research on prison healthc

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HEALTH CONCERNS AND HEALTH SERVICE UTILIZATION OF INMATES

AT SAN RAMON PRISON AND PENAL COLONY, ZAMBOANGA CITY

___________________________________________________________

A RESEARCH PAPER

PRESENTED TO

THE FACULTY OF

ATENEO DE ZAMBOANGA UNIVERSITY

GRADUATE SCHOOL

ZAMBOANGA CITY

IN PARTIAL FULFILLMENT OF THE

REQUIREMENTS FOR THE DEGREE OF

MASTER IN PUBLIC HEALTH

____________________________________________________________________

BY

DR. AUGUSTO MANOLO G. ALPICHI

APRIL 2008


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APPROVAL SHEET

This Thesis entitled: Health Concerns and Health Service Utilization of Inmates at

San Ramon Prison and Penal Colony, Zamboanga City prepared and submitted by

Augusto Manolo G. Alpichi, MD in partial fulfillment of the requirements for the

degree of Master in Public Health is hereby accepted.

________________________

Servando D. Halili, Jr, PhDResearch Adviser

Approved by the Oral Examination Committee with a grade of PASSED.

________________________

Rosemarie S. Arciaga, MD

Chairman

________________________ _________________________

Fortunato L. Cristobal, MD Ricardo N. Angeles, MDMember Member

________________________Jocelyn D. Partosa, PhD

Member

ACCEPTED in partial fulfillment of the requirements for the degree of MASTER IN

PUBLIC HEALTH.

______________________

Servando D. Halili Jr., PhDDean, Graduate School

Ateneo de Zamboanga University


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ACKNOWLEDGEMENT

My heartfelt gratitude to the following individuals, who in their unselfish

assistance, have made this paper a work of adulation.

To my family for the auspicious reassurance and unwavering support. To mymom and my sister Leila, thank you for the much needed financial subsidy. To my

sister Giselle for the editing and proof reading chores. To my two nephews, JM andElijah, seeing you metamorphose from adorable infants into care free and playful young

adults is truly a stress-busting experience. To my youngest nephew, Gadiel, another

source of bliss and brainwave.

I am very much grateful to Dr. Ben Halili, my adviser and mentor. He always

made himself available every time I consulted despite his frenzied schedule. He always

kept his cool and personal warmth despite my numerous shortcomings. Thank you sirfor the words of insight and support.

I am especially indebted to the panel of evaluators for their invaluable suggestionsand constructive criticisms which greatly improved this paper. I am very much grateful

especially to Dr Rosemarie Arciaga and Dr Ric Angeles, the moderate ones in the

panel.

To the management of San Ramon Prison and Penal Colony, especially to those at

the Records Section and the health personnel, for helping me out during the

implementation of my study

My profound gratitude to the very cooperative inmates of the penal colony who

have gamely participated in this study

To the very professional management team of the Zamboanga City Reformatory

Center for assisting me during the pretesting of my questionnaire

My earnest thanks to my dear classmates and great buddies Janet, Joseph, and

Sitti.

With Gods guidance and strength, this work was completed.

