Aging Prisoners’ Views on Healthcare Services in Swiss Prisons

Abstract

Objective: Due to the higher morbidity prevalent in the increasing older population, prisons are facing new challenges on a structural, ethical, and financial level. This study’s goal was to explore older prisoners’ views and experiences regarding the quality of medical services. Method: In this qualitative study, 35 semi-structured interviews were conducted with older inmates aged 50 years and above in 12 different prisons in the German-speaking (23 interviews) and the French-speaking parts (12 interviews) of Switzerland. Results: The majority of older prisoners in this sample expressed concerns about quality of treatment throughout incarceration. Topics addressed reached from quality of the entrance to routine examinations, quality of the treatment received, and delays in care and services provided. Conclusion: This study’s findings suggest that healthcare in prison is often perceived as insufficient and inadequate by older inmates.

Keywords

aging detainees prison healthcare inmates rights principle of equivalence of care

Introduction

Although aging inmates constitute a small percentage—only 13.9% are aged 50 and older (Bundesamt für Statistik, 2016)—of the prison population in Switzerland, their number has been steadily rising during the last few decades. The number of Swiss prisoners aged 50 years and above increased from 212 in 1984 to 690 in 2015 (Bundesamt für Statistik, 2016). This tendency is very likely to continue in the future and is paralleled by a comparable trend worldwide, which has been emphasized by many studies, as outlined in Loeb and Abudagga’s literature review (2006). This development is attributable particularly to changes in sentencing practices toward harsher and longer sentences (Clear & Frost, 2013; Colsher, Wallace, Loeffelholz, & Sales, 1992; Ginn, 2012). In Switzerland, there has also been an evolution toward more restrictive sentence practices. Specifically, indeterminate sentences represent the main reason for the rising number of older inmates (Baumeister & Keller, 2011). Furthermore, the increasing number of older inmates reflects the demographic shift toward population aging detected in the general population (Birg, 2001; Bourgeois-Pichat, 1981).

It is assumed that the physiological aging process is accelerated among prisoners (Collins & Bird, 2007), resulting in a biological age 10 to 15 years higher than their actual age. This means that the health of prison inmates corresponds to that of people at least 10 years older living outside prison (Loeb, Steffensmeier, & Lawrence, 2008), which has led many authors to use 50 as the minimum age to define an “older prisoner” (Handtke & Wangmo, 2014; Kuhlmann & Ruddell, 2005; Loeb & Abudagga, 2006). Furthermore, this acceleration of health decline has been described to be proportional to the duration of incarceration (Loeb & Abudagga, 2006).

The rates of occurrence of both somatic and mental diseases are generally higher in prisoners than in the community-based population (Fazel, Hope, O’Donnell, Piper, & Jacoby, 2001; Lindquist & Lindquist, 1999), and the most frequent issues encountered in prison healthcare include communicable diseases, mental disorders, substance abuse (Watson, Stimpson, & Hostick, 2004), and chronic conditions (Colsher et al., 1992). As summarized by Lindquist and Lindquist (1999), the disproportionally high level of morbidity in prison can be traced back to competing explanations. They name factors such as the high prevalence of prisoners originating from socioeconomically disadvantaged conditions associated with an unhealthy lifestyle prior to incarceration, risks associated with the prison environment, and its health-threatening stressors.

Within the prison population, those who are older are known to have a particularly elevated level of disease prevalence (Loeb & Abudagga, 2006). Fazel et al. (2001) compared older prisoners’ health with that of both younger inmates and members of the general population of similar age, and reported older inmates’ health conditions to be vastly inferior. Furthermore, illnesses were often found to either remain undetected or inadequately treated (Collins & Bird, 2007). Older inmates appeared to particularly suffer from chronic health conditions (Loeb et al., 2008), generally including three or more comorbidities (Loeb & Abudagga, 2006), meaning that the majority (an estimated 85%) of older inmates was referred to as suffering from multipathology (Watson et al., 2004). Wangmo et al. (2014) compared somatic disease data of older and younger prisoners in Swiss prisons and identified older prisoners suffering from an average of 4.27 diseases, while younger prisoners suffered on average from only 1.62 diseases.

In summary, these factors point to the fact that older prisoners represent a particularly disadvantaged and therefore vulnerable group. This is supported by previous studies agreeing that female and older prisoners have needs that differ from those of other prisoners (Watson et al., 2004), necessitating particular care and attention. In many Western countries, particularly in Europe, healthcare standards in correctional institutions are based on the principle of equivalence of care (Recommendation No. R. (98) 7 of the Council of Europe, 1998), which requires prisons to provide healthcare at a level equivalent to that available to the population outside prison. Nonetheless, the aim of achieving equivalent care raises some difficulties. For instance, efforts to provide adequate healthcare must be aligned with the necessary level of security in the correctional setting. A study conducted by White, Jordens, and Kerridge (2014) discussed the influence of prison structure on the role of healthcare practitioners. Personal security concerns of practitioners, such as the perception of the risks derived from the general unpredictability of a patient prisoner’s behavior, were found to sometimes override ethical and professional obligations. Furthermore, ethical dilemmas can occur due to the “dual loyalty” of medical staff (Pont, Stöver, & Wolff, 2012). In Switzerland, cantons (respective federal states) are responsible for penal institutions due to the countries’ federal structure. In 23 Swiss cantons, the justice department is responsible for prison healthcare, and only in three cantons (Vaud, Geneva, Valais, also partly Bern) prison healthcare is subordinated to the health department. This means that healthcare personnel are employed and paid by the justice department, which can cause medical staff to face a conflict of dual loyalty (Spectra Nr. 96, Bundesamt für Gesundheit, 2013), when having to simultaneously cope with governor’s instructions and adhere to medical professional ethics while providing healthcare to prisoners. For example, when medical tasks required by the security or penal system should be carried out by the healthcare personnel (who usually just act as caregivers), it could interfere with fostering a trustful relationship with the patient, such as approving/checking the healthcare status during solitary confinement.

