Abstract
Internationally, best practice for prison health care recommends transferring health service provision from corrections to health authorities. Although it is expected that this change will result in improved health care, there is little evidence of evaluation. This article used qualitative interviews with health service providers to gain insight into the health needs of women’s prisons in Queensland, Australia, both prior to and after the transition in health care service provision. We found that service providers identified that problems persisted regardless of service provider and that improvement required increased resources and more fundamental structural changes within prison environments.
Women remain a minority within prison populations, even though internationally the proportion of females incarcerated in adult correctional centres has increased over the last decade (J. Martin, Kautt, & Gelsthorpe, 2009). As a result, prison systems lack policies and services designed specifically for women (World Health Organization [WHO], 2009), including in Australian prisons (Anti-Discrimination Commission Queensland [ADCQ], 2006; Bartels & Gaffney, 2011). This is seen in prison health care, where services designed for the majority male population are simply extended to women (Smith, 2000). Yet women prisoners have complex health needs exacerbated by limited prior access to comprehensive services, compared both with male prisoners and the general community (Australian Institute of Health and Welfare [AIHW], 2011; D. S. Young, 1996). Prison therefore provides an opportunity to provide health interventions tailored to an otherwise difficult to access population (Gatherer, Møller, & Hayton, 2009). Improving the physical and mental health of women returning to the community may, by addressing underlying issues, help reduce their likelihood of recidivism (Anthony & McFadyen, 2005; Forsythe & Adams, 2009). Achieving improved health care for incarcerated women is therefore an important objective for public health and crime reduction purposes, as well as being a fundamental human right (Exworthy, Wilson, & Forrester, 2011).
In Australia, each state and territory government is responsible for its own correctional system including the provision of health services. Health services for prisons may be delivered directly by the prison (correctional service) or be purchased from private providers (AIHW, 2013). There are also differences in the manner in which health services are provided to prisoners, both between and within jurisdictions. For example, in some prisons, prisoners may need to be transported to hospital to access specialist services, whereas other prisons may have access to specialist services on-site. On entry to prison, Australian prisoners also lose access to Australia’s health care scheme (Medicare) and pharmaceutical benefits scheme, and so are completely reliant on the state provided health care of their particular prison (AIHW, 2013).
Critics have long identified the struggles inherent in providing health services within the context of a correctional institution (e.g., Sim, 1990). In response, recent international best practice for health care provision in prisons involves shifting responsibility for services from corrections to health authorities (WHO, 2007). The expectation of such a shift is that it will improve health care outcomes, including for women prisoners. In the state of Queensland, responsibility for prisoner health services was transferred from the Department of Corrective Services (QCS) to Queensland Health (QH) on July 1, 2008. Similar shifts have occurred in other Australasian jurisdictions, and internationally (e.g., in Norway, France, England, and Wales; see Hayton & Boyington, 2006). However, there has been little evaluation of this shift and in particular of any outcomes for female prisoners, and this article aims to contribute an exploratory case study to help in understanding the effects of the shift, especially for women prisoners.
This article describes perceptions of health service deliverers and prisoner advocates about what changes, if any, have occurred in health care delivery for women prisoners in Queensland as a result of the 2008 shift. We are particularly interested in whether these stakeholders perceive the improvement in service provision that would be expected to result from the transfer of responsibility and any continuing barriers to such an improvement. We begin by examining the female prisoner population and what is known of their health needs, including identifying subgroups with special health needs. We then describe the transfer that took place in 2008, before setting out our methodology for assessing its impact. In discussing our results, we highlight the need for future research, especially with regard to the views of the prisoners themselves.
Female Prisoners and Their Health Needs
Although women remain a minority in the Australian prison population, the proportion of incarcerated females has increased in the last decade. In Australia, in 2011, 7% of the prisoner population were female, representing a 35% increase over a 10-year period (Australian Bureau of Statistics [ABS], 2011). Within this group, Indigenous women (including both Aboriginal and Torres Strait Islander peoples) are overrepresented, and the increase in the proportion of Indigenous women being incarcerated exceeds that of non-Indigenous women (ABS, 2011). Women prisoners are a vulnerable population, with greater disadvantages prior to imprisonment and greater health needs than the general population once imprisoned. Relative to their community counterparts, incarcerated women have higher rates of health risk behaviours (AIHW, 2011), childhood sexual and physical abuse (Hockings, Young, Falconer, & O’Rourke, 2002), and mental health concerns prior to incarceration (Forsythe & Gaffney, 2012). Once imprisoned, the major health issues of women are drug abuse, mental health, childhood sexual abuse (ADCQ, 2006), chronic disease, and communicable diseases (AIHW, 2011). Despite these complex health needs, women in prison tend to have had limited prior access to health care (D. S. Young, 1996) and are more likely than male prisoners to have needed, but not sought, treatment from health professionals in the community prior to imprisonment (AIHW, 2011).
Prison offers an opportunity to provide health interventions to a population that would otherwise be difficult to reach (Gatherer et al., 2009). Returning women to the community with improved physical and mental health can prevent the spread of communicable diseases between prison and the community (Lindberg & Huang, 2006) and reduce the likelihood of recidivism (Anthony & McFadyen, 2005; Forsythe & Adams, 2009). While women have been found to utilise prison health services more frequently than male prisoners, the adequacy of the services has been criticised (AIHW, 2011; Carlen & Worrall, 2004; Smith, 2000; Smith & Borland, 1999). Furthermore, the prison environment and institutional regime is not conducive to good health and may create health problems or exacerbate existing health conditions (Faith, 2009; Smith, 2000).
