadas pelo sistema prisional.

Assessment of need for inpatient treatment for mental disorder among female prisoners: a cross-sectional study of provincially detained women in Ontario.

BACKGROUND: International studies show a consistent finding of women in prisons as having a high prevalence of mental disorder. Most will be treated within the prison however the most severely ill require transfer to a hospital facility. The primary aim of our study was to survey the total provincial female prison population in Ontario, Canada, to determine the proportion that require treatment in a psychiatric hospital, and the security level required. The secondary aim was to investigate the validity and psychometric properties of DUNDRUM-1 and DUNDRUM-2 in making these assessments. METHODS: We carried out a cross-sectional study of all remand and sentenced female inmates detained in all 16 provincial jails that hold women in Ontario. The severity of mental health need was categorised by mental health staff on a five-point scale. Two forensic psychiatrists then examined all medical files of prisoners that had been categorised in the highest two categories and a random sample of nearly a quarter of those in the third category. An overall opinion was then made as to whether admission was required, and whether a high intensity bed was needed, and files were rated using DUNDRUM-1 and DUNDRUM-2. RESULTS: There were 643 female inmates in provincial prisons in Ontario. We estimated that approximately 43 (6.7%) required admission to a hospital facility, of which 21.6 [prorated] (3.4%) required a high intensity bed such as a psychiatric intensive care bed within a secure hospital. The DUNDRUM-1 and -2 tools showed good internal validity. Total scores on both DUNDRUM-1 and DUNDRUM-2 were significantly different between those assessed as needing admission and those who did not, and distinguished the level of security required. CONCLUSION: This is the first study to determine level of need for prison to hospital transfers in Canada and can be used to inform service capacity planning. We also found that the DUNDRUM toolkit is useful in determining the threshold and priorities for hospital transfer of female prisoners.

The economic consequences of attention-deficit hyperactivity disorder in the Scottish prison system.

BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) is highly prevalent amongst prison inmates and the criminal justice system (CJS) likely bears considerable costs for offenders with ADHD. We aimed to examine the relationship between ADHD and health-related quality of life (HRQoL) and quality-adjusted life years (QALY) amongst imprisoned adults; and to estimate the annual expenditure associated with ADHD status in prison. METHODS: An observational study was performed in 2011-2013, at Porterfield Prison, Inverness, United Kingdom (UK). The all male sample included 390 adult prison inmates with capacity to consent and no history of moderate or severe intellectual disability. Participants were interviewed using the Diagnostic Interview for ADHD in Adults 2.0. The Health Utilities Index Mark 3 (HUI3) was used to measure health status, and to calculate attribute specific HRQoL scores and QALY. Health service utilisation was obtained through inspection of medical prison records. Inmates with ADHD were compared with inmates without ADHD. RESULTS: Inmates with ADHD had significantly lower QALYs, with a clinically significant adjusted difference of 0.13. Psychiatric co-morbidity accounted for the variation of ADHD on the HUI3 emotion domain only. Medical costs for inmates with ADHD were significantly higher; and behaviour-related prison costs were similar to prisoners without ADHD, reflecting a low frequency of recorded critical incidents. CONCLUSIONS: ADHD may directly contribute to adverse health and quality of life through cognitive and executive function deficits, and co-morbid disorders. The extrapolation of conservative cost estimates suggests that the financial burden of medical and behavior-related prison care for inmates with ADHD in the UK is approximately £11.7 million annually. The reported cost estimates are conservative as there is great variability in recorded critical incidents in prisons. In turn, for some prison establishments the prison care costs associated with prisoners with ADHD may be considerably greater.

The School-to-Prison Pipeline: A Primer for Social Workers.

The school-to-prison pipeline (STPP) refers to a path from the education system to the juvenile or adult criminal justice system. Over the past two decades, this path has grown significantly, and scholars attribute a myriad of contributing factors to this increase. Each factor has its own impact and consequences, which are covered in detail based on an extensive literature review and macro practice through Race Matters for Juvenile Justice. Prior to the STPP concept, education had largely been considered a protective factor for children and a route to success as opposed to a risk factor or track toward juvenile justice involvement. Staying in school and getting good grades were regarded as strategies that even at-risk students could use to overcome poverty, prejudice, and powerlessness. But since the 1990s, the approach to discipline in U.S. public schools has changed, and the effects of this change are only now becoming evident. This article explains the correlates of the STPP and its disparate outcomes, most notably for students of color; those with disabilities; and lesbian, gay, bisexual, transgender, queer, and questioning students. The article concludes with implications for social workers in various settings and specific strategies for reducing the impact of the STPP.

The critical link between health care and jails.

As a group, jail-involved individuals, which we define here as people with a history of arrest and jail admission in the recent past, carry a heavy illness burden, with high rates of infectious and chronic disease as well as mental illness and substance use. Because these people have tended to also be uninsured, jail frequently has been their only regular source of health care. Three thousand three hundred local and county jails processed 11.6 million admissions during the twelve-month period ending midyear 2012. The Urban Institute estimated as much as 30 percent of some local corrections budgets is allocated to inmate health care services. This investment is largely lost when people are released back into the community, where they typically do not get treatment. For people with untreated substance use or mental illness, this issue reaches beyond public health, because without treatment, these people are at heightened risk of cycling into and out of jail for low-level, nonviolent offenses. This article offers eight policy recommendations to build a continuum of care that will ensure that jail-involved people get the care they need, regardless of where they reside. With the expansion of Medicaid eligibility under the Affordable Care Act, there is now a critical opportunity to bring the jail-involved population into the mainstream health care system, which benefits the health care and criminal justice systems and society at large.

Survey finds that many prisons and jails have room to improve HIV testing and coordination of postrelease treatment.