As described by Watson et al. (2004), the importance of health promotion in prison and the associated need for education of prison staff members is increasingly recognized. Especially in terms of the particular necessities of the specific sub-group of aging prisoners, which require flexible handling of unique demands in institutions whose infrastructure was initially not designed for aging people (Curran, 2000). Despite these specific difficulties encountered while applying the commitment to equivalent healthcare to older prisoners, various efforts have been undertaken to propose and put into practice solutions to improve their situation.

Examples of already implemented solutions include hospital sections providing long-term care (Kuhlmann & Ruddell, 2005), special prison sections for elderly inmates (Tarbuck, 2001), such as the 60-plus unit in the prison “Lenzburg” in Switzerland (specified below). In contrast to the primary focus on resocialization and successful reintegration into society when dealing with younger prisoners, the primary goal of such prison sections for older inmates is to try to meet the specific needs arising from illness-related disabilities. For instance, as reported in a documentary about the 60-plus unit (Lebensabend hinter Schloss und Riegel, SRF, 2013), the conditions of the sentence are less restrictive: The movement aspect is taken in account (and consequently more space is provided), a sickroom is available (equipped with the required facilities/medical apparatuses), and the obligation to work is reduced (the elderly having to work only 50% instead of 100%). Marquart, Merianos, and Doucet’s (2000) findings suggest that these age-segregated sections of older prisoners are desirable, whereas in Wangmo, Handtke, Bretschneider, and Elger’s 2015 study, an almost equal part of the interviewed prisoners and stakeholders had arguments for and against age-segregated housings.

Still, research about prisoners’ views on prison health services remains inconclusive (Condon et al., 2007). In Elger’s 2011 study, some general information on healthcare provision for prisoners in the canton of Geneva is provided, particularly on the application of the principle of equivalence. Although the focus is not explicitly on aging prisoners, the principle of equivalence also applies to them. Apart from the “Agequake in prisons”-study (in the framework of which this article was created, as described in the “Method” section below), there are no other studies published on data from Switzerland on aging prisoners. Therefore, this study aimed to explore the personal views of older prisoners on the quality of prison healthcare, with the objective of complementing knowledge about medical care in prison to improve older prisoners’ individual health and reduce the perceived inequality of care in the longer term. This study discusses older prisoners’ perceptions of available care, but some of the issues raised could be relevant for younger prisoners as well.

Method

This study consists of a total of 35 semi-structured in-depth interviews conducted with older prisoners aged 50 and above. The interviews were conducted between November 2012 and October 2013, as part of the SNSF¹-funded project “Agequake in prisons: Reality, policies and practical solutions concerning custody and health care for ageing prisoners in Switzerland” in 12 prisons in the German- and French-speaking parts of Switzerland (for more details, see Handtke et al., 2016). The study was submitted to and approved by 10 cantonal ethics committees, the main one being the ethical committee of the cantons Basel Stadt and Basel Landschaft (EKBB²).

To ensure the data gathered contained a wide variety of views, the prisoners were recruited in institutions with different types of prison regimes, ranging from open and closed prisons to preventive detention (the prisoner is already imprisoned before getting the sentence—in cases when a long prison sentence is expected, Article 236 StPO³—Accelerated execution of sentences and measures of undefined duration). We used medical and incarceration records and interview responses to collect data on participants’ offense, age, gender, sentence length, number of conditions, and so on.

The inclusion criteria were as follows: age 50 years or older, ability to speak French, German, or English, a health state enabling participation, and the prisoner not being judged too dangerous by the prison staff or members of the healthcare team; for example, prisoners who were housed in the high security unit of the prison were not available for interviews due to security issues. Potential participants were initially informed about the study by medical or other prison employees. Interested prisoners then received the participant information. The day of the interview, prisoners were informed in more detail, and written informed consent was obtained from them. All interviews took place within prison, in a separate room provided by the medical service or by the prison administration. All interviews were held in private, without the presence of prison staff. Upon starting with the interview, the researchers informed the interviewees about their status being independent from prison services and administration, and explicitly mentioned that the possibility to refuse or withdraw from participation was guaranteed at any moment, without any negative consequences.

The semi-structured interview guide was developed with the support of collaborators from different disciplines, including prison health, ethics, gerontology, geriatrics, and occupational therapy. The interview guide was designed based on the study purpose, with a special focus on topics that already existed in the literature, such as the discussion on age-segregated housing or compassionate release of older prisoners. The interview guide was first piloted with two community-based older adults to check the comprehensibility and phrasing of questions, and further refined after the first four interviews with aging inmates, to better adapt it to the overall research goal.

Open-ended questions were chosen to enable the exploration of the specific health-related needs and issues of older prisoners in Switzerland and covered the following topics: demographic information, diseases and their symptoms, medication, substance use, healthcare utilization, and problems concerning activities of daily living. The average interview duration was 96 min. The audio-recordings of the 35 interviews were transcribed verbatim and anonymized by independent assistants to prevent identification of persons or institutions. A pseudonym was given to each prisoner cited in the results. To ensure anonymity within the small number of female prisoners, a new pseudonym was attributed to every code.

The coding and analysis of the open-ended responses were done in a text-based manner using conventional qualitative content analysis (Hsieh & Shannon, 2005). The qualitative content analysis was conducted by the lead author, a medical student with training in qualitative methods, who coded the data into themes; another member of the team with several years’ experience in empirical research consolidated the coding. To give a general overview of older prisoners’ experiences with the healthcare service in prison, those parts of the transcribed interviews in which interviewees addressed these issues were selected. First, information on health-related aspects were isolated, then statements were grouped into the larger category titled “perceptions of medical service provided within prison” and further sub-divided into four categories with their respective sub-themes.