The Queensland Women Prisoners’ Health Survey (Hockings et al., 2002) was the first formal study to specifically assess the health needs of incarcerated women in Queensland. The survey was conducted over 1 month in 2002 in all custodial correctional centres for women in Queensland. The women prisoners (212 women, reflecting a participation rate of 77%) completed a one-on-one interview, physical assessment, and provided a blood sample, and additional data were provided from medical records and the Corrective Services Information System. High prevalence rates of a range of health concerns were identified including current smoking (82.9%), depression (82%), anxiety (60%), drug dependence (47%), Hepatitis C (45%), long-term illness (including mental health, 44%), and back problems (40%). These rates were generally comparable with incarcerated women in other Australian states (e.g., Butler & Milner, 2003; Indig et al., 2010; Victoria Department of Justice, 2003) but are considerably higher than the prevalence of these issues for women in the community.
Provision of adequate mental health services has been identified as a priority for female prisoners in Queensland (Alexander, Martin, & Williams, 2010; ADCQ, 2006). The Kyiiv Declaration on Women’s Health in Prison (United Nations Office on Drugs and Crime & WHO, 2009) states that health services should specifically address mental illness, particularly substance use disorders and posttraumatic stress disorder. M. E. Martin and Hesselbrock (2001) claim that although female prisoners utilise mental health services in prison more than their male counterparts, their mental health needs often remain unmet. Criticisms of mental health services provided to prisoners include failing to take physical health issues into account when addressing mental health issues (Butler, Indig, Allnutt, & Mamoom, 2011), restricting access to prisoners suffering acute disorders and considered at risk of harming themselves or others, and not providing ongoing treatment and support (Alexander et al., 2010; ADCQ, 2006).
Notably, the Queensland Women Prisoners’ Health Survey did not distinguish the health needs of older women or Indigenous women. The poor health of Indigenous Australians relative to the general population has been well documented with higher prevalence rates of asthma, cardiovascular disease, diabetes, and communicable diseases (ABS, 2006; MacRae et al., 2012; O’Dea, 2005); however, limited information is available regarding their specific health needs in prison. A Victorian prisoner survey identified differing prevalence rates in physical health conditions between Indigenous and non-Indigenous prisoners, which has important implications for treatment interventions (Victoria Department of Justice, 2003). Moreover, the mental health needs of Indigenous women prisoners remains a largely underresearched area (Butler, Allnutt, Kariminia, & Cain, 2007) and concern has been expressed regarding the cultural sensitivity of previous studies (see Butler et al., 2007; Heffernan, Andersen, & Kinner, 2009). One culturally sensitive Queensland study of incarcerated Indigenous individuals identified a very high prevalence of mental illness (86.1%) and a high rate of comorbid mental health conditions (Heffernan, Andersen, Dev, & Kinner, 2012). These findings are particularly concerning in light of the overrepresentation of Indigenous women in Australian prisons.
Other specific subpopulations of incarcerated women also present unique health needs due to their “minority-within-a-minority” status in prison. These subpopulations include pregnant women (Hutchinson, Moore, Propper, & Mariaskin, 2008; Williams & Schulte-Day, 2006), women from non-English speaking backgrounds (Easteal, 1992, 1993), and older women (Baidawi et al., 2011; Harris, Hek, & Condon, 2007). Research examining the health of aging prisoners in Australia has been identified as a priority area (Baidawi et al., 2011). Older prisoners may have special requirements related to physical problems and limitations (Bartels & Gaffney, 2011). Due to life events prior to imprisonment, limited access to medical care, and the prison environment itself, incarcerated individuals are 10 years older “health-wise” compared with individuals in the community (Baidawi et al., 2011; Reviere & Young, 2004). Consequently, prisoners are at risk of early onset of age-related declines in physical and mental health (Baidawi et al., 2011). Comorbidity of chronic disease is high among aging prisoners (Deaton, Aday, & Wahidin, 2009), and they present unique psychological issues (Dawes, 2009; Deaton et al., 2009).
Responsibility for Health Care in Prisons
The concept of the “right to health” has been a guiding principle in developments in prison health care internationally (Exworthy, Samele, Urquía, & Forrester, 2012). The right to health is a fundamental human right, identified in the 1966 United Nations (UN) International Covenant on Economic, Social, and Cultural Rights. Specifically, the UN defines the right to health as the highest attainable standard of health for every person, and outlines the Available, Accessible, Acceptable, and Quality (AAAQ) framework as a paradigm to assess the attainment of this right. The AAAQ framework states that health care should be available, accessible, acceptable, and of good quality. Exworthy et al. (2011) propose this framework to examine provision of prison health care, and outline a number of indicators to assess the achievement of the AAAQ framework within this context. Thus, health care services should be sufficiently available and operated by properly trained health professionals to protect prisoners’ health. Accessibility is determined by the physical and geographical availability of services within a good timescale (including hospital care), that services are economically accessible to users, offer relevant information and choice, and are accessible to all without discrimination, including marginalised groups. Acceptability depends on whether prison health services meet a good standard of cultural and ethical acceptability, including the provision of individualised care. Good quality is determined by whether the environment is appropriate (minimal standards of accommodation, nutrition, and sanitation), whether the health service is clinically safe and effective, whether medical equipment is of a suitable standard, and whether modern and appropriate medicines are provided.
