Project: Identifying Research Components

CLINICAL SCHOLARSHIP

Health Education Needs of Incarcerated Women Shirley Dinkel, PhD, APRN, BC1 & Katie Schmidt, BSN, RN2

1 Associate Professor, School of Nursing, Washburn University, Topeka, KS, USA 2 Director of Nursing, Topeka Corrections Facility, Topeka, KS, USA

Key words Incarcerated women, health education, prison

nursing, naturalistic design, qualitative nursing

Correspondence Dr. Shirley Dinkel, School of Nursing, Washburn

University, 1700 SW College Ave., Topeka, KS

66611. E-mail: Shirley.dinkel@washburn.edu

Accepted: February 3, 2014

doi: 10.1111/jnu.12079

Abstract

Purpose: This study identifies the healthcare education needs of incarcerated women in a state corrections facility. Methods: This was a naturalistic qualitative study. Focus groups included two groups of adult women incarcerated in a state corrections facility. One group consisted of women housed in maximum security, and one group consisted of women housed in medium security. Data were analyzed using a constant comparison approach. Findings: Three guiding questions provided the foundation for the identified themes. Themes included six healthcare education topics important to incar- cerated women and three related to health education strategies best suited for incarcerated women. Conclusions: Trust, respect and empowerment are key concepts in educating incarcerated women about their personal health and health of their families. Clinical Relevance: With over 200,000 women incarcerated in the United States today, creating policies and practices that focus on the healthcare edu- cation needs of women that are woman focused may enhance knowledge and skills and may ultimately lead to reduced recidivism.

Over 200,000 women are currently imprisoned in the United States, a number that has grown more than 800% over the past three decades (Institute on Women & Crim- inal Justice, 2009). Because the majority of prisoners are male, prison programs often focus on issues faced by male prisoners and overlook those faced by female prisoners (Bissonnette, n.d; Stolnik, 2011). As the population of in- carcerated females continues to increase at a rate nearly twice that of males (Stolnik, 2011), health-related pro- grams, educational opportunities, and initiatives focus- ing on the specific needs of female inmates are becoming more and more essential.

Incarcerated women often have a history of sub- stance abuse; physical, sexual, and emotional trauma (Bissonnette, n.d.); and limited access to healthcare ser- vices (Palmer, 2007). The World Health Organization has identified this trend globally, as research conducted in the United Kingdom (Palmer, 2007) revealed simi- lar conclusions. Because of intense, pre-incarceration liv- ing situations, women often neglect their health while at

liberty. When they enter prison, they make great de- mands on corrections health services (Yeager, 2012). The limited research conducted on incarcerated females throughout the United States consistently identifies the intense physical and mental health needs of both the newly and long-term incarcerated woman, including care of chronic health conditions (Binswanger, Mueller, Clark, & Cropsey, 2011). Project: Identifying Research Components

A need for a radical increase in specific health-related educational opportunities for the incarcerated female has emerged. Women entering prison are more likely to re- quire healthcare education to help them build a self-care skill set to better prepare them for release. This skill set may ultimately lead to reduced recidivism (Robertson- James & Nunez, 2012; Zaitzow, 2010). Hatton and Fisher (2011) stress the importance of using participatory meth- ods to examine and educate this high-risk population. The purpose of this qualitative study, therefore, was to understand the health education needs of female inmates in a state correctional facility.

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Methods

A qualitative, naturalist design was used for this investigation. Two focus groups were conducted at a Mid- western, state correctional facility for women. The facil- ity houses three groups of women: minimum-, medium-, and maximum-security inmates. Because focus groups were conducted within the correctional facility, inmates provided unique insight into their lives within prison walls. Their responses to guiding questions were al- lowed to unfold and guided the development of emergent themes.

Recruitment and Informed Consent Procedure

Approval was obtained from the university institu- tional review board (IRB) and the state Department of Corrections (DOC) IRB. One inmate was chosen by the DOC to serve on the university IRB as required. The chair of the university IRB met with the inmate at the correc- tional facility, provided IRB training, and reviewed each section of the proposal. The inmate granted her approval of the proposal.