Results

Of 35 prisoners, 18 had a time-limited custodial sentence, whereas the other 17 were serving indeterminate sentences, for example, on the basis of a measure (Article 59 StGB or Article 64 StGB; Wangmo et al., 2015).

From the quantitative part of the study (for more details, see Wangmo et al., 2014), it could be deduced that reasons for participants’ incarceration varied, for example, offenses against sexual integrity, offenses against property. The number of interviews per institution varied between two and six. In general, the interviews were carried out with the oldest inmates recruitable. Their ages ranged from 51 to 75, resulting in an average age of 61 years. Of the 35 older inmates interviewed, 23 lived in prisons located in the German-speaking part of Switzerland, whereas 12 lived in prisons located in the French-speaking part. Five of the participants were female and 30 were male. The average length of incarceration was 6.13 years with a range of 4 months to 25 years (see for more details Handtke, Bretschneider, Elger, & Wangmo, 2016). On average, prisoners had 7.8 (n = 26; range = 0-17, SD = 5.0) diagnoses reported in their medical records, including both somatic and mental health conditions. Those who described their health as good or better according to 12-Item Short Form Health Survey (SF-12) (n = 17) had on average 6.8 (SD = 5.0) diseases, whereas those participants reporting poor or bad health (n = 7) suffered on average from 11.0 (SD = 4.1) diseases. Excluding mental health illnesses, older prisoners experience common chronic diseases like their community-living counterparts, for example, arthritis, hypertension, diabetes, heart diseases, and so on. The most frequent diagnoses by International Classification of Diseases (ICD-10) categories included mental and behavioral disorders; diseases of the circulatory system; diseases of the musculoskeletal system and connective tissue; diseases of the digestive system; endocrine, nutritional, and metabolic diseases; diseases of the respiratory system; and diseases of the eye and adnexa.

The interviews raised a remarkable number of issues concerning the healthcare delivery in prison. Asked about general satisfaction with the healthcare service in prison, most of the participants expressed their dissatisfaction and reported having encountered problems with healthcare utilization during the time of their detention. Seven of the prisoners had a quite neutral opinion about prison healthcare, in a sense that they did not complain about it. Six prisoners even seemed to be quite satisfied, as Paul’s statement shows, “Well I had a very good follow-up . . . . And still now, every fifteen days I go see the doctor.” The prisoners who were satisfied with care did have healthcare problems as well, and heterogeneity of satisfaction within one prison could be observed. Complaints varied from “incompetent,” as Reto described it, to “I was really shocked” by Anna. She also mentioned the importance that age plays and points to the different needs that are related to it:

You know, here in [prison name removed], the medical assistance [is] a huge catastrophe. They don’t take you seriously . . . . If you can’t help yourself—[that is] very bad. And they are not considerate of, as I said, if you have a certain age, you also have slightly different needs.

Dieter not only criticizes prison healthcare, but he also makes the very condition of being in prison responsible for further health deterioration: “This makes people ill. Especially older people, I got all the illnesses there. I used to be completely physically healthy before.” Later in the interview, he got to the conclusion that

it’s unacceptable this prison, and this should be looked at by people who make studies, to get to know the causes, where this comes from, you know. That something has to be done, urgently. That it doesn’t get that far, that people become ill in prison.

This article focuses on the most frequently mentioned themes and attempts to give a general overview of prisoners’ personal perceptions about the quality of the healthcare services provided. The findings were further sub-divided into statements depicting (a) the quality of the first examination on prison entry, which constitutes a prisoner’s first contact with the prison-intern medical services; (b) the quality of habitual examinations a prisoner has to undergo throughout the time of his or her detention; (c) the quality of treatments received; and (d) delays in care and services provided.

Quality of First Examination on Prison Entry

Some interviewees, such as Beat, stated that the entrance examination had not taken place at all: “No, nothing at all. Presumably it said in my documents, that I’m healthy.” Or Gustav, who had suffered a cerebral apoplexy the day before being incarcerated, and was asked, if an entrance examination had taken place upon admission to prison: “That doesn’t interest them.” Several prisoners had experiences similar to those of Sabine, who stated that the physician did not even look at her medical records:

I came to the healthcare service. My documents where available there . . . in an envelope. And when I left, the doctor handed it over to me—closed as it was when I first came. This was the entrance examination.

Like Andreas, many interviewees thought that the entrance examination was not comprehensive enough:

They actually only asked questions . . . . But a complete “sound check” I say now, you know, I would appreciate to get it eventually, because—after all I’m already 60 and you never know if there is something inside—a nodule or so—you never know, you know. If you can detect it earlier, I would be glad.

The absence of a complete health check/or screening upon admission represented a common criticism among prisoners.

Quality of Habitual Examinations

A number of prisoners stated that the quality of examinations throughout their detention was similar to that of the entrance examination: not comprehensive enough. Harald’s conclusion is that examinations consist of “measuring the blood pressure,” and that that is “the only thing he [the physician] does.” Harald attributed it to the fact that the number of patients seen was disproportionate to the time slots physicians have per patient: “Now, you can imagine, how the courses of action of the consultations are, if he [the physician] gets through with twenty men within two hours.”

Two more specific issues that were highlighted in a substantial number of interviews were the unavailability of routine examinations for prevention (screenings) and the lack of follow-up examinations. The screenings not offered upon demand ranged from gynecological, for example, mammography, and urological, for example, prostate-specific antigen (PSA) measurement, to more general preventive measures such as vitamin substitution and other food-related issues. For example, a diabetic prisoner reported that blood glucose measurements took place only because of her explicit personal demand to have them carried out once a month.

