Prison health and public health responses at a regional prison in Western Australia
Marisa Gilles, PO Box 733 Geraldton WA 6531. Fax: +61 8 9956 1991; e-mail: firstname.lastname@example.org
Objective: To describe the health of inmates in a Western Australian regional prison and evaluate the coverage of public health interventions.
Design: Cross-sectional audit of all paper-based and electronic medical notes of inmates at one regional prison in Western Australia.
Setting:A mixed medium-security prison in regional Western Australia.
Participants: 185 prisoners, 170 men and 15 women
Main Results: The prisoners were mainly young (70% < 35 years of age) and Indigenous (84%). Fifty two percent of prisoners had at least one chronic health condition. There was a significantly higher prevalence of diabetes to that found in the general Indigenous population (15% vs 6% p=0.001), and a significantly lower prevalence hepatitis C (4.5%) compared with both national (29–61%) and State (20%) data. Screening for sexually transmitted infections and blood borne viruses within the first month of incarceration was achieved for 43% of inmates. Vaccination coverage for influenza (36%) and pneumococcal disease (12%) was low.
Conclusion: This study makes visible the burden of disease and reach of public health interventions within a largely Indigenous regional prisoner population. Our study demonstrates that the additional risks associated with being Indigenous remain in a regional Australian prison but also shows that interventions can be delivered equitably to Indigenous and non-Indigenous inmates.
Implications: Ongoing monitoring of prisoner health is critical to take advantage of opportunities to improve public health interventions with timely STI and BBV screening and increased vaccinations rates.
Although there have been attempts to raise the profile of prison health care on moral and ethical grounds1–4it is the emergence of HIV/AIDS and hepatitis C and the accompanying resurgence of tuberculosis (TB), which have high prevalence in prisons internationally, that has drawn attention to the role of prisons in controlling diseases.5 Three factors led to this situation.
- 1Prisoners often come from poor, deprived or marginalised groups in society, and these groups are vulnerable to HIV, sexually transmitted infections (STIs), blood borne viruses (BBVs), and TB.6–10
- 2Prisoners often have had limited primary care, disease prevention, and early detection of diseases before incarceration.11
- 3Prisons are not closed-off worlds. The health of prisoners and staff is a public health priority of concern to society in general.12,13
Prison provides an opportunity to deliver health services to a hard-to-reach group, but because of the first two issues a higher investment in health care is required to achieve health outcomes equitable to the community1–16 Acquiring and sustaining that investment can be challenging given the historically punitive nature of the custodial system.16 The role of ongoing evaluation and documentation of prison health in keeping this issue on the agenda has been recognised.17,18
Western Australia's regional prisons provide a case study of the challenges and opportunities to achieving equitable health outcomes for inmates. Indigenous prisoners represent 22% of the total Australian prison population but 41 % of the prison population in Western Australia (WA).19 Incarceration rates continue to increase and preventable deaths continue to occur despite the report of the Royal Commission into Indigenous deaths in custody19–21
With these facts in mind, this study was conducted as part of a cycle of quality assurance activities to assess health care provision within a regional Western Australian prison, one of 14 correctional services in the state. In this regional prison 84% of the prisoners are Indigenous.19 Twenty to 30 transfers can occur each week resulting in a transient population which changes every three months. There are nursing staff available from 7am until 8pm but no after hours care. A doctor provides a three hour clinical session twice a week, and a psychiatrist visits once a month. Medical records are paper based, although previous scanned medical notes are accessible electronically and a second electronic database, the Total Offender Management System (TOMS), is also used to record medical details including BBV status and vaccination history. The health service has a policy of offering STI and BBV screening to all prisoners within a month of incarceration.22 Prison policy follows the Australian Immunisation Handbook recommendations for influenza and pneumococcal vaccination,23 hepatitis B vaccination is offered to all prisoners and hepatitis A vaccine is offered to all hepatitis B carriers and hepatitis C positive prisoners.24
This study documents the burden of disease in a regional prison with a largely rural Indigenous population with a focus on the chronic disease burden and opportunities for public health interventions. Where possible, findings are compared to other community and prison populations to understand which health conditions are related to the largely rural Indigenous prison population and which are amenable to improved prison health care.
