Health equity for people living in correctional facilities: Addressing bias, stigma, and dehumanization

Abstract

Individuals living in carceral systems oftentimes are not prioritized in ways that ensure that their rights and dignity are protected. Many families and communities have been and continue to be separated and negatively impacted by disparities in judges' sentencing practices resulting in inequities in treatment and outcomes. As we continue our series on learning the language of health equity, we elucidate health inequities for justice-involved individuals in correctional facilities. This paper contributes to systematically identifying the role of nurse researchers in eliminating health inequities for adults living in correctional health settings to improve health outcomes. It is our determined belief that only through heightening the awareness of nurses on workforce and public biases about people living in prison and their deservedness of compassionate care; advocating for the elimination of stigmatizing and dehumanizing care practices that are regularly levied on them across settings; and including them in health-related research, that we can achieve health equity for this population. Across multiple disciplines' definitions of health equity, the unifying tenet is that it is achieved when everyone can attain their full potential for health and well-being with respect for individual choice in the absence of avoidable differences between individuals because of socially defined circumstances (National Academies of Sciences, Engineering, and Medicine, 2017). This broad conceptualization of health equity includes demographic, geographic, economic, social, and other dimensions of equity (World Health Organization, 2023). In this regard, incarceration is a societal condition contributing to health inequity among predominantly Black and ethnic minoritized populations (Pew, 2023) and those living in poverty. Bias, stigma, and dehumanization thrive in correctional environments and for people involved with the criminal justice system, promulgating unjust health outcomes and extreme inequity. Public stigma is pervasive in the United States (Parcesepe & Cabassa, 2013), particularly as it relates to perceptions of people living or formerly living in prisons. Stigmatization occurs in the delivery of healthcare and affects the mental and physical health of individuals who experience it (Corrigan & Watson, 2002; Frank et al., 2018; Moore et al., 2022; Reinka et al., 2020). Despite our designation as the most trusted profession, nurses globally are not immune from imposing wider societal stigmas on those in their care, particularly when our clients are those who are or have previously been incarcerated. For example, Crampton and Turner's (2014) phenomenological study of Australian perioperative nurses revealed that despite a desire to deliver nonjudgmental care, these nurses held prejudices about their clients who were incarcerated and described caring for them during hospitalization as being challenging and emotionally draining. People living in prisons are more likely to have a chronic condition and co-occurring disorders that are associated with a high degree of stigma and poor health outcomes (Sarteschi, 2013). Two in five incarcerated persons have a history of mental illness (Bronson & Berzofsky, 2017; Centers for Disease Control, 2023). Puglisi and Wang (2021) report that the effect of incarceration upon those who have aged while incarcerated, those with a substance use disorder or mental illness experience greater stigma when seeking health care. Types of stigmas to note include public stigma, stigma perceived by the individual, and professional bias (Feingold, 2021). Because public stigma is so pervasive in society, the impact on mental and physical health is significant. Stigma imposed by a health care professional can create or exacerbate health disparities for individuals in their care. The literature is rich with innovative interventions that can positively impact the health of people living in correctional facilities and improve workplace attitudes and behaviors. Such strategies are guided by evidence-based antistigma models (van Brakel et al., 2019; Fazio, 1990; Knaak & Patten, 2016; Scambler, 1998; Weiss, 2008). Such models focus on changing the attitudes and behaviors of both individuals who are stigmatized and who are the sources of stigmatization. Antistigma models are slowly finding their way into the correctional environment (Moore et al., 2023). Many individuals who live in correctional facilities experience a myriad of health disparities before ever encountering the criminal justice system. Historical research on the social determinants of health has led to a better understanding of the people incarcerated within the US criminal justice system. The US prison populations are over-represented by people who: are racially and ethnically minoritized; have achieved lower educational attainment; have experienced childhood trauma; lacked access to health resources; and lived in environments that are fraught with violence and devoid of safe green spaces (Graf et al., 2021). Of note these challenges are experienced across multiple generations in some families (Stensrud et al., 