Some interviewees pointed out the absence of follow-up examinations. For example, Hanna was asked whether she had undergone regular follow-up examinations after her cancer treatment. She denied, “No, they should have—after six months . . ., the scanner examinations should have been done . . .” Similarly Peter, who had been diagnosed with an aortic aneurysm some years before, and even though it was medically recommended to get the diameter of the aorta measured once a year, reported that “it hasn’t been done yet either.”

Quality of Treatments Received

Concerning the quality of treatment, several participants reported that the healthcare service refused to give appropriate treatment. The treatments in question concerned both preexisting chronic conditions and treatment after surgeries or accidents, directly upon being transferred from hospital to prison. For example, Laura reported that the physician in prison did not take her diabetes seriously and took her blood glucose measurement device away. When she informed her family doctor about her blood glucose values, and that she had not undergone measurements for the last 6 to 7 months, she claimed that he said, “This is crazy, you come here next week, that’s not possible.” Laura also stated that “the follow up treatment in a prison is utterly terrible. Because you are left to your own resources, you don’t have analgesics, you don’t have patches, you don’t have bandage material. Nothing!”

Regarding postoperative and accident treatments, non-adherence to officially recommended physiotherapeutic moving instructions seemed to cause particular problems. Daniel, who had undergone hip surgery 2 weeks before incarceration, reported, “I then couldn’t properly heal. I had to move the leg [being inside prison], even if I wasn’t allowed to.” Speaking about the postoperative context, Johannes mentioned the problem of being discharged from the hospital too quickly:

There is a tendency to have the prisoners back [after a surgery] here [in prison] as soon as possible. . . . Now, during the last follow-up examination [after a shoulder operation] they advised the surgeon to certify that I am 100% fit again in order to be able to perform all the working activities here.

However, it should also be mentioned that sometimes hospitals were eager to send back prisoners as soon as possible.

Another frequent problem was the focus on symptoms at the expense of a comprehensive approach. For example, according to Sara’s testimony, the symptom-focused treatment consisted of “always Dafalgan,⁴ Perskindol,⁵ Dafalgan, Perskindol and Dafalgan,” and treatment was not undertaken with a curative intention. For her, this led to insufficient analgetic coverage while having to perform physical activities.

At the time the interviews were conducted, more than half of the participants reported health problems which had not yet been treated. Roland recounted an incident he experienced, where the lower part of his dentures was glued to the door by fellow inmates while he was being distracted by them. Asked about the exact date of the reported episode, he replied that it had taken place almost 2 years ago, which corresponds to the time span this participant had been living with only part of his dentures: “I still don’t have them now. . . . And now three weeks ago I wash the upper teeth—you know. They fall on the floor and again, a piece broke off.” Consequently, he stated that the eating process was painful: “Well, if I eat French fries, after the meal everything [the gums] is sore, scratched open and painful.”

Asked about the prevalence of pain over the last 6 months, many of the participants reported suffering from burdening discomforts or multiple pain foci spread over different parts of their bodies. For example, René stated, “Listen, I currently suffer from severe pain in the leg . . . but I never went showing it to the healthcare service, because I think that they wouldn’t be able to tell me anything.” And Jean-Pierre—instead of going to see a dentist—extracted his teeth himself:

I extracted the teeth myself. I have all the teeth falling out, being loose, hurting constantly. I extracted the teeth myself, because I have the impression that the only solution is to extract the teeth.

Asked if he was afraid of going to see a dentist, he affirmed, and mentioned in addition that he did not like to make requests of this type.

Delays in Care and Services Provided

Almost half of the interviewees discussed problems related to delays in care and service provided. Jean-Pierre narrates an episode in which he felt having received insufficient analgesic treatment for an anal abscess that made him suffer severe pain for 10 days until eventually an anal fistula was discovered: “The medical care for my pain by the healthcare service has been very bad. I spent about ten days in my cell suffering, but really a martyrdom.”

A circumstance mentioned twice during the interviews was a procedure commonly practiced in Swiss prisons where detainees get only told they are going to the hospital the very morning they have the consultation. This makes the waiting time feel undetermined, as Didier described, and it can lead to communication problems:

I still wait to go get an imaging done or I don’t know what. It’s been almost one month I’m waiting now. “Yes, but it’s coming, it’s coming.” It’s easy to say that, isn’t it? Because here [in prison] they don’t tell you when you go there. They don’t inform us 24 hours before. Because they are afraid of the escapes, that’s all.

Anton summarized the timing problem like that: “They always wait until an emergency comes and then they do something, not before. That’s the way it is in prison, if you’re ill or suffer from anything, as long as it isn’t really acute, nothing gets done.”

Discussion

The aim of this article was to explore older inmates’ perceptions of the quality of healthcare services provided within prison and to describe the associated problems. Open-ended questions exploring prisoners’ subjective views enabled identification of relevant issues resulting from the interaction with the prison healthcare system from a firsthand account. The quality of prison healthcare provision was perceived as deficient by the majority of respondents in our sample of aged prisoners. Many participants highlighted the general dissatisfaction they felt toward prison healthcare, a feeling consistent with other study findings (Aday & Farney’s, 2014). The heterogeneous and often dissatisfying handling of the first examination on prison entry mentioned by the participants may partly derive from the variability of healthcare organization models in Switzerland due to its federal structure, followed by the different types of prison regimes the participants lived in. As mandated by the United Nations,

The medical officer shall see and examine every prisoner as soon as possible after his admission and thereafter as necessary, with a view particularly to the discovery of physical and mental illness and the taking of all necessary measures . . . . (United Nations Standard Minimum Rules for the Treatment of Prisoners, 1955)