Two focus groups were conducted to assess the health- care educational needs of women incarcerated at this fa- cility. The Director of Nursing at the prison posted par- ticipation information in public areas. Participants were selected from inmates who indicated an interest in the project. Final selections were made by the prison Direc- tor of Nursing to represent diversity in race or ethnicity, age, and educational accomplishments. All participating inmates provided written, informed consent and were in- structed to offer no personal identification. All inmates were numerically identified based on which group they were in and how they entered the room. Project: Identifying Research Components

Data Collection

Confidential, aggregate demographic data were ob- tained from the prison Director of Nursing. Focus groups were conducted in correctional facility classrooms with guards posted outside the door. Women were counted when entering and leaving the classrooms. Each group was conducted in English and lasted approximately 1 hr. While healthcare education is offered at this facility, to better understand the experiences of inmates, three guid- ing questions were asked of each group. They included: “What are the top ten health education needs of inmates in this facility?”; “What is the best method for educat- ing inmates on these topics?”; and “What would a health fair look like for you?” Participants freely shared informa- tion and stimulated other participants to elaborate, con- tradict, and add to the discussion. Knowledge generation

was viewed as participatory and co-created by all mem- bers of each focus group. Groups were allowed to answer each question until no inmate had additional new infor- mation to offer. While one interviewer presented guid- ing questions to the inmates, the second interviewer kept written field notes. Participants were not known to the researchers and no prison staff were present in the class- room during the focus group discussions.

Data Analysis

Two research team members are doctorally prepared, with one having expertise in qualitative analysis. The third research team member has expertise in correctional health care. All three were involved in data analysis.

Prior to thematic analysis, the research team members reviewed and discussed inmate comments. Data were an- alyzed using a constant comparison approach to identify emerging patterns using a concept map approach. Field notes were reviewed and initial themes were identified for each guiding question. Repeating ideas were com- pared and contrasted across the interview groups to en- sure that each category adequately conveyed the perspec- tive of the participants. The process continued until the research team felt satisfied that all pertinent data were discussed and categorized. The summarized data were written in narrative description and reviewed for clarity and accuracy. While data were reviewed to reflect an- swers to guiding questions, researchers identified an ad- ditional theme that emerged from focus group observa- tions. All are discussed below.

Results

Participants

The sample was a purposive sample. Focus Group One consisted of eight women housed in the maximum- security building and ranged in age from 25 to 51 years. Focus Group Two consisted of eight women housed in medium security. Their ages ranged from 22 to 48 years. Six Black women, six White women, and four Latina women participated in the groups. Projected release dates ranged from less than 1 year to 19 years. Project: Identifying Research Components

Health Topics Important to Incarcerated Women

When asked about the top health education needs of incarcerated women in this facility, inmates identi- fied a variety of topics. While all overlapped, six specific themes emerged. They included the importance of nutri- tion and exercise to prevent and treat obesity, women’s health concerns, communicable disease transmission and

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prevention, dental hygiene, pathophysiology and com- plications of chronic disease, and mental health condi- tions. Group One specifically identified hygiene as an additional important topic, while Group Two identified information on terminal disease as a health education need.

It is well understood that healthful nutrition and reg- ular exercise promote health and prevent obesity. In- carcerated women share this understanding, but with two particular considerations: limited choices in nutrition and exercise needs of those living in small spaces. While all inmates receive nutritionally balanced meals, several women in both groups expressed concern about the dif- fering nutritional needs of women as compared to men, and the changing nutritional needs of women across the lifespan. Inmate G17 stated that meals for all prisons in the state are the same for both men and women and is concerned that her needs as a woman might be differ- ent from her male counterparts. She also stated, “Some- one who is in their 20–30s may need something different than someone in their 50–60s or older.” Women in both groups requested an assessment of their individual nu- tritional needs based on age, height, weight and health conditions. Project: Identifying Research Components

Conversation about nutrition naturally led to discus- sion about exercise. Women in both groups talked about how hard it is to exercise daily while living in an 8-foot by 14-foot space often shared with other inmates. Many participate in the prison sponsored running club. How- ever, women from both groups expressed concern about how foot health and a lack of access to high quality ex- ercise shoes impair their ability to exercise. Inmate G14 requested information on foot health, specifically injury prevention and treatment, as part of an overall exercise program. “If your foot is messed up then the rest of you is messed up” (Inmate G27).

Women’s health was the second theme and encom- passed a broad range of topics, including age-specific screenings, menstruation and menopause, physiologic changes related to aging, and signs, symptoms, and treatment of chronic diseases more commonly seen in women. Overall, women wanted to know what they could expect as they aged and how they could stay healthy. Inmate G25 stated succinctly, “We just want to know the normal signs of aging and what to ex- pect as we get older.” “I want to see what I’m lead- ing up to as I get older” (Inmate G18). Younger women in both groups wanted health educators to teach prison staff and other inmates about menstrual health and hy- giene. “Women bleed and we have different cleanliness needs [than men]” (Inmate G17). Lastly, women from both groups expressed a need for education on healthy sexual relationships. “We need information on how to

have healthy relationships. Some of us may make differ- ent choices on the outside” (Inmate G23).