The tension inherent in meeting standards such as these in a prison context was identified by Sim in 1990. This tension is seen in issues such as medical power over inmate patients being used to legitimise the role of the imprisoning state, and the problem of prisoners being perceived as having “less eligibility” and right to health care. To address concerns such as these, a trend away from prison provision of health services has occurred and current international and national best practice suggests that these requirements are best met by health authorities rather than corrective services. Specifically, it is argued that when prison health care is the responsibility of health authorities, stronger linkages between prison and community health services may be fostered, benchmarking with wider health strategies and public health standards is enabled, professional isolation of prison health staff may be reduced, and potential conflicts of interest between health concerns and security imperatives are minimised (WHO, 2010, cited in Australian Medical Association, 2012). In Queensland, responsibility for provision of health care to prisoners was transferred from QCS to QH in July 2008 (AIHW, 2011). Since then, QH-provided services in correctional facilities include primary services via the Offender Health Services Unit (OHSU), secondary and tertiary services through public hospitals and other units, and mental health services through the Forensic Mental Health Service, except in South East Queensland where services are provided by Prison Mental Health Services (AIHW, 2011).
Given the argued benefits of health rather than correctional services providing care in prisons, it could be expected that the transition of responsibility of prison health care in Queensland would have resulted in improved care for prisoners, especially after some 4 years had elapsed. However, since the transfer to QH, no analysis of health care in Queensland prisons has been conducted to assess the changes, if any, in health care provision as experienced by women prisoners. In addition, although increasing research is focused on the health needs of prisoners, few studies have assessed whether services are available, accessible, and appropriate (within the AAAQ framework) to meet these needs. This preliminary study aims to gain insight into the health needs of female prisoners in Queensland, and the current services and structures in place to meet these needs. To achieve these aims, the article explores the perceptions of key stakeholders as to whether any improvements in the health care provided to female prisoners has flowed from the transfer to QH and to identify any areas of continuing unmet need and barriers to improvements.
Method
The focus of this initial exploratory research is on understanding the services provided in Queensland women’s prisons and perceptions of any gaps or unmet needs. It has been noted that obtaining information about prison services is notoriously difficult due to issues of privatisation, lack of routine computerised data collection and recording, and, some authors have argued, a culture of secrecy in prisons. For example, medical information on inmates may only be collected in paper form (Anderson, 2003). In Queensland, the Office of the Chief Inspector was introduced in 2005 to conduct “healthy prisons” inspections and produce reports. However, the first publically available reports on Queensland women’s prisons were only produced in 2010. Thus, the only method to gain information on the shift in health service provision, which occurred in 2008, was through interviews with key stakeholders who were present during the transition in services. Although there are some limitations in using an interview method to examine an event that occurred a number of years earlier, given the paucity of prior research, in-depth interviews with key stakeholders enabled us to gain insight into the needs of women prisoners from informed perspectives. The interviews for the current study were conducted from February to May of 2013. Future stages of the project will involve interviews directly with incarcerated women and an analysis of official data regarding service provision. This study used qualitative interviews with stakeholders who have an interest in incarceration practices and health care to conduct a needs-gap analysis of female prisoner health care in Queensland. The study also aims to overcome the limitations of previous research and surveys of women’s health in Australian prisons by examining the health needs of specific subpopulations within women’s prisons. 1
Participants
A purposive sample of nine key stakeholders was identified on the basis of their knowledge of, or involvement in, health care delivery in women’s prisons in Queensland. Stakeholders were approached and were invited to be interviewed for the purpose of the current research study. The final sample included stakeholders from a range of organisations including an independent counselling service, QH (clinical nursing staff working in the Offender Health Services), QCS (psychologists and counsellors), and Prison Mental Health Services. These participants all have current, expert knowledge about the research area gained from their daily professional activities. In addition, most have worked in Queensland prisons for considerable periods, so were also able to give insights on the 2008 transfer of services.
Participants were invited to take part in a telephone interview, all conducted by the same research assistant. Based on themes identified from the existing literature, respondents were asked to comment on areas such as the existing health needs of women in prison and how these health needs were currently addressed, areas of health that they perceived as not being addressed, and the impact of the change in service provision in 2008. Of particular relevance were questions asking about unmet health needs, which allow a needs-gap analysis to be performed. Participants were not only prompted to respond about known vulnerable groups, such as Indigenous women and older prisoners, but also had opportunities to raise any unidentified issues. Consistent with the in-depth interviewing method, participants were encouraged to expand on each topic throughout the interviews. Interviews ranged from 30 min to 75 min duration, and extensive notes were taken during each interview to provide a verbatim transcript for coding and analytical purposes.
Data Analysis
Interpretive thematic analysis is a foundational method for qualitative research and involves “identifying, analysing and reporting patterns (themes) within the data” (Braun & Clarke, 2006, p. 79). Thematic analysis involves the researchers reading and rereading each verbatim transcript to make sense of the interview data (Liamputtong, 2013). Then, the data are examined as part of a collective set. This enables the researchers to make sense of what is being said by the respondents as a group (Minichiello, Aroni, & Hays, 2008). Thematic analysis involves “searching across a dataset in order to find repeated patterns of meaning” (Braun & Clarke, 2006, p. 86). Once the researchers have examined the dataset as a collective, initial and axial coding is performed to “deconstruct data, put them into codes, and find links between them” (Liamputtong, 2013, p. 250). This method allows the researchers to organise the data and to make links between major categories and subcategories and to find themes in the data.