2019). Additionally, individuals who lack resources to maintain and improve their health often engage in behaviors that negatively impact both their physical and mental well-being (e.g., high-risk sexual behaviors and substance use, including illicit drugs, alcohol, and nicotine (Andermann, 2016; Pampel et al., 2010). Preincarceration disparities result in individuals who are sicker (Dirkzwager, et al., 2021), in need of considerable health resources upon entering correctional facilities, which are settings where healthcare staffing is significantly short and budgets are very limited (Rosen et al., 2023; Williams et al., 2012). The literature presents two opposing views about the improvement and decline of health and well-being for those who live in correctional facilities and upon their release (Healthy People, 2030, n.d.). Rich et al. (2012) remarked on both aspects at a National Academies Workshop on Health and Incarceration. Living in a correctional facility provides health care (e.g., diagnosis and treatment of chronic conditions) which could improve the health of some people who lacked access to health care before incarceration. In contrast, the stress of incarceration overcrowding, social deprivation, and prison violence can lead to worsening of chronic health conditions, poorer mental health, and increased likelihood of infectious diseases. Taken together, the generally poorer health experienced by people living in correctional facilities when compared to their community-living counterparts is commonly referred to as accelerated aging (Aday, 2003). In fact, people who live in correctional facilities often have a biological age that is estimated to be 10–15 years older than their chronological age (Loeb et al., 2008; Wang, 2022). Health disparities experienced by individuals from racial and ethnic minoritized groups in the community population are comparable to the criminal justice populations. This disparity is compounded by the fact that racial and ethnic minoritized individuals are more likely to be incarcerated relative to White people. Specifically, Black, American Indian or Alaska Natives, and Hispanic US residents are 5.1, 4.1, and 2.5 more times more likely respectively than White people to be incarcerated (Bui et al., 2019). This disparity in which racial and ethnic groups are disproportionately incarcerated not only negatively impacts the health of the criminal justice-involved person but also their entire family and community. For example, in the United States, 1 in 28 children in the general population compared to one in nine African American children had an incarcerated parent. Having an incarcerated parent increases a child's risk of homelessness, financial instability, challenges at school, and behavioral/mental health conditions like depression and anxiety (Bui et al., 2019). Correctional facilities are built with custody and control at the forefront, with less emphasis on caring for people with health conditions. The stark living conditions of the built environment, such as lack of temperature regulation, bunk beds, and stairs instead of elevators, create challenges for people with health conditions. These living conditions are compounded by the impacts of climate change (Cloud et al., 2023; Skarha et al., 2022). High temperatures and humidity can exacerbate health conditions like heart disease; lead to increased violence, and in some cases, contribute to death. Extreme weather conditions have been attributed as biological and social threats for people living in correctional facilities. For example, flooding has resulted in contaminated water and pest infestations in correctional facilities, which can lead to bacterial, viral, or fungal infections (Wang, 2023). Correctional facility administrators must consider the cost and logistics of dealing with the built environment and climate change issues, as well as facility evacuations, mitigating pests, and health care costs related to elevated temperature exposure. The overwhelming need for resources and the cost attributed to these issues alone may motivate correctional facility administrators to consider a better plan. Globally, there are transformative ideas and models for healthy prison design that the United States could adopt, and that nurses could lead to manage environmental and system-wide issues and humanize the environment (Engstrom & van Ginneken, 2022; Ramdath et al., 2023). Although many health needs of people who are incarcerated are manageable within the prison infirmary, some are not. When health care needs exceed the capacity of the correctional facilities' infirmaries, people who are incarcerated are typically transferred to a nearby hospital for care. Unfortunately, health disparities in care do not end at the hospital door. Haber et al. (2019) reported that best practice guidelines are needed to inform the care and management of people who are incarcerated but receiving care in a hospital setting. One study of nurses and physicians in a safety-net hospital in Provo, Utah, reported that both groups of healthcare professionals believed that their incarcerated patients should receive the full range of medical care, but differences were noted between the two groups. Eighty percent of physicians noted concern that