Communicable disease was the third theme identified by inmates. Two primary topics emerged: skin infections and sexually transmitted infections (STIs). Because of close quarters and shared bathrooms, women in both groups were concerned about disease transmission and infection control. Inmate G23 is knowledgeable about measures to decrease the spread of disease and stated, “You’re never gonna live with me because I am uned- ucated. I’m gonna bleach you every 5 seconds!” All pro- fessed to their own cleanliness but wanted other inmates to be educated on measures to prevent the transmission of disease. “They don’t get that they can get stuff . . . drinking after each other . . . sharing make-up . . .” (In- mate G15).

Sexually transmitted infections were a concern for both groups, and although women in each group felt knowl- edgeable on the topic, they wanted other inmates to re- ceive information. “We are all open—when we wipe with a towel—we have more risk than men” (Inmate G12). While prohibited, inmates did discuss masturbation and the potential to spread STIs to each other. “. . . women don’t know that they can still pass disease and how infec- tions are passed” (G14). Women in both groups expressed the need for community resource information upon re- lease to prevent and treat STIs. Project: Identifying Research Components

Dental hygiene was a topic that women from both groups felt passionate about and it emerged as the fourth theme. Inmate G17 felt that women in her facility don’t understand the importance of proper dental care and “. . . how dangerous poor mouth care can be. It affects nu- trition and other diseases.” Inmate G28 was more con- cerned about “how to tell people that they need to brush and floss because gingivitis and pyorrhea is nasty.”

The fifth theme identified was a need for more in- formation on the process of aging and, specifically, on the signs and symptoms of chronic diseases most af- fecting women in adulthood. There was concern about being able to distinguish age-related changes from disease-related changes. Inmate G25 was more concerned about the warning signs of stroke, aneurysm, and early Alzheimer’s disease. She stated, “I need to know what is normal and what is not.” Discussion on heart disease ran parallel with discussion on diabetes. Inmate G13 de- scribed a situation where she “ain’t feeling quite right,” was prescribed medication, and now feels she “traded in symptoms for medication-related symptoms.” While death and dying were not openly addressed, Inmates G23 and G27 felt information on the potentially fatal diseases of hepatitis C, chronic obstructive lung disease, and breast and cervical cancer would be important. Interestingly, younger inmates from both groups expressed the need

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to know more about diabetes and arthritis so they could support other inmates.

The last theme was mental health. As with women’s health, this topic was broad and included stress man- agement/coping, testing and treatment of mental health conditions related to substance abuse, recovery, and preparation for release. Many inmates receive mental health services while incarcerated. However, Inmate G18 was interested in learning more about being proactive with her mental health and “not just things to reverse damage.” Several women in Group Two expressed an in- terest in knowing more about nonpharmacologic stress management and coping. Inmate G23 illustrated this when she stated, “[We need to know] what happens to the brain when you put in good, including good thoughts and motivation.” She went on to say that early in her incarceration she “. . . let my time do me. Now I am doing more for myself. I want to be ready when I’m out.” Education on drug detoxification and potential out- comes of long-term addiction was identified as an im- portant need. “Face it . . . we are inmates and most all drug addicts” (Inmate G23). Inmate G27 wanted more in- formation about pharmacological treatment of substance abuse so she would not be “not going from one drug to the next.” Women in both groups were concerned about returning to illicit drug use upon release and wanted information on community treatment resources such as Narcotics Anonymous and credible websites. To stop the familial pattern of drug addiction, Inmate G23 believed that drug addicts should have education about genetic testing for children of those addicted to drugs.