There are no consistent guidelines applicable throughout the whole of Switzerland’s prison landscape, defining the scope and the health examinations, that is, the first examination of incoming older inmates that ought to be included. This could have been included in the three prison concordat (Strafvollzugskonkordate⁶) agreements, but so far only one of the three concordats contains the requirement that an “entrance examination according to the internal regulations” should take place (Strafvollzugskonkordat der Nordwest- und Innerschweiz, 2015). This might represent a factor contributing to an overall feeling of arbitrariness regarding the medical examinations performed or omitted. Condon et al. (2007), who carried out 111 prisoner interviews in 12 prisons in England to explore prisoners’ views about healthcare, also presented findings indicating an incomprehensive entrance examination for prisoners. In Bretschneider and Elger’s (2014) study, interviews were held with 40 stakeholders in prisons of three Western Europe countries. They included healthcare professionals or researchers working in prison; members of prison administration and policymakers; members from relevant international and non-governmental organizations (IOs, NGOs); and ombudsmen. According to the reported views of some stakeholders, geographical proximity to the next available hospital was described to positively affect the occurrence of general health examinations or screenings upon entrance to prison. As mentioned in Fearn and Parker’s (2005) study with regard to female prisoners, prison can represent the first opportunity to obtain systematic medical attention for many incoming prisoners. However, based on the above-presented results, the opportunity for health screening on prison entry seems to be missed. Also, comprehensive health examinations were not performed at a later stage during detention.

Complaints about the entrance examination are similar to the findings concerning the quality of the routine examinations undertaken throughout the time of detention. The lack of follow-up and routine examinations (screenings) constituted a central concern. This corresponds to findings that screenings are not prioritized enough (Kuhlmann & Ruddell 2005). Loeb and Abudagga (2006) indicate that the prison stay could provide an opportunity to improve healthcare for prisoners who had low healthcare standards prior to incarceration. Conversely, prisoners in our study who used to enjoy high healthcare standards before incarceration found it difficult to maintain them during their stay in prison.

Many concerns about the quality of treatment were raised in this study; for instance, experiences of inadequate postoperative treatment. In this regard, lack of adequate accommodation facilities for postsurgical prisoner patients was also described in Reviere and Young’s study (2004). Difficulties in accessing rehabilitation requirements correspond to Collin & Bird’s (2007) findings.

The medical neglect reported by some participants concerning delays in care and services provided suggests a long waiting time between symptom onset and treatment; a delay in obtaining healthcare, which compromises the principle of equivalence. As participants reported, and as exposed by Bretschneider and Elger (2014), delays could amount to outcomes of differing gravity, ranging from premature death to increases in subjective suffering. Furthermore, delayed treatment—as a manifestation of inadequate access to healthcare in prison—may amount to cruel, inhuman, or degrading treatment (Trestman, 2014; United Nations Convention against Torture, 1984).

As the quality of the entrance examination, the habitual examinations, and the quality of treatment were often rated as inadequate in this study, recommendations can be made for examinations and treatment as elements constituting care. Care should be comprehensive in the sense that the individual is being taken seriously not only as a prisoner but also as a patient, and that the focus should not only be on symptoms, as mirrored in many prisoners’ statements.

Consistent integrative guidelines concerning the examination upon admission to prison with a focus on health screenings should be developed. In accordance with Watson et al.’s (2004) recommendations, this should include standardized protocols and be adapted to nationally recommended and insurance-covered screenings for the general population, as well as to the risk profiles of the individual prisoner for determined illnesses. A nationwide standardized examination protocol needs to be implemented to ensure routine assessment of every older prisoner’s health at prison entry. This should include a thorough anamnesis, a complete physical examination, as well as a measurement of blood pressure and body weight. In addition, an electrocardiogram could be performed, as well as a urinalysis and a blood sample (including blood count, electrolytes, lipid values, glucose, inflammation values, liver and kidney values), provided that consent is given.

Making prison healthcare more geared toward the provision of more continuous care could represent a good answer to the multiple risk factors that come along with the vulnerable condition of being an older prisoner. About 85% of older prisoners suffer from multipathology (Loeb, Steffensmeier, & Myco, 2007), and it should therefore be required to make use of screenings, diagnostic examinations, laboratory tests, and follow-up examinations that exceed those of the younger prisoner population (Reviere & Young, 2004). This study’s findings suggest defining and implementing comprehensive and preventive strategies designed especially for older prisoners. Preventive efforts should also include strategies reaching beyond the aforementioned screening upon admission. For example, to guarantee more regular contact with the healthcare service, enabling continuous care and implementation of preventive measures, an annual general checkup could take place for every older prisoner. Depending on an individual prisoner’s specific pathologies or risk profiles, the frequency could also be increased to semi-annual controls, and the general checkup extended to more specific examinations. Access to all preventive and medical measures available in the general population would form part of a full and inclusive application of the principle of equivalence (Bretschneider & Elger’s, 2014). Screening for incoming inmates (and throughout the time of detention if necessary) could be carried out in various domains. In this context, it is important to take into account that in Switzerland’s general population, not all types of screenings are routinely offered and covered by basic health insurance. Health checkups in prison should therefore be oriented on statistics about the prevalence of specific illnesses in the population of older prisoners, as well as on the knowledge about the existence of a sufficient degree of evidence for a respective screening procedure (Hunziker, Hengstler, Zimmerli, Battegay, & Battegay, 2006). For example, costs for gynecological checkups, including cervical and breast cancer screenings, at defined time intervals and age criteria are covered by statutory health insurance in Switzerland (Grundversicherung – Leistungen aus der obligatorischen Krankenpflege-Versicherung, 2015; Krebsliga Schweiz – Mammografie-Screening, 2015; Schweizerische Gesellschaft für Gynäkologie und Geburtshilfe – Expertenbrief No 40, 2012). In addition, according to a “case finding” procedure (Hunziker et al., 2006), prisoners with specific risk factors, for example, higher risk for tuberculosis in HIV patients, could be identified before possible further screenings are executed. These could include screenings for infectious diseases, diabetes, prostate and colorectal cancer, dementia and other mental health problems. Furthermore, screening procedures could involve assessments of liver function in alcoholic prisoners and of pulmonary function in heavy smokers. To complete this preventive approach, education of prisoners in terms of what they can contribute to the maintenance of their own health, what is attributed to risky behavior, and how such practices could be avoided should be included. Prison systems could serve as a conduit of information about healthcare, to enable informed decision making both within prison and after release (Loeb, Penrod, McGhan, Kitt-Lewis, & Hollenbeak, 2014). Especially against the background of the high probability of a negative trajectory after release, the development of prerelease health interventions seems justified (Loeb & Steffensmeier, 2011). This would help foster prisoner autonomy and could promote a more trusting relationship between older prisoners and healthcare personnel.