patients who were incarcerated received significantly fewer nonmedical interventions (Brooks et al., 2022), when compared with 67% of nurses in the study. Helping nurses to identify and reduce biases across all patient populations may improve care for all patients, including those who live in correctional facilities. Further, 26% of physicians voiced concerns about differential care pertaining to “shackling,” privacy, and patient-informed discharge counseling since family members of patients were rarely, if ever, provided this information. Interestingly, none of the nurses in this study shared this concern. Similarly, Armstrong et al. (2023) conducted a narrative review of the care of emergency room patients who were incarcerated and found that shackling and lack of privacy were major factors related to inequitable care of this population. A lack of formal training in caring for this population with reduced rights was identified as contributing to bias experienced by patients who were incarcerated. Research is needed to clarify the workforce impacts like concerns for safety and security upon bias and outcomes of care as well as the efficacy of educational programs. Nurses who are researchers have a critical role in advocating for persons living in correctional settings or affected by the criminal justice system to facilitate transformative change in a system that often favors custody and security over caring. We must foster understanding and eliminate stigmatizing and dehumanizing practices that affect the health of this population. First, we must refrain from using dehumanizing language. We should call the population affected by the criminal justice system a name selected by the population we are working with, or when that is not possible, the terms “people,” “person,” or “individual” is appropriate. For clinicians or researchers working with or disseminating research with this population, monikers such as “inmates,” “prisoners,” “convicts,” or any derivative of these words tend to have a negative connotation and are perceived as dehumanizing and stigmatizing (Bedell et al., 2018; Cox, 2020). Although the American Psychological Association (2019) guidelines recommend using bias-free language, for example, person-first language, a search of PubMed using the keywords “prisoner and health” or “inmate and health” still yields over a thousand articles respectively, which is an indication that we should do better. Elderbroom et al. (2021) reported the results of a 2021 study that yielded 10,000 social media articles not using person-first language compared to 480 using person-first language. If the people involved in the research in any aspect, for example, study participant or team member, request the use of specific language, we should honor their preferences to be inclusive. We have learned from other communities, like persons with specific disabilities, that identity language (e.g., deaf people) may be preferred over person-first language (e.g., people who are deaf) (Dunn & Andrews, 2015; Gernsbacher, 2017; Wooldridge, 2023). Second, research initiatives should involve people with a history of incarceration or those living in different correctional facilities (e.g., jails and prisons or recently released). At a recent academic conference with persons affected by the criminal justice system, the phrase, “Nothing without us, about us, is for us,” was a repeated theme across many of the sessions about research and people participating in the research (Academic Consortium on Criminal Justice Health Conference, 2023). The phrase is an adaptation of one used in the 1990s disability rights movement as a rallying call for activism against people, possibly well intended, who make decisions or take actions on matters central to the lives of others without involving them (Koontz et al., 2022). Although research protections for people in correctional facilities have made it challenging to reach people to involve them in research, it is possible (Sivakumar, 2021). Involving persons in correctional facilities or those with a history of incarceration in research initiatives communicates a message of respect for these individuals' autonomy and self-control, thereby enhancing human dignity and humanization of the environment (Vera, n.d.). Importantly, nurse researchers can advocate for and contribute to the development and implementation of policies and interventions that eliminate stigma and bias for individuals with an incarceration experience and chronic health conditions, particularly mental illness and substance abuse. For example, antistigma models appearing in theoretical and evidence-based literature have the promise to reduce stigma and bias. Many models focus on the individual and the interplay of attitude and behavior. Some models focus broadly on the impact of stigma within the environment, the community, and the media (van Brakel et al., 2019; Fazio, 1990; Knaak & Patten, 2016; Pescosolido et al., 2008). There are many models used to illustrate how to educate healthcare providers about stigma and inform better health outcomes (Baybutt & Chemlal, 2016; Jewkes, 2018; Kinner & Young, 2018; Massoglia & Pridemore, 2015; Shelton, 2015). We advocate for the use of an action-oriented model and one that