In the current study, the interview transcripts were read and reread by the researchers to ensure goodness of fit between the data and the identification of themes. In this process, three key themes emerged around (a) equivalence of care, (b) the prisoner as patient and the inherent contradictions between health care and disciplinary control, and (c) the experience of moving prison health care out of the jurisdiction of QCS and into QH, thus integrating prison health services with public health services.
Findings
Equivalence of Care
While it is widely recognised that prisoners often present with complex and multiple health needs, much greater than those found in the general population, much of the debate around prison health care provision centres on questions of equivalence and the principle of equity. Here, there is increasing consensus, both nationally and internationally, that prison health services should be “equivalent” to those of the community (Ross, 2013). Prison health services, however, operate under many constraints and respondents were quick to highlight the difficulties of providing “equivalent care” in women’s prisons, where physical and mental health problems far outweigh those in the general community: If you compared them [women in prison] with women in the general population, they’ve got 25 things wrong with them at the same age when a woman in the general population may have one or two. It’s the nature of the lifestyles that they lead which ends up with them getting incarcerated that generally speaks to that—the drugs, the violence, they’re not taking care of themselves . . . So, because of that, they are often much sicker and require much more assistance than someone in their own age bracket normally would. (Interviewee 2) I guess in general you’re seeing a population from an overall lower socioeconomic status, with less access to health services, less inclined to access health services in the community. So, in general, the population, if you compared it to the community population, would definitely have some health concerns. (Interviewee 9) Prisoners basically have substantially more health needs than people in the community, but I think, I don’t know if anyone has done this, but if you look at the availability of primary, secondary and tertiary hours available to prisoners, it would be substantially less than is available to the general community. (Interviewee 1)
The higher levels of complex health needs for women prisoners identified in the current study are consistent with research on women’s health in prisons both internationally and in Australia (ADCQ, 2006; Fazel & Baillargeon, 2011; Staton, Leukefeld, & Webster, 2003). The quality of health care for incarcerated women has been the subject of intense criticism, specifically in relation to prisoners being “less eligible” to receive quality health care (see, for example, Carlen & Worrall, 2004; Maeve, 1999; Sim, 1990; Smith, 2000; Wilson & Leasure, 1991). However, there was not a sense in the current study that the quality of services in women’s prisons in Queensland was poor per se. Rather, it seems that demand for services far outstrips the supply: There’s a methadone program and there’s also another program that’s available, but its numbers are capped at 12 and if you’ve got a prison population of 300, 12 is a very insignificant proportion who will have serious addiction problems. (Interviewee 1) I think the services we have are good but I just think the frequency of visits of those services, coupled with the needs of people who require them, are probably not sufficient. So, that comes down to funding. (Interviewee 8)
In the respondents’ accounts, the key barrier to the provision of equivalent care was most often linked to a lack of resources and, in particular, a lack of staff: We only have four doctors. You know we’ve only got 18 hours of doctors in here per week, so we have to spread our resources appropriately. (Interviewee 3) We currently don’t have any Hep C treatment and that’s all about not having sufficient staff to be able to run it. (Interviewee 2) There’s a lot of stuff that the nursing staff could provide but we can’t because of staffing. We literally don’t have the staff. (Interviewee 6)
Prison health personnel complained they could only offer reactive rather than proactive care: We address the immediate need but not the whole complexity of the situation that the females come in with. That’s our main limitation, time and resources. (Interviewee 3) Mental health issues aren’t really addressed properly. It’s like a Band-Aid approach. Risk management, you know? If something happens then we respond. (Interviewee 4) We’re reactive nursing and reactive medicine rather than proactive. (Interviewee 6)
Health care provision to prisoners has been criticised internationally for providing access to health services to only a small proportion of prisoners during the duration of prisoner incarceration (Staton et al., 2003; Wilper et al., 2009). In addition, prison mental health facilities have been criticised for restricting access to prisoners suffering acute disorders and considered at risk of harm to themselves or others, and not providing ongoing treatment and support (Alexander et al., 2010; ADCQ, 2006). Prisoners may return to their communities with their physical or psychiatric conditions having been untreated or worsened during their period of incarceration (Fazel & Baillargeon, 2011).
The inability to be proactive seems to be exacerbated by decreases in staffing and cuts to health care services: And at the moment, everything’s all up in the air because we’re all about to lose our job, because they’re doing a spill where everyone loses their job and has to reapply. We’ve got 12 full-time clinical nurses and are going down to four, four registered nurses and four ENs [Enrolled Nurse]. So that’s not looking good. (Interviewee 3) About three or four months ago, we lost our night duty, simply because of staff. We were using an astronomical amount of agency staff throughout the whole 24 hour period [and then] they decided to minimise our agency use and took away the nights and used the people who were working nights to fill shifts during the day. So, we haven’t had a night duty for at least about three months. (Interviewee 6)
Decreases in funding or staffing of health services is inconsistent with WHO guidelines regarding prison health care quality, which state that governments should provide prisoners with the best possible health care, even in times of substantial economic difficulty (WHO, 2007).