To facilitate continuous monitoring throughout the time of detention, as well as to allow for a better overview over prisoners’ health status, including the evaluation of response to therapy over time, the implementation of a data administration system containing all prisoners’ health data could be helpful. At the time of the entrance examination, every prisoner’s medical data should be gathered and documented in this system. To ensure confidentiality, the accessibility of data should be limited to the healthcare staff directly involved in the treatment of a respective prisoner patient. The medical data should contain vaccination history, a list of current and earlier diagnoses, results of medical examinations (such as test results and X-rays), prisoners’ medical history, and current medications. This would enable continuous documentation of prisoners’ clinical data, and the coordination of the course of treatment could be facilitated. In this way, a loss of information, for example, during transfer from the external general practitioner to the prison healthcare service, or between two examinations during a prison stay could be avoided. Furthermore, unnecessary repetitions of recently performed examinations, which increase costs (Haux, Winter Ammenwerth, & Brigl, 2013) and represent a superfluous and time-wasting burden for the prisoner, could be circumvented. Finally, if linked to external hospital systems, any such systems could also alert and remind prison healthcare staff about the need for follow-up scans, tests, or treatments following discharge from hospital.

Issues of perceived delayed treatment could be related to the capacity and resources of prison healthcare staff and prison staff in general. Sometimes, prison staff can face difficulties in coping with acute health problems and the additional requirements caused by the higher rate of disabilities in the prison population (Williams, Stern, Mellow, Safer, & Greifinger, 2012). Health problems that require careful monitoring over a longer time period and more substantial interventions make it challenging to adhere to security standards and can lead to logistical problems, when organizing a prisoner’s transfer from prison to hospital. This finding is consistent with Bretschneider and Elger’s (2014) study results, in which stakeholders expressed the view that prisoner patients’ waiting times to access healthcare services exceeded those of patients living outside of prison, especially when the care in question required transfer to the hospital. The same reason for delayed access to treatment was also found in Aday and Farney’s study (2014), and could represent a factor that should be addressed to improve early diagnosis of acute healthcare needs of older prisoners.

Limitations

As discussed in Ammar and Erez’s (2000) study, reporting of personal narratives of inmates about perceived care must be done with caution. Prisoners’ perceptions often conflict with those of their care providers (Aday & Farney, 2014). Another study, in which prisoners’ evaluations of healthcare services were examined without focusing on older prisoners, found that inmates reported extremely low ratings of quality and accessibility of healthcare services (Lindquist & Lindquist, 1999). In this regard, it is important to further acknowledge their finding that the strongest predictor for negative rating of the perceived personal health condition was older age (Lindquist & Lindquist, 1999). It also has to be taken in account that five of the participants had a diagnosed depression, which has been found to sustain a direct negative association with perceived health status (Bishop et al., 2014). As deducible from the present study’s participants’ statements, the relationship between prisoners and prison health personnel often appeared to be affected by a general distrustfulness. This could be an explanation for some of the negative statements of the prisoners, as well as for what is possibly a frequently biased conception about the level of care currently achievable in prisons, as described by Fearn and Parker (2005). Finally, generalizability of the study’s findings is limited due to the study’s qualitative nature, which describes subjective impressions.

Due to the interview design allowing a largely explorative approach, a wide range of themes was covered (based on these, the following papers were already published: Handtke, Bretschneider, Elger, & Wangmo, 2015; Handtke et al., 2016; Handtke & Wangmo, 2014; Shaw & Elger, 2016; Wangmo et al., 2015); the emphasis on perception of prison healthcare was chosen as a secondary objective for this study and was not an initial study aim. Therefore, future research with a more focused, confined approach to the identified issues could generate more precise information on the provision of healthcare and the detected difficulties, allowing for an even deeper and detailed understanding on why aging prisoners perceive the healthcare provided to them this way. This research could also explore why age-related medical problems do not appear to feature dominantly in participants’ discourse.

Conclusion

The results of this study indicate that aging prisoners perceive a high threshold for delivery of healthcare inside prison compared with the community. This discrepancy needs to be reduced. Incarceration represents deprivation of freedom but should not impair access to the highest attainable standard of healthcare (Lines, 2008). Based on the findings presented in this study, two solutions are proposed to achieve equivalent healthcare. First, guidelines including standardized protocols on examination at prison entry should be developed. Second, the focus throughout incarceration should be on the provision of preventive measures and continuous healthcare monitoring. All this should be paralleled with empowerment of older prisoners by encouraging them to claim their rights themselves and by enhancing their self-care abilities (Bretschneider, 2015). Meeting aging prisoners with a preventive and health-enhancing approach over the course of incarceration can reduce prison healthcare costs in the long term (Aday & Farney, 2014). The described recommendations should be implemented to support the main commitment of promoting health and thus contributing to a better quality of life for members of a vulnerable group, who are spending the evening of their lives in prison.