The medical notes of all prisoners were audited over a four-week period in May 2006 by the visiting prison medical officer, a Master of Applied Epidemiology scholar and a research assistant. Paper and electronic records were examined in alphabetical order. Clinical notes that were present at the time of the audit of each section were included. Prisoners that arrived after their alphabetical section had been completed were excluded. Due to the high frequency of internal transfer, prisoners may have been included as part of the regional prison health service audit but had tests performed at one of the other Western Australian prisons. Therefore the audit provides an overall picture of health care within the WA corrective services system.
A standardised data collection sheet was developed and piloted. Data collected related to tobacco, alcohol and drug use, screening for STIs and BBVs, vaccinations, and diagnosis and management of chronic diseases.
Tobacco, alcohol and drug use was defined by documentation in the clinical notes. Screening for STIs and BBVs and vaccination status was determined by reviewing the paper-based and electronic records with laboratory confirmation where possible.
Chronic diseases audited were diabetes, ischaemic heart disease, hypertension, Hepatitis C, Hepatitis B and asthma. Disease status was defined by the health practitioner, as documented in the medical notes, and wherever possible with laboratory confirmation.
Data were analysed using SPSS Version 14.0. A 0.05 level of significance was used to determine whether there were any statistically significant differences between study populations. The study was exempted from ethics approval by the University of Western Australia's Human Ethics Committee as it is a quality assurance activity25
There were 185 prisoners at the time of the audit, predominately young Indigenous men. Half these inmates had been incarcerated for less than six months. Table 1 shows the characteristics of the prisoner population.
Table 1. Demographic documented characteristics of prisoners at the regional prison in 2006.
|Duration of incarceration at the time of the audit|| |
| <6 months||50%|
| 6–11 months||20%|
| 12 months-4 years and 11 months||21%|
| >5 years||9%|
|Proportion documented smoking status n = 115 (62%)||85 (89)a||14(70)|
|Aboriginal n=95, 61% doc||non-Aboriginal n=20, 67% doc|| || |
|Proportion documented hazardously drinking prior to incarceration n = 119 (64%)||90 (96)b||11 (68)|
|Aboriginal n=103, 66% doc||non-Aboriginal n=16, 53% doc|| || |
|Proportion documented regarding illicit drugs use n = 105 (57%)||62 (75)b||8 (36)|
|Aboriginal n=83 54% doc||non-Aboriginal n=22, 73% doc|| || |
|Proportion documented regarding using IV drugs n = 105 (57%)||21 (34)||3 (38)|
|Aboriginal n=83 54% doc||non-Aboriginal n=22, 73% doc|| || |
Lifestyle risk factors
Drug use was poorly reported in the medical notes, with smoking status documented for 62% of all prisoners, alcohol use for 64%, and illicit drug use for 57%. Of those with documentation, there was a significant difference between Indigenous and non-Indigenous inmates. The majority of Indigenous inmates smoked (89%), had a history of binge drinking (96%) and used illicit drugs (62%) prior to incarceration. There was no difference in the proportion of Indigenous or non-Indigenous prisoners with documented intravenous drug use (Table 1).
Prevalence of chronic disease
More than half (53%) the prisoners had at least one of the audited chronic diseases and 19% had more than one. Hypertension, psychiatric conditions and diabetes were the most prevalent diseases (Table 2).