Respondents reflected on the complex health needs of Indigenous women and on the ways in which cultural and linguistic factors complicate the pathways to effective treatment and care: There’s certainly Aboriginal women who are usually in jail for very minor charges and very often have a history of violence, trauma and abuse and being removed from their own family. They have a fairly high incidence of diabetes, very high incidence of addiction problems, quite a bit of chronic heart disease. There seems to be increasing amounts of diabetes. (Interviewee 1) Addiction, sexual health, their general well-being. Because when they come in here, you get them very, very healthy. But when they leave they just get very, very sick again. We have a few cases of HIV. We have a lot of cases of Hep C, that’s from sharing needles. We have a lot of sexually transmitted disease, because that’s a lack of understanding with our Indigenous clients . . . so there’s quite a complex range of problems here, especially with the Indigenous with the diabetes. (Interviewee 3) Yep, language barriers, we still have interpreters and so on but that only gets you so far. Cultural barriers and we see . . . with our Aboriginal girls . . . over a period of time they get to know that it’s OK to talk to us. But initially we won’t get much out of them because culturally that’s not cool. So, we’ve got those sort of barriers. (Interviewee 2)
Similarly, access to health and other services can be hindered by a number of barriers for foreign national and non-English speaking women: We’re seeing more women from other places, Sudanese ladies and that, that’s a little less familiar to us and then we’ve got the language stuff. I mean we’ve got them in here from all over the world. So we see many different nationalities and cultures. We’ve got a lady here who’s Muslim and that, itself, is not a problem, but for things like when she’s doing Ramadan actually with the medication because she’s only allowed to partake in sustenance once a day, so then we’ve got to change all the medication up to the evening and have to change all the med charts around and people don’t understand that. The doctors don’t want to do it because the efficacy of the medication is not there when giving it in one dose. It’s all that sort of stuff that causes issues at times. (Interviewee 2) Another barrier may be there are some offenders that have poor command of English. So, because they have a poor command of English, they probably don’t request help as often as they probably should, or they rely on other people interpreting on their behalf, which can cause confusion. (Interviewee 8)
Other subgroups within the female prison population were also identified as causes for concern. For instance, respondents were quick to highlight the insufficient and/or inappropriate services for older women and for pregnant women prisoners: For older female prisoners, well, once they start to come to the point where they’re losing their ability to self-care, at this point in time there is no process in place. We’ve been lucky so far because we haven’t had anyone who has been to the point where they’ve had to be bedridden for any period of time but that day will come. I mean they’re getting older as we speak, so at some point I’m going to have to deal with that. And I don’t have any funding, and I don’t have any interface between Corrective Services and Queensland Health, despite my best efforts to do so, to get them starting to think about perhaps we need to be thinking about setting up a unit within residential that can accommodate this type of prisoner. Or where do we put them, what do we do, what sort of funding do we need to change the infrastructure? Those are the kind of conversations that need to be had. (Interviewee 2) Childbirth is a pretty terrible process if you’re a prisoner. You get taken away from prison to X hospital usually and if there isn’t a mothers and babies place available, which almost always there isn’t, you’ll be sent back to prison without the baby, who’ll be taken into care unless you’ve got family or other arrangements can be made. But, very often, the child is taken directly from the hospital and into care and it’s very difficult for the mother to get that child back ever. (Interviewee 1) In terms of these women, by the nature of why they are here, are not particularly into looking after their health when they’re out of here. So, they usually come in sicker, they usually come in pregnant with no natal care, or very limited. They have less knowledge, they’re not as informed as the general public in terms of good choices while they are pregnant, in terms of drugs, alcohol. So, the fact that they’ve halved our midwifery clinic is concerning. (Interviewee 2)
For older women, needs identified in the current study, including decreased ability to self-care, chronic health conditions, and long-term pain management, are consistent with research on aging prisoner health needs (Baidawi et al., 2011; Deaton et al., 2009). Previous research has identified both older women prisoners and pregnant prisoners as having been neglected in research due to their “minority-within-a-minority” status in prison. The findings confirm the unique health needs of these populations and the need for specialist health services within the prison environment.
Finally, respondents also commented on a lack of services/resources for women serving short prison sentences and women prisoners with mental health problems and/or addictions: They have problems but can’t access appropriate counselling. There’s no alcohol, tobacco or other drug counsellor, no CBT or anything like that . . . For something like dentures, they’ve got to be held in custody for a minimum of 18 months or sentenced to a period longer than 18 months to be able to access that service. For the optometrist, that period is six months. So, it depends on what it is you’re seeking as to how long you have to be serving to access certain things . . . For anxiety, Prison Mental Health will deal with you if you are extremely mad, extremely depressed . . . If you don’t fall into that category, you don’t meet the category to be seen because they don’t have that many clinicians. (Interviewee 2) For prisoners to see Prison Mental Health, the wait list is, like, months. They might come in, put in a request form to see them, and be released before they even see Prison Mental Health. That’s a big issue there. (Interviewee 4)
The findings of this study indicated that some groups of women were particularly disadvantaged, specifically, women on short sentences and those with mental health problems and/or addictions. Stakeholders reported that these women were unlikely to access appropriate health services within prison due to eligibility requirements (e.g., only able to access some services if serving sentences of sufficient length) or lengthy waiting lists for services. This approach relies on women to seek alternative appropriate health care in a timely manner in the community on their release. Moreover, the findings indicated that follow-up of women’s health care in the community after their release was poor. Previous research on women prisoners has indicated that prior to incarceration, they are most likely to suffer from complex health needs yet are least likely to seek treatment for these (AIHW, 2011). Thus, the opportunity for addressing the health needs of this hard to reach population while incarcerated is missed.