Early diagnosis of HIV and effective antiretroviral treatment are key elements in efforts to reduce the morbidity and mortality associated with HIV. Incarcerated populations are disproportionately affected by HIV, with the disease's prevalence among inmates estimated to be three to five times higher than among the general population. Correctional institutions offer important opportunities to test for HIV and link infected people to postrelease treatment services. To examine HIV testing and policies that help HIV-positive people obtain treatment in the community after release, we administered a survey to the medical directors of the fifty state prison systems and of forty of the largest jails in the United States. We found that 19 percent of prison systems and 35 percent of jails provide opt-out HIV testing, which is recommended by the Centers for Disease Control and Prevention (CDC). Additionally, fewer than 20 percent of prisons and jails conform to the CDC's recommendations regarding discharge planning services for inmates transitioning to the community: making an appointment with a community health care provider, assisting with enrollment in an entitlement program, and providing a copy of the medical record and a supply of HIV medications. These findings suggest that opportunities for HIV diagnosis and linking HIV-positive inmates to community care after release are being missed in the majority of prison systems and jails.

How health care reform can transform the health of criminal justice-involved individuals.

Provisions of the Affordable Care Act offer new opportunities to apply a public health and medical perspective to the complex relationship between involvement in the criminal justice system and the existence of fundamental health disparities. Incarceration can cause harm to individual and community health, but prisons and jails also hold enormous potential to play an active and beneficial role in the health care system and, ultimately, to improving health. Traditionally, incarcerated populations have been incorrectly viewed as isolated and self-contained communities with only peripheral importance to the public health at large. This misconception has resulted in missed opportunities to positively affect the health of both the individuals and the imprisoned community as a whole and potentially to mitigate risk behaviors that may contribute to incarceration. Both community and correctional health care professionals can capitalize on these opportunities by working together to advocate for the health of the criminal justice-involved population and their communities. We present a set of recommendations for the improvement of both correctional health care, such as improving systems of external oversight and quality management, and access to community-based care, including establishing strategies for postrelease care and medical record transfers.

The impact of policies promoting health information technology on health care delivery in jails and local communities.

The 1976 Supreme Court decision in Estelle v. Gamble declared that jails must provide medical treatment to detainees consistent with community standards of care. Yet despite their important role providing health care to about ten million people a year, jails remain largely siloed from the surrounding health care community, compromising inmates' health and adding to health care spending. Health information technology promises solutions. The current policy landscape, shaped by the Health Information Technology for Economic and Clinical Health (HITECH) Act and the Affordable Care Act, is favorable to jails' implementation of health information technology (IT). In this article we examine how decisions largely external to jails-coming from the Supreme Court, Congress, and local policy makers-have contributed to the growth of health IT within jails and health information exchange between jails and local communities. We also discuss privacy concerns under the Health Insurance Portability and Affordability Act and other legislation. This article highlights a rare confluence of events that could improve the health of an overlooked population.

Coverage expansion and the criminal justice-involved population: implications for plans and service connectivity.

People who have served time in US prisons and jails have high rates of undiagnosed chronic and infectious diseases, behavioral health conditions, and trauma. Because a large portion of this population are young men-a demographic previously underrepresented in Medicaid rolls-who have been uninsured, Medicaid payers and the managed care plans they contract with have little experience serving this population. To meet the Affordable Care Act's policy objectives of cost-efficient and effective care through improved and expanded access, health plans need to understand the epidemiology and care-seeking patterns of this population. Plans also need to develop outreach, communications, and engagement strategies and create service models designed to address these individuals' health care needs. Corrections departments and health plans should exchange information about the medical histories of people entering and leaving prisons and jails, promote models of peer support, and advocate for suspension rather than termination of Medicaid benefits during incarceration, so inmates can quickly regain coverage once they are released.

Public health and the epidemic of incarceration.

An unprecedented number of Americans have been incarcerated in the past generation. In addition, arrests are concentrated in low-income, predominantly nonwhite communities where people are more likely to be medically underserved. As a result, rates of physical and mental illnesses are far higher among prison and jail inmates than among the general public. We review the health profiles of the incarcerated; health care in correctional facilities; and incarceration's repercussions for public health in the communities to which inmates return upon release. The review concludes with recommendations that public health and medical practitioners capitalize on the public health opportunities provided by correctional settings to reach medically underserved communities, while simultaneously advocating for fundamental system change to reduce unnecessary incarceration.

Implementing change: staff experiences of changes to prison mental healthcare in England and Wales.

PURPOSE: Stemming from substantial criticism during the late twentieth and early twenty-first century, the UK government and HM Prison Service developed a number of policies and protocols aimed at improving the state of prison mental healthcare. While it is difficult to fault the purpose of the government's intentions, criticism has continued relating to problems with the implementation of government led change within the prison system. Existing research leads people to question whether policies are being implemented as intended; and if not, why not? The only clear way to answer these questions is to ask those involved in the actual implementation of these recommendations within the prison service. This paper aims to answer these questions. DESIGN/METHODOLOGY/APPROACH: This paper documents findings from a national survey of senior mental healthcare staff working in prisons in England and Wales. Staff were surveyed about their views on the implementation of recommendations from recent key government documents, their perceptions of prison mental healthcare versus community mental healthcare, and their views on the relationship between HM Prison Service and the National Health Service. FINDINGS: While many staff report improvements in prison mental healthcare, many have struggled with the implementation of new ways of working and the findings here suggest there is still some way to go towards providing offenders in prison with effective and appropriate care. Where effective ways of implementing change were identified, these are discussed. ORIGINALITY/VALUE: Listening to the experiences of the staff involved in prison healthcare has helped identify where implementation of changes could be improved and thus highlights where support might best be targeted in future.