Footnotes

Acknowledgements

The authors want to thank Tenzin Wangmo for her valuable advice.

Authors’ Note

We do not provide evidence of human subject review or compliance in the manuscript document. The research was approved by the local ethics committee.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Notes

References

Aday

Farney

(2014). Malign neglect: Assessing older women’s health care experiences in prison. Journal of Bioethical Inquiry, 11, 359-372.

Ammar

N. H.

Erez

(2000). Health delivery systems in women’s prisons: The case of Ohio. Federal Probation, 64, 19.

Baumeister

Keller

(2011). Alt werden im Straf- und Massnahmenvollzug [Growing old in prison and preventive detention]. Dübendorf: Zürcher Hochschule für Angewandte Wissenschaften, Departement Soziale Arbeit, Forschung und Entwicklung.

Birg

(2001). Die demographische Zeitenwende. Der Bevölkerungsrückgang in Deutschland und Europa [The demographic turning point. The demographic decline in Germany and Europe] (Vol. 1426). München: CH Beck.

Bishop

A. J.

Randall

G. K.

Merten

M. J.

(2014). Consideration of forgiveness to enhance the health status of older male prisoners confronting spiritual, social, or emotional vulnerability. Journal of Applied Gerontology, 33(8), 998-1017.

Bourgeois-Pichat

(1981). Recent demographic change in Western Europe: An assessment. Population and Development Review, 7, 19-42.

Bretschneider

(2015). Ageing prisoners and ethics behind bars: Law, human rights and health care—Old (age) problems and new challenges (Doctoral dissertation). University of Basel, Switzerland.

Bretschneider

Elger

B. S.

(2014). Expert perspectives on Western European prison health services: Do ageing prisoners receive equivalent care? Journal of Bioethical Inquiry, 11, 319-332.

Bundesamt für Statistik, 2016. Straf- und Massnahmenvollzug: Mittlerer Insassenbestand der über 49-jährigen Personen [Federal Statistical Office, 2016. Execution of sentences and measures: Medium number of detainees of the people over 49 years]. Retrieved from https://www.bfs.admin.ch/bfs/de/home/statistiken/kriminalitaet-strafrecht.assetdetail.303596.html

10.

Clear

T. R.

Frost

N. A.

(2013). The punishment imperative: The rise and failure of mass incarceration in America. New York: New York University Press.

11.

Collins

D. R.

Bird

(2007). The penitentiary visit—A new role for geriatricians? Age and Ageing, 36(1), 11-13.

12.

Colsher

P. L.

Wallace

R. B.

Loeffelholz

P. L.

Sales

(1992). Health status of older male prisoners: A comprehensive survey. American Journal of Public Health, 82, 881-884.

13.

Condon

Hek

Harris

Powell

Kemple

Price

(2007). Users’ views of prison health services: A qualitative study. Journal of Advanced Nursing, 58, 216-226.

14.

Curran

(2000). Blue hairs in the bighouse: The rise in the elderly inmate population, its effect on the overcrowding dilemma and solutions to correct it. New England Journal on Criminal and Civil Confinement, 26, 225-264.

15.

Elger

B. S.

(2011). Prison medicine, public health policy and ethics: The Geneva experience. Swiss Medical Weekly, 141, w13273.

16.

Fazel

Hope

O’Donnell

Piper

Jacoby

(2001). Health of elderly male prisoners: Worse than the general population, worse than younger prisoners. Age and Ageing, 30, 403-407.

17.

Fearn

N. E.

Parker

(2005). Health care for women inmates: Issues, perceptions and policy considerations. California Journal of Health Promotion, 3, 1-22.

18.

Ginn

(2012). Elderly prisoners. British Medical Journal, 345, e6263.

19.

Grundversicherung - Leistungen aus der obligatorischen Krankenpflege-Versicherung (KGV) [Basic health insurance - services from the mandatory basic health insurance]. Retrieved from https://www.comparis.ch/krankenkassen/info/glossar/leistungen-krankenpflegeversicherung.aspx

20.

Handtke

Wangmo

(2014). Ageing prisoners’ views on death and dying: Contemplating end-of-life in prison. Journal of Bioethical Inquiry, 11, 373-386.

21.

Handtke

Bretschneider

Elger

Wangmo

(2015). Easily forgotten: Elderly female prisoners. Journal of Aging Studies, 32, 1-11.

22.

Handtke

Bretschneider

Elger

Wangmo

(2016). The collision of care and punishment: Ageing prisoners’ view on compassionate release. Punishment & Society. doi:1462474516644679

23.

Haux

Winter

Ammenwerth

Brigl

(2013). Strategic information management in hospitals: An introduction to hospital information systems. New York, NY: Springer Science & Business Media.

24.

Hsieh

H. F.

Shannon

S. E.

(2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15, 1277-1288.

25.

Hunziker

Hengstler

Zimmerli

Battegay

(2006). Der internistische check-up [The internist’s check-up]. Der Internist, 47, 55-68.

26.

Justizvollzug Schweiz. Strafvollzugskonkordate [Law enforcement Switzerland, penal system concordats]. Retrieved from http://www.prison.ch/de/justizvollzug-schweiz/justizvollzug-was-ist-das/pflichten-und-kompetenzen-der-kantone/strafvollzugskonkordate

27.