The Woman Prisoner as Patient
The implementation of the principle of equivalent care in prison health is likely to be further complicated by the position of health care vis-à-vis the prison (Carlen & Worrall, 2004; Sim, 1990; Smith, 2000). Here, we can also see the role of health care staff as “gatekeepers” to the system: I think the challenge that we have in this context is purely the context that we work within. If you go into a health care centre and go to the desk and make an appointment and go and wait in the waiting room, you’ll essentially get seen by a doctor or a nurse, depending on what your issue is. In this context, if they want to see a nurse or one of the other service providers, be it a dentist, optometrist or so forth, they need to fill out a medical request. Those medical requests are then vetted by the clinical nurses or staff. (Interviewee 8) Only people who need to see the doctor get to see the doctor. It’s not like a doctor’s surgery. You don’t get triage before you go to a doctor’s surgery. Here we have to because of the resources we have. (Interviewee 3) If a woman is distressed, she can go through the process of going to the nurse and saying I need to see someone. The nurse may refer her to the prison mental health. Prison mental health will come out and do an assessment and decide whether or not she needs to be referred to the psychiatrist. There’s one psychiatrist covering all of the prisons in South East Queensland, so access to that particular intervention is very limited. That’s why people often have to wait until they get out. (Interviewee 1)
This “gatekeeping” process also serves as an additional barrier to treatment for vulnerable populations such as Indigenous women or non-English speaking prisoners who may have difficulty communicating their health concerns into medical terminology. This process not only contravenes the principle of equivalence but also the principles of accessibility and acceptability of the UN AAAQ framework with regard to prisoner health care. Indigenous women, in particular, are doubly marginalised—they suffer from much poorer health and prior access to services before entering the prison system and once in prison, cultural and language issues were reported as further barriers to health care access beyond those experienced by the general women prisoner population. There is some research to indicate that Indigenous offenders make greater use of health services during incarceration than in the community (Kariminia, Butler, & Levi, 2007). By facilitating Indigenous women to overcome the reported language and cultural barriers, it may allow even greater utilisation of the health services offered during incarceration and potentially improve the health needs of this typically underserved population. However, the provision of the health care to Indigenous women in prison is a contentious issue as the experience of prison in itself is traumatic for Indigenous women (Krieg, 2006). Respondents articulated clearly the hurdles to accessing care in a timely manner: It would probably be quicker for me to go to University and become a podiatrist than it would be for me to get someone through the [waiting] list. So, it’s those sorts of things, accessing things like that, that are going to be problematic. Even our diabetics, and some of our diabetics are quite young, but even getting them on a list for things like that is quite difficult . . . Other barriers in terms of access to simple things such as you can’t get a pair of crutches and leave them out the back until the next person twists their ankle and needs to be on crutches for three days . . . We have women who have been in a wheelchair for three days because you can get them into a wheelchair and they’ll be back hobbling around by themselves far quicker than you would ever get them to the [hospital] for a pair of crutches. (Interviewee 3)
As well as discussing the problems of accessing health care in prison, the respondents in this study highlighted the inherent incompatibility of providing care in conditions that are punitive and often humiliating for women prisoners: Corrective services do have a psychologist and counsellor on board and we do refer them across to there. But, the problem with that is that QCS’s matrix is about secure containment and the safety and security of the centre. So, if you were talking about your drug use, you would, once you get to a point of being comfortable with the person who is your counsellor, yeah, when I say to you “have you used in the past 24 hours,” you’d look me in the eye and go “yeah, yeah, I got on last night and used one quarter of an eighth” or “look, I had some pot this morning before I came to see you.” You’d be honest and tell me that, so I know what I’m dealing with. They don’t say that to QCS, because they can’t. They’re going to get drug tested, they’ll get breached, they’ll get tossed back to secure or whatever. You know, they end up in a world of hurt because the QCS have a responsibility to report that stuff back. So, there can’t be a true therapeutic relationship there based on the conflicting elements of their role. (Interviewee 2)
The same respondent continues, A lot of women will refuse to go out for treatment because they have to go out in very uncomfortable paddy wagons. I don’t know if you’ve ever sat in a SV transport, they are very uncomfortable. If the guys take a corner at any sort of angle, you get tossed. And there are no seat belts. So, if you’re not particularly able bodied or you’re unwell with a legitimate ailment and you are being transported to hospital to be seen about it, you quite often end up in a worse shape than when you left here. So, that’s the first problem. A lot of them refuse to go because of the transport. The other problem is that they quite often refuse to go because they can be gone all day and not able to access a cigarette . . . Having to get strip searched and the rest of it doesn’t help a hell of a lot either. Some of the girls will say “you know what, it’s not that bloody important. I’ll get it seen to when I leave.” (Interviewee 2)
Thus, security procedures (such as searches) can prohibit help-seeking and have the potential to further traumatise vulnerable women, especially those with histories of abuse, as is the case with many women prisoners: [Strip-searching] exacerbates the very high incidence of trauma as a consequence of sexual assault and abuse. Research suggests that 92% of women [prisoners] identify as being sexually assaulted or sexually abused on an ongoing basis, and everyone else was a victim of violence of some sort. So, the strip-searching actually exacerbates a lot of their existing problems. (Interviewee 1)
Carlen (2002) argues that imprisonment regimes that are universally applied to both men and women can have differential impact, with women experiencing more pain from these processes than men (e.g., strip-searches). Moreover, women’s health needs are more complex than men’s and hence women will experience more problems in relation to having their needs met while incarcerated (Carlen & Worrall, 2004). These findings reinforce the importance of women-specific policies in relation to prisoner health care.