facilitates intervention development. One such model is the Assessment and Intervention Model (van Brakel et al., 2019; see Figure 1), which was developed as an expansion of an earlier model on hidden distress (Weiss, 2008). In this model, specific interventions such as counseling, skill building, or empowering can be developed with persons living in correctional facilities or supervised community facilities. van Brakel et al. (2019) concluded that people who are stigmatized may anticipate being stigmatized, internalize the stigma, and experience discrimination (enacted stigma) which results in negative attitudes toward the other. The sources of stigma may come from the communities, systems, and structures. The goal of this work is to suggest further interventions for people both stigmatized by health conditions and the community at large, including those in positions to impact health policy and administration. A second example is found in the peer-to-peer programming literature. One systematic review of the effectiveness of peer-based interventions reported mixed effectiveness of peer-to-peer programming on health-related behaviors among adults in a community sample (Webel et al., 2010). This body of literature has been growing for 20 years, yet language varies, and outcomes that were measured varied. Overall, studies indicate that peer-based programs hold promise for addressing health equity issues (Doull et al., 2004). Fourteen peer roles have been identified for correctional settings by another systematic review (South et al., 2014), but publication biases (over-reporting of positive findings) were noted. Not surprisingly, a variety of outcomes and methods were utilized. Intuitively, these interventions appear to make sense, but much more research is needed. Improved attention to data management and involvement of those with the lived experience of incarceration will refine and provide more robust research results. More nursing and midwifery researchers, including doctoral nursing students are needed to partner with communities to address the root causes of pre-incarceration health disparities and advocate for equitable access to education, healthcare resources, and safe environments. Research initiatives can be tailored to break the cycle of generational challenges, ensuring healthier communities, and reducing the strain on healthcare provided in correctional facilities. Boch and Ford (2021) conducted a secondary analysis using the 2016–2019 National Survey of Children's Health to explore protective factors to promote health and flourishing among Black youths exposed to parental incarceration. Family Connectedness was the strongest predictor of flourishing and was associated with better health outcomes in youths. These findings supported investing in the evidence-based Nurse–Family Partnership program to enhance family connectedness, such as parent-child bonding and attachment. Nurse scientists looking for upstream solutions to lessen the effects of parental incarceration on the health and well-being of Blacks youth will contribute to improving health equity in this population and addressing the root causes of incarceration. Nurse scientists have ample opportunity to advocate and create a culture of health in correctional facilities. To paraphrase a comment from a person with a history of incarceration speaking at a conference keynote, “when I hear that as a population, we are hard to reach when it comes to research, I say, we are here and are not looking in the Research with people in correctional facilities or jails can inform evidence-based care, addressing both physical and mental healthcare needs of individuals in the correctional system. of persons in research the promise of and outcomes for chronic conditions such as mental and The role of nurse scientists in correctional as across the of nursing is as At the and (2023) noted that it is through a of within the of and that challenges in nursing research are Public data have revealed the for this and correctional This environment is rich with to health policy and the effects of family Nurse scientists have to and the effectiveness of and community nursing initiatives that provide healthcare to individuals affected by the criminal justice system and to the health inequity to the of we note that in the carceral system are to dehumanizing and unjust the use of shackling during from and to the of this and attention these issues are the not address In nurse scientists and clinicians in and community that people who are incarcerated must be to ensure that their research and care respectively are of to those provided to their patients who are not incarcerated. Additionally, must ensure that are care and respect with the human dignity of all patients where work with people living in correctional facilities is challenging but the need for research in this and the need to and humanize care in working with this population the As nurse our to equitable research and compassionate care for this population as a call to a to and the dignity of person affected by the criminal justice system. Overall, a is needed to eliminate disparities and enhance the of healthcare provided to this population.

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