Table 2. Prevalence of medical conditions in the regional prison (RP) 2006 by Aboriginally of inmates.
|Hypertension||28 (18)||3 (10)||NS|
|Diabetes||23 (15)a||0||p<0.001 CI0.03, 0.16|
|Asthma||17 (11)||5 (17)||p<0.001|
|IHD||16 (10)||1 (3)||NS|
|Hepatitis C||7 (4.5)||6 (20)||p<0.001|
|Hepatitis B||5 (3.2)||1 (3.3)||NS|
Screening and prevalence of BBVs and STIs
Overall, 79% of prisoners had been screened for HIV, 84% for hepatitis B (immunity or infection) and 82% for hepatitis C infection. However, fewer than half of the prisoners had been screened in the first month of incarceration (43% for HIV, Hepatitis B and Hepatitis C) and just over half had been screened within the previous 12 months (54% for HIV, 53% for Hepatitis B and 56% or Hepatitis C (Table 3).
Table 3. Screening for BBVs and STIs showing the number positive and the vaccination coverage achieved in the RP 2006 audit.
|Hepatitis B SAg +ve||154||5a||1||3.9||43||53||84|
|Notes: (a) p=0.001|| || || || || || || |
|Fluvax||56 (36)||10 (33)|
|Pneumovax||19 (12)||2 (6.7)|
The number of Indigenous prisoners who were hepatitis C positive (n=7) was similar to non-Indigenous prisoners (n=6), indicating a significantly lower prevalence of this disease in Indigenous inmates (p0.001) (Table 3). Eight of the prisoners with hepatitis C had a history of injecting drug use recorded. Only two prisoners with hepatitis C were identified as not immune to hepatitis B.
The prevalence of hepatitis B surface antigen among prisoners was low, with six prisoners testing positive, a significantly higher proportion f these (five) were Indigenous p0.001) (Table 3).
Only 23% of prisoners were documented as receiving vaccinations for hepatitis B. Serological testing showed that 79% of prisoners were immune to hepatitis B and there was no significant difference in the immunity of Indigenous or non-Indigenous prisoners.
Less than half the inmates (44%) had been screened for chlamydia and gonorrhoea within the first month of incarceration. Screening rates had risen to 71% by the end of the first year of incarceration with 6.7% and 5% positive for chlamydia and gonorrhoea respectively (Table 3).
Thirty-six per cent of prisoners were documented to have been given fluvax and 11% had been vaccinated with pneumovax with no significant difference in the proportion of Indigenous or non-Indigenous inmates receiving these vaccines (Table 3).
Our findings are consistent with other studies in two respects; the prisoners, despite their predominantly young age, have a disproportionate chronic disease burden7–9 and a high prevalence of lifestyle risk factors reflecting their Aboriginality, rurality and incarceration.7,9,10,20,21,26–28
For both Indigenous and non-Indigenous inmates, levels of smoking, alcohol use and illicit drug use were much higher than the general population. Indigenous and non-Indigenous men living in rural and remote areas have significantly higher rates of smoking and harmful alcohol consumption than men in major cities.28 National surveys estimate that 50% of Indigenous adults are tobacco smokers with 17% of Indigenous adults identified at risk from chronic alcohol consumption and 28% reporting having used an illicit substance in the last 12 months.26
Similarly, our results for both diabetes and asthma were comparable to those found in the general Indigenous population. However, both these results differed significantly from published data from NSW prisons.7 Kariminia et al. have used this data to argue that for Indigenous inmates in NSW prisons, there is no difference between the morbidity of Indigenous and non-Indigenous prisoners.29 This might well be the case in NSW but it must not be seen as true for all prisons.
There are several reasons for the contradictory findings. Unlike the regional WA prison, in NSW Indigenous prisoners account for a smaller proportion of the prison population (17%) and are largely from metropolitan areas. ‘The NSW study is based on prisoners’ self-report of their health. The Indigenous prisoners may have been less likely to know that they have diabetes as that requires a diagnosis from a doctor. On the other hand, it is very common for people to self-report that they have asthma, often leading to an over-estimation of the burden, while at the same time our method of defining asthma on the basis of reports in the clinical record may have resulted in an under-estimation.