The Best Methods for Educating Inmates

Question Two asked inmates “What are the best meth- ods for educating inmates on these topics?” Answers were similar in both groups and included two primary themes. The first theme was respect for adult learners. Inmate G15 stated, “Inmates want do decide on something that is meaningful.” Inmate G12 followed with, “Don’t talk to me like I’m two. We are not stupid.” Within Group One there was a resounding need to have optional health ed- ucation experiences that are not open to all inmates “. . . to prevent bitch fests . . .” (Inmate G12). Inmate G22, of Group Two, identified similar concerns when she stated, “People need to be interested so others don’t be loud and ruin it for everyone else.” Lastly, Inmate G22 expressed that having an opportunity to share stories in small group settings would enhance learning. Project: Identifying Research Components

The second theme, about preferred educational meth- ods, was use of a variety of teaching and learning techniques that include hands-on activities. Inmate G12 stated that pamphlets “. . . go in the trash.” She went on

to say “[the information] needs to be more important to us . . . [and we need] to be able to see, touch and feel.” Inmate G15 believed that if the information was dull, pic- tures “can shine it up.” Inmate G13 then added, “I can remember what I’ve seen but not always what I hear.” Inmates G23 and G25 expressed a need for information on credible websites so they could have “resources avail- able when [they] get out.” Additionally, there was con- sensus between both groups that a variety of presenters are necessary to stimulate learning.

Visions of a Health Fair

The third guiding question was related to the inmates’ vision of a health fair. Responses to Question Three were similar between groups where women envisioned a health fair where inmates were free to walk around and visit educational booths that used color, words, images, and hands-on activities to make information appealing. All stressed that topics must be significant to inmates in order to positively impact learning. Both groups also ex- pressed an interest in obtaining screenings pertinent to their healthcare needs, such as cholesterol, blood pres- sure, bone density, and cancer, with a private area where inmates could have an individualized interaction with a healthcare expert. Inmates in Group Two specifically re- quested information pertinent to release, such as commu- nity resources, information on child health, and genetic testing. However, Inmate G23 stated, “Needs are differ- ent based on time. If you’re here for 6 months—don’t say anything . . .,” implying that those with longer sentences have the greater long-term need for inmate participation. Based on responses, it is clear that there is a need for ad- ditional investigation on the healthcare education needs of female inmates over time.

Overall, women in this study articulated a need for comprehensive health education at all levels of preven- tion. They clearly expressed a desire for involvement in the educational process and offered suggestions that would be interactive and interesting to meet the needs of these adult learners. In addition to the themes expressed specifically by inmates, the interviewers observed an ad- ditional theme: the intersection of respect, trust, and em- powerment in this correctional facility, which is discussed in the following section. Project: Identifying Research Components

Discussion

While women discussed specific issues related to the three guiding questions, embedded within the conver- sations was the complex relationship between respect, trust, and empowerment. In this study, women described a scenario where empowerment involves respect for and

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from others. Self-respect was expressed when women talked about how to be proactive in their health care, both while incarcerated and after release. This idea was il- lustrated by Inmate G13 when she stated, “When I am 45 and I hit this gate, I need to be ready.” Inmates from both groups expressed concern for other incarcerated women. Inmate G17 succinctly stated, “Help us help each other and help ourselves.”

The need for respect was most evident in discussions involving the best methods for educating inmates. As stated earlier, women from both groups wanted an op- portunity to provide input into meaningful topics, to be provided with an adult learning environment, and op- portunities to choose which educational sessions they at- tended. Inmate G12 stated, “Knowledge is power. We are not stupid. We have to do our part.” Inmate G15 sup- ported this idea when she replied, “Inmates want to de- cide on something that is meaningful.” The researchers believe that the mere opportunity to participate in the focus groups and potentially make a valuable contribu- tion to their future health care while incarcerated may have contributed to building respect for self and for others.

Respect is paramount to trust. Bissonnette (n.d.) de- scribed trust in the corrections environment as the pro- vision of culturally competent care with an under- standing of women within the context of their lives prior to and during incarceration. While participants did not expressly describe trust during the focus groups, trust was evident. Women spoke freely about sensitive health topics. They listened and responded respectfully to other inmates within the groups and expressed ap- preciation to the researchers. They validated each other’s experiences. Project: Identifying Research Components

Lastly, the concepts of trust and respect have been linked to empowerment (Bissonnette, n.d.; Laschinger & Finegan, 2005). Kanter (1977) defined empowerment as having access to information and the opportunity to learn and grow. Laschinger and Finegan (2005) built on this definition and linked empowerment to interactional justice, respect, and organizational trust. They defined interactional justice as the “perception of quality of in- teractions among individuals involved in or affected by decisions” (p. 2). Interactional justice includes the extent to which individuals are treated with respect and dig- nity and how information is provided in a timely and meaningful way. While much of the work by Kanter (1977) and Laschinger and Finegan (2005) is grounded in workplace settings and employee satisfaction, these concepts are equally visible in corrections. Bissonnette (n.d.) has woven similar concepts into a program of trauma-informed practice. Inmates and staff are encour- aged to build an environment that is culturally compe-

tent, creates an atmosphere of respect, strives to maxi- mize women’s choices and control, and solicits women’s input in designing and evaluating services. While inmate empowerment was not measured in this study, the re- searchers believe that participation in the focus groups may have increased their personal sense of empower- ment. Women in each group were given access to in- formation, participated in meaningful dialogue with each other and researchers, were treated with respect and dig- nity, and identified opportunities for choice in healthcare education. While the translation of these data into poli- cies and practices has yet to emerge, the stepping stones to healthcare education at this facility have been set.