Prisons are not primarily concerned with health and prioritisation of security and discipline can overshadow the perception of prisoners as patients (Sim, 1990; Watson, Stimpson, & Hostick, 2004). The boundaries between correctional and health staff are also blurred through practices such as the elimination of health staff after hours, requiring prisoners to convince correctional staff (without medical training) of the serious nature of their health concerns to obtain assistance. Similar issues in relation to the conflict between health care and correctional goals have been identified in multiple studies (e.g., Condon et al., 2007; Wolf, Silva, Knight, & Javdani, 2007).
How a woman is (security) classified also has an impact on her access to services. One respondent discussed the particular problems of providing care to women in protection: It can be very frustrating for that particular group of women to get seen in a timely manner purely because of the nature of how they are classified and the challenges we face in getting access to them. (Interviewee 8)
At the end of the day, prisons are not primarily in the business of promoting health (Ross, 2013). In the following excerpts we can see the contradictory aims between health and security: So it may well be problematic that you could be trying to access a prisoner for three days in a row, purely because of the lack of custodial staff to facilitate these moves, then we can’t get access to them. So that’s a challenge and probably a barrier. (Interviewee 8) The psychologists that are employed by the prison service are there for assessment, not treatment . . . [they] don’t have treatment as their primary function . . . You know the focus of prison is on incarceration not on addressing things . . . [The women] don’t have a comprehensive health assessment but they do get tested for things that could cause problems for the prison. (Interviewee 1) I guess the difficulty when you’re looking from a mental health perspectives of mental health issues is that obviously a prison environment is not set up like a hospital environment. So, when there are patients that are acutely unwell, where they need hospitalisation, there can sometimes be a delay in getting them to hospital, just based on resources and access to hospital beds, which means for that waiting period of time they’re in an environment that’s not the best. (Interviewee 9)
Under a correctional model of health (as before the shift in provision), the commitment to health care provision may also be complicated by the fact that prison health personnel are responsible not only for providing general medical care to prisoners but also for implementing prison rules (Sim, 1990). The contradictory nature of this dual role is evident. Whether it be the protection of confidentiality, for example, or the enforcement of security procedures, the core problem is always this duality; prison influences the way that health services are provided and their effects on prisoners are also modified by the prison (Tomasevski, 1992). Sim (1990) described this issue as medical knowledge being deprioritised in favour of order, security, discipline and classification. Respondents reflecting on the situation prior to transition highlighted this: The problem was that they [QCS] weren’t employing the [nurses] appropriately and they had them acting outside their scope consistently. Because of the environment, a nurse could not stand her ground and say, no I will not do that because I can’t. They would be ordered to and would lose their job if they couldn’t. (Interviewee 2) Back in those days, Corrective Services thought they had the right to everything including the medical files. And I’m not talking out of school, it’s only because they didn’t understand health and health management, and also because they were paying the nurses they thought they had control of the nursing staff. You know, you’re working for us kind of thing and there was an expectation that we would do as we were told. (Interviewee 8)
Integrating Prison Health Services With Public Health Services
Whatever the rationale for the shift in provision of health care in Queensland and the integration of prison health services with public health services, questions about the experience of the process of transfer elicited varying and conflicting responses: To be completely honest, it hasn’t improved by a lot because staffing is still an issue. There isn’t enough of us to go around. (Interviewee 2) Prison culture is so strong and so pervasive that it seems to captivate anybody who gets into it, so there seems to have been very little change. (Interviewee 1) Mass confusion . . . just policies and procedures, who is running who. (Interviewee 3) Now, we run as two separate entities and there’s very strict legislation guidelines, that we are bound by and we follow those. (Interviewee 8) It’s extensively improved . . . when we were in Corrective Services before we couldn’t do it. But now we’re in health we can push the limits a long way and provide a lot better service and a lot more confidentiality is achieved because we’re not Corrective Service officers. We don’t have to answer to them. There’s a clear line between what we do and what they do, and they don’t need to know, which is normal for health. (Interviewee 3)
Respondents described the process of change and the obstacles to the successful integration of prison and public health services. In particular, fundamental conflicts of interest and differences in philosophy between QCS and QH were cited as key barriers to success: It’s just because there are two government agencies working in one area. We’re a small government agency working in a bigger area, so it’s just the understanding that health is health and security is security. That’s the big thing, we only do health, we don’t worry about security, but they worry about security but they try to worry about health too. It’s just dealing with people who can’t get their heads around, you know, prisoners actually do need health care. That’s the big thing. (Interviewee 3)
Here, we can see the central conflict between health and prison cultures and between two groups with very different professional views. This is further complicated by the fact that QH cannot function independently from QCS. The prison environment prohibits QH from functioning as it does in the community: We have no access to Queensland Health emails, their QEP system, we have no internal intranet that everyone in Queensland Health has, we don’t have access to that whatsoever. It makes it very hard to be compliant with the way things are done across the state . . . we can’t get the internal site which is where all the clinical decisions and clinical pathways and all that stuff are—which would be good for us. (Interviewee 3) We actually don’t have a computerised treatment system. Ours is manual. We sit on the QCS server so we can’t access Queensland Health stuff. (Interviewee 2)