Finally, we found the prevalence of serologically proven hepatitis C was significantly lower in Indigenous inmates in the regional prison (4.5%) compared with both national (29–61%)30,31 and State (20%)32 data. In this prison, 34% of Indigenous inmates had documented evidence of injecting drug use compared with 59% of prisoners in the National Prison Entrants BBV survey in 2004.30
Public health opportunities
The high prevalence of lifestyle risk factors and the established medical consequences, require additional resources to provide education, pharmacological and environmental support to result in effective interventions.33–36 In July 2008, one WA regional prison commenced a smoke-free policy with such support. Injecting drug use in the general Indigenous population is an area of growing concern,31,32 and the prisoner population provides an excellent environment for surveillance of trends in hard to reach population groups. Further, it presents the opportunity to intervene with education regarding safe injecting practices, methadone substitution and, if required, early diagnosis and treatment of hepatitis C infection.
Systems need to be put in place to ensure improved immunisation coverage is achieved. This population is eligible the 23-valent pneumococcal polysaccharide vaccine recommended for individuals at increased risk of complications from invasive pneumococcal disease because of chronic illness, alcohol-related problems and tobacco.23 Despite this, only one in 10 had been vaccinated against pnuemococcal disease at the time of the audit. Annual influenza vaccination is also advised for this group, yet only one-third of inmates had received a vaccination. In contrast, the National Indigenous and Torres Strait Islander health survey in 2004/05 gave rates of 60% coverage for Influenza and 34% coverage for pneumococcal disease for Indigenous and Torres Strait Islanders 50 years and over.37 The shortage of nurses accredited to give immunisation in the facility and the pressured twice weekly visits of the medical officer together with the transient nature of the population may explain these low rates. It is encouraging that the coverage of vaccination programs were the same for Indigenous and non-Indigenous inmates. Other studies have found that good systems of health care can result in the same health outcomes, regardless of patients’ Indigenous status.38 In 2008, specific immunisation training for the delivery of influenza and pneumococcal vaccine training was provided to nurses across the state in an effort to improve this coverage.
Although the prevalence of STI found in this population was surprisingly low given the prevalence in the general population39 screening only reached 71% after 12 months. Around half of the inmates spend less than six months in prison and only 43% of the inmates were screened in the first month of incarceration. Most individuals with chlamydia are unaware of their infection.40 As a urine specimen from men is suitable for testing for STIs, screening levels could easily be improved on admission to prison. This provides an opportunity for detection and treatment, reducing the risk of transmission of chlamydia both within and following release from the prison system back into the community.
The prevalence of diseases in this population was based on clinical notes and laboratory results only It is possible that not all health care screening and prevention activities were captured by this information as half of the prisoners were incarcerated for less than six months, and may have had multiple health care providers in the community. Transfer of health information to prisons is often incomplete. These issues make the delivery of care for chronic medical conditions and vaccination programs challenging and dependant on good documentation and recall systems which bridge the correctional and mainstream public and private systems.
Despite improvement in the integration of prison health services and an international agreement that ‘All prisoners have the right to health care, including preventative measures, without discrimination and equivalent to what is available in the community’,2health care remains inadequate and inequitable,41,42 and requires further investment.43–45
Studies such as this make visible the differences in the both the burden of disease and the degree of public health interventions within a largely Indigenous regional prisoner population. As a result of this study, staff have instituted changes to the process that increase the focus on the management of chronic illness such as diabetes, including improved documentation and have promoted an increased response to treating drug addiction and reducing lifestyle risk factors. There have also been efforts to improve rates of STI, and BBV screening and ensure immunisations for all Indigenous inmates. Improvements to prison health care, for the sake of prisoners and the community they return to, makes financial, medical and ethical sense.
This study was possible owing to funding from the Commonwealth Department of Health Ageing through the auspices of The Combined Universities Centre for Rural Health and the Australian National University. We wish to thank Dr Tim Moss, Dr Tony Butler and Elizabeth Unwin for help with early drafts of this paper. The audits would not have been possible without the support of Heather Murray and her caring health staff at the regional prison and the encouragement of Dr Ralph Chapman from the Department of Corrective Services.