Trustworthiness and Limitations

Trustworthiness in qualitative research has inherent bias and limitations. This study was no exception. All attempts were made to maintain credibility, dependabil- ity, confirmability, and transferability during data collec- tion and analysis. Credibility was strengthened in three ways. By using a nonrandom, purposive sample, infor- mants provided unique insight. Including the perspec- tives of women from diverse cultural backgrounds and who are incarcerated for various lengths of time pro- vided depth and breadth of experience. Credibility was also strengthened by the confidentiality of the groups. No prison staff was present during the sessions. Dependabil- ity was enhanced by utilizing a constant comparison ap- proach to examine the data by all research team mem- bers. Confirmability is most challenging. Two research team members have experience working in corrections and offer some understanding of the healthcare needs of incarcerated women. However, researchers were un- able to share the analyzed data with participants. This is partially due to some participants being released from prison prior to full data analysis. Continued efforts are being made to share conclusions with participants. To en- hance transferability, thick descriptions of healthcare ed- ucational needs of incarcerated women as well as the use of direct quotations are included. However, transferabil- ity is limited. All participants were from the same correc- tional facility; therefore, findings may not be transferable to women incarcerated at other facilities, nationally or internationally. Additionally, women incarcerated in the minimum-security setting were not included in the focus groups. Their experiences, especially related to trust, re- spect, and empowerment, might be quite different from those in medium- and maximum-security settings. Lastly, the length of incarceration may be a factor that influences healthcare education needs. This difference was not con- sidered as part of the investigation. Project: Identifying Research Components

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Implications for Practice and Future Research

Results from this study highlighted several areas ger- mane to future practice and research. Participants in this study clearly identified healthcare education needs. This can directly translate to healthcare practice considera- tions. Opportunities to build intra-agency healthcare edu- cational programs, collaborate with community resources such as schools of nursing, and develop peer programs addressing health education are evident. Strategies may include a health fair, formal healthcare educational pro- grams offered by experts in the community, and one-on- one sessions between individual inmates and corrections healthcare providers. Part of any corrections healthcare education program must include an atmosphere that is respectful of women’s needs for safety, respect, and ac- ceptance, and it must involve inmates in designing and evaluating services (Bissonnette, n.d.). Project: Identifying Research Components

This study focused on a diverse group of women in a midwestern, medium- and maximum-security correc- tional facility. Clearly, an understanding of the same needs of women in minimum security is desirable. Ad- ditionally, while this study included women from diverse backgrounds who are incarcerated for various lengths of time, a better understanding of the impact of length of in- carceration on healthcare educational needs is necessary. Similarly, educational needs of those about to be released may be substantially different from those who will not be released in their near future.

Lastly, this study revealed the links between trust, re- spect, and empowerment of female inmates and their po- tential impact on healthcare learning. Special considera- tions may need to be given to those in continuous segre- gation who have different opportunities for building trust and respect with staff and other inmates. Further under- standing of the complex relationship between these con- cepts may guide correctional agencies to further develop gender-informed policies, procedures, and practices.

Conclusions

There is a continuing challenge in health care to pro- vide culturally relevant care to vulnerable populations (Palmer, 2007). This includes incarcerated women. The Department of Justice, Department of Corrections, Na- tional Institute of Corrections, and Substance Abuse and Mental Health Services Administration have made great efforts to operationalize gender-informed practices with female inmates (Bissonnette, n.d.). Continuing to provide quality, safe health care and proactively providing health- care education that is meaningful to women may im- prove the health of incarcerated woman and ultimately reduce the recidivism rate of women released from prison (Bissonnette, n.d.). Project: Identifying Research Components

Clinical Resources � Clinical care of incarcerated adults: http://www.

uptodate.com/contents/clinical-care-of-incarcerated- adults

� Creating trauma-informed correctional care: http:// www.seekingsafety.org/7–11–03%20arts/2012% 20miller%20naj%20trm%20corrs%20ejp.pdf

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