Krebsliga Schweiz. Mammografie-Screening [Cancer League Switzerland - mammography screening]. Retrieved from http://www.krebsliga.ch/de/praevention/pravention_krebsarten/brustkrebs_/mammografie_screening/?gclid=CIzF_6rdv8gCFcZuGwodtCYJrA

28.

Kuhlmann

Ruddell

(2005). Elderly jail inmates: Problems, prevalence and public health. Californian Journal of Health Promotion, 3, 49-60.

29.

Lebensabend hinter Schloss und Riegel [Evening of life behind bars]. SRF [Swiss Radio & Television], August 6, 2013. Retrieved from http://www.srf.ch/player/tv/schweiz-aktuell/video/lebensabend-hinter-schloss-und-riegel?id=7de4d3a0-cbaa-4e8e-a104-fef24b4e5306

30.

Lindquist

C. H.

Lindquist

C. A.

(1999). Health behind bars: Utilization and evaluation of medical care among jail inmates. Journal of Community Health, 24, 285-303.

31.

Lines

(2008). The right to health of prisoners in international human rights law. International Journal of Prisoner Health, 4, 3-53.

32.

Loeb

S. J.

Abudagga

(2006). Health-related research on older inmates: An integrative review. Research in Nursing & Health, 29, 556-565.

33.

Loeb

S. J.

Penrod

McGhan

Kitt-Lewis

Hollenbeak

C. S.

(2014). Who wants to die in here? Perspectives of prisoners with chronic conditions. Journal of Hospice & Palliative Nursing, 16, 173-181.

34.

Loeb

S. J.

Steffensmeier

(2011). Older inmates’ pursuit of good health: A focus group study. Research in Gerontological Nursing, 4, 185-194.

35.

Loeb

S. J.

Steffensmeier

Lawrence

(2008). Comparing incarcerated and community-dwelling older men’s health. Western Journal of Nursing Research, 30, 234-249.

36.

Loeb

S. J.

Steffensmeier

Myco

P. M.

(2007). In their own words: Older male prisoners’ health beliefs and concerns for the future. Geriatric Nursing, 28, 319-329.

37.

Marquart

J. W.

Merianos

D. E.

Doucet

(2000). The health-related concerns of older prisoners: Implications for policy. Ageing & Society, 20, 79-96.

38.

Pont

Stöver

Wolff

(2012). Dual loyalty in prison health care. American Journal of Public Health, 102, 475-480.

39.

Recommendation No. R (98) 7’ of the Committee of Ministers to Member States concerning the ethical and organisational aspects of health care in prison. Council of Europe. Retrieved from http://hrlibrary.umn.edu/instree/coerecr98-7.html

40.

Reviere

Young

V. D.

(2004). Aging behind bars: Health care for older female inmates. Journal of Women & Ageing, 16, 55-69.

41.

Schweizerische Gesellschaft für Gynäkologie und Geburtshilfe – Expertenbrief No 40, Update des Screenings für Gebärmutterhalskrebs und Follow-up mittels Kolposkopie [Swiss Society of Gynaecology and Obstetrics - Expert letter No 40, Update of the screenings for cervical cancer and follow-up by colposcopy]. Retrieved from http://www.sggg.ch/fileadmin/user_upload/Dokumente/3_Fachinformationen/1_Expertenbriefe/De/40_PAP-Abstrich_2012.pdf

42.

Shaw

Elger

(2016). Assisted suicide for prisoners? Stakeholder and prisoner perspectives. Death Studies, 40, 479-485.

43.

Strafvollzugskonkordat der Nordwest- und Innerschweiz, Standards für den geschlossenen Strafvollzug [Penal system concordat for northwestern and inner Switzerland, Standards for closed confinement]. Retrieved from http://www.prison.ch/images/stories/pdf/konkordat_nw_ch/0715/062_Standards_geschl_Vollzug.pdf

44.

Tarbuck

(2001). Health of elderly prisoners. Age and Ageing, 30, 369-370.

45.

Trestman

R. L.

(2014). Ethics, the law, and prisoners: Protecting society, changing human behavior, and protecting human rights. Journal of Bioethical Inquiry, 11, 311-318.

46.

United Nations, 1955. Standard Minimum Rules for the Treatment of Prisoners. Retrieved from http://www.ohchr.org/EN/ProfessionalInterest/Pages/TreatmentOfPrisoners.aspx

47.

United Nations, 1984. Convention against torture and other cruel inhuman or degrading treatment or punishment. Retrieved from http://www1.umn.edu/humanrts/instree/h2catoc.htm

48.

Vademekum für bessere Gesundheit im Gefängnis [Vade mecum for better health in prison]. Spectra 96, Ethik und Public Health, January 2013 [Spectra 96, Ethics and Public Health, January 2013], p. 6. Retrieved from www.spectra.bag.admin.ch

49.

Wangmo

Handtke

Bretschneider

Elger

B. S.

(2015). Prisons should mirror society: The debate on age-segregated housing for older prisoners. Ageing and Society, 1-20.

50.

Wangmo

Meyer

A. H.

Bretschneider

Handtke

Kressig

R. W.

Gravier

. . . Elger

B. S.

(2014). Ageing prisoners’ disease burden: Is being old a better predictor than time served in prison? Gerontology, 61, 116-123.

51.

Watson

Stimpson

Hostick

(2004). Prison health care: A review of the literature. International Journal of Nursing Studies, 41, 119-128.

52.

White

K. L.

Jordens

C. F.

Kerridge

(2014). Contextualising professional ethics: The impact of the prison context on the practices and norms of health care practitioners. Journal of Bioethical Inquiry, 11, 333-345.

53.

Williams

B. A.

Stern

M. F.

Mellow

Safer

Greifinger

R. B.

(2012). Aging in correctional custody: Setting a policy agenda for older prisoner health care. American Journal of Public Health, 102, 1475-1481.