This brings us back to the concept of equivalence discussed earlier. It seems that, for many prison health staff, prison remains a separate health site and, while continuity of care between prison and the community is a key argument for the integration of prison and public health services, respondents highlighted a lack of “joined-up care”: And they may come in on a specific medication that we don’t supply in here because it’s not considered part of the LAM (List of Approved Medicines) List, so LAM is the approved medications within Queensland Health. And if it doesn’t fall in the LAM List, it’s cost prohibitive so they get taken off it and either put on an alternative or reduced off it in some fashion so they’re no longer on that medication . . . There is no computer system I can tell you that now. There is no tracking system in our jail or any that I know of that tracks health . . . So, we’re relying on the medical charts and on the offenders being fairly reasonable historians. If they’re not telling us stuff, we don’t know. (Interviewee 8) We get them sometimes in an awful state, manage to get them to a liveable level, and then there’s no kind of follow up. (Interviewee 6) The woman has a diagnosis before she goes to prison, we always recommend that they take a letter from their doctor and their scripts and any current medication that they have and present that as they are going through the reception process. However, what frequently happens is that all of that is just put into their property to be picked up when they leave prison. (Interviewee 1)
Conclusion
Both nationally and internationally, the transfer of prisoner health care provision from corrections to health authorities has been promoted with the intent of enabling improved linkages with the community, benchmarking with wider public health standards, reducing isolation of professional staff, and reducing conflicts of interest between health and security. With regard to the impact of this transition of responsibility for prison health care provision from QCS to QH in 2008, the findings of the current study indicated that many of these benefits have not transpired. Specifically, stakeholders identified a number of barriers that prevented the provision of health care to prisoners at a level equivalent to that which they would receive in the community. These barriers included conflicting priorities between health care and correctional staff, difficulties in providing health care within the constraints of a correctional setting, limited health resources and staffing, and disconnection from information sources and record keeping facilities available to nonprison QH staff. The themes that emerged from the current study (equivalence of care, the prisoner as a patient and the resulting contradictions between health care and disciplinary control, and the experience of the change in health care responsibility from QCS to QH) were similar to those that emerged in a stakeholder study of incarcerated women in California (USA), where prison health services were provided by the correctional facility (Wolf et al., 2007), and to some degree, echo long-standing criticisms of prisoner health care (e.g., Sim, 1990).
Thus, the findings suggest that despite the changeover in prison health care provision responsibility in Queensland, a number of cultural and pragmatic barriers remain, which may have hindered the full benefits potentially available as a result of health care provision to prisoners by QH professionals. These barriers appear to limit opportunities for prison health care staff to address the accumulated health problems of women prisoners. These deficits in health care provision in women’s prisons have flow-on effects beyond the immediate impacts on physical and mental health. Minimising physical and mental health concerns of women prisoners has a number of potential benefits including allowing women prisoners to more easily integrate into family and employment on release (Wilper et al., 2009) and, by addressing underlying issues, help reduce their likelihood of recidivism (Anthony & McFadyen, 2005; Forsythe & Adams, 2009). Moreover, failure to address issues such as substance abuse in prison contributes to future crime and parole violations (Wolf et al., 2007).
While the current study addresses an important area of prisoner treatment and health provision, it is subject to a number of limitations. Specifically, the study used a small sample of stakeholders and retrospective interviews rather than utilising a pre–post design. The research would have been further enhanced by inmate interviews, and interviews of an inmate sample are intended for a future study. The research may also have limited generalizability due to the data being obtained from one correctional jurisdiction; however, the findings of the current study highlight a number of important issues with respect to health care governance in corrections. These issues may be applicable to other jurisdictions in relation to making improvements in health care provision or developing guidelines for best practice.
*Further research is needed examining patient satisfaction with health care service provision in women’s prisons. Previous research in other countries has identified a range of issues through prisoner surveys of health care. A U.K. study identified issues of access, being seen as a legitimate patient, confidentiality, conflict between the prison regime and health care, and lack of autonomy as factors identified by prisoners as barriers to fully meeting their health needs (Condon et al., 2007). In the United States, prisoner surveys have also identified high levels of physical and mental health needs, which are not adequately treated during incarceration, highlighting the need for improved health care both during imprisonment and in the community (Wilper et al., 2009). The findings of the current study have been discussed with regard to provision of health care within the prison environment. However, given the nature of women’s crimes and short sentences, and the challenges of providing adequate health care in prison, it is acknowledged that alternative approaches may be necessary to address the health needs of women offenders (e.g., diversion and treatment in the community).
The major implications from this study are first that the mere transfer of responsibility from one government agency to another does not necessarily effect a transformation in service provision. Our findings show that although some informants saw an improvement in the role conflict that existed when health staff worked for corrections rather than health authorities, many other problems persisted. In addition, the transfer led to some fragmentation and shifting in responsibility between agencies. Second, the findings indicate that within the AAAQ and Healthy Prison frameworks, problems of equivalence of care, accessibility, and acceptability persist regardless of who provides the services. This suggests that these problems are deeper and more entrenched than the issue of which agency has responsibility. Improving health care provision to prisoners is primarily a question of more resources, more fundamental structural changes within prison environments, and recognition of the long-term benefits that can be achieved.
Furthermore, we have shown that female prisoners have very specific needs meriting specific policies and that this need extends even further to important subgroups such as Indigenous women, older women, and mothers in prison. Additional research is needed to tease out these findings and to suggest more specific reforms to improve policy and practice in this area. Women in prison represent a highly vulnerable population due to histories of victimisation and at-risk behaviours, and a range of physical and psychological health issues. Providing adequate health care in prison offers potential benefits for the overall well-being of the women themselves, their families, and the wider community.
Footnotes
Acknowledgements
The authors thank the participants in this study for generously helping them in this research. They also thank the Queensland Department of Corrections and Queensland Health Services.
Authors’ Note
Please note that the views expressed herein are solely those of the authors and do not necessarily reflect the views or policies of Queensland Corrective Services or Queensland Health Services.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.