Noy AlpichiApril 2008


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LIST OF TABLES

Table 1. Educational Attainment 21

Table 2. Occupation Prior to Incarceration 21

Table 3. Age of First Incarceration 22

Table 4. State of Health Inside Prison 25

Table 5. Self-reported Lifestyle 26

Table 6. Claimed Diseases Suffered in the Past Year 28

Table 7. Health Complaints in the Past Year 29

Table 8. Parameters of Emotional Health 30

Table 9. Top Five Illnesses Based on Medical Records 31

Table 10. Consulted Jail Physician 35

Table 11. Consulted Jail Nurse 36

Table 12. Consulted Jail Dentist 36

Table 13. Health Programs and Screenings Attended 37

Table 14. Satisfaction on Health Services Rendered 38


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LIST OF FIGURES

Figure 1. Conceptual Framework of the Study 6

Figure 2. Smoking Habit 23

Figure 3. Sick in the Past Week and Year 27


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TABLE OF CONTENTS

Page

APPROVAL SHEET i

ACKNOWLEDGEMENT ii

LIST OF TABLES iii

LIST OF FIGURES iv

TABLE OF CONTENTS v

ABSTRACT vii

CHAPTER I INTRODUCTION 1

Background of the study 1

Statement of the Problem 3

Objectives of the Study 3

Significance of the Study 4

Scope and Delimitation 4

Operational Definitions 5

CHAPTER II REVIEW OF RELATED LITERATURE 7

CHAPTER III METHODOLOGY 15

Research Design 15

Study Site 15

Respondents 16

Sampling Method 16

Research Instruments 16


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Pre-data Collection 18

Data Collection 18

Data Management and Analysis 19

CHAPTER IV PRESENTATION AND INTERPRETATION

OF RESULTS 20

CHAPTER V CONCLUSIONS AND RECOMMENDATIONS 40

BIBLIOGRAPHY 80

APPENDICES 43

Appendix 1. Health status and health service

utilization questionnaire 43

Appendix 2. Filipino Translation of the Questionnaire 55

Appendix 3. Guide Questions for the Structured Interviewfor Health Personnel 66

Appendix 4. Excerpts from the interview with the jail physician 67

Appendix 5. Excerpts from the interview with the jail nurse 69

Appendix 6. Excerpts from the interview with

the jail pharmacist 72

Appendix 7. Excerpts from interview with the dentist 74

Appendix 8. Description of the Infirmary according to an Inmate 75

Appendix 9. Annual Health Data Report for 2007 76

Appendix 10. Letters 77


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ABSTRACT

Little is known about the health concerns of inmates as well as the health services

availability in the oldest and third largest correctional facility in the country. Hence, this

study was carried out to determine the health concerns and health services utilization of

inmates at San Ramon Prison and Penal Colony. This is a cross-sectional descriptivestudy utilizing 215 inmates and all health personnel as respondents. The five jail

personnel of the penal colony are the jail physician, two jail nurses, dentist, and

pharmacist. The respondents were interviewed utilizing the 53 item interviewer-

administered questionnaire to determine health concerns and health service utilization.

Inmates` medical records were utilized to determine the past illnesses. Interview of the

health personnel and ocular inspections were conducted to determine the available

health facilities/services. More than half of the respondents either stated that their health

worsened slightly (34.9%) or stayed the same (29.8%), since incarceration. Close to 33%

reported to be sick in the past week. Upper respiratory tract infections (25% prevalence

rate) and hypertensive urgency (6.5%) were the most commonly self-reported sicknesses

in the past week. Sixty percent reported to be sick in the past year. The five most commonclaimed diseases in the past year were essential hypertension (11.2%), pulmonary

tuberculosis (10.7%), skin diseases (9.9%), upper respiratory tract infections (7.9%), and

wounds of all kinds (5.6%). The most commonly reported health complaints in the past

year were cough, dental and hearing problems. Thirty two percent experienced

depression in the past four weeks. The five most common physician-diagnosed diseases in

the past year, based on medical records, are upper respiratory tract infections (13.9%),

essential hypertension (11.6%), skin diseases (11.1%), pulmonary tuberculosis (10.7%),

and wounds of all kinds (6.9%).The available health facilities include a jail clinic, a

pharmacy, and an infirmary. The health services available include physical

examinations, blood pressure monitoring, and admission at the infirmary for those

admissible for medical care, Directly Observed Treatment Short Course for TB patients,

tooth extraction, and free medicines for common health complaints. Fifty five percent

consulted the jail physician in the past six months. The most common reason for consult

is for common health complaints such as skin problems and cough and colds. Sixty six

percent consulted the jail nurse. The most common reasons of contact are for medication

(46%) and for blood pressure assessment (15%). Twenty three percent of respondents

consulted the dentist. Only five out of 215 respondents were hospitalized in the past six

months. The reasons for hospitalization were hypertensive urgency and pulmonary

tuberculosis. The most common health program attended in the past year is physical

examination (37.7%) and the most common health screening attended is blood pressure

monitoring (36.1%).


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CHAPTER I

THE PROBLEM AND ITS SETTING

Background of the Study

The prison system came into being at the end of the 18th

century (Gupta, et al, 2001). The

penitentiary was conceived as a place of reforming criminals and was considered by its founders

to be less harsh and more humane than traditional such as stocks, whipping, or other gallows.

The primary intent of correctional facilities is to rehabilitate offenders by removing them

from all sources of corruption, providing them with a well-disciplined routine, and

isolating them from one another so they could become penitent for their misdeeds

(Rothman, 1971).

The correctional system is supposed to be a rehabilitative institution rather than a

punitive place for punishment. It is a venue for rehabilitation and is supposed to have a system of

organized care and treatment program aimed at the promotion of the dignity of the confined

persons. Further into the system is a comprehensive multi-disciplinary rehabilitation program

aimed at the total human development of the inmates which cover educational services, spiritual

development, livelihood opportunity, enhancement, and other welfare services inclusive of

health and medical provisions (Philippine Commission on Human Rights (CHR) Report, 2004).

Despite the declaration, it is a sad fact that little systematic planning has been conducted

to address the different problems besetting the prison system for the reason that majority of

countries place the prison system at its tail end of budgetary allocation. It appears that priority

is not a recognized word for these policy makers when talk of supporting these correctional

institutions surfaces. Most criminal justice system need an overhaul from policymakers in terms

of infrastructure/facility upgrade and innovative health programs geared to cater the varied health

needs of inmates.

During the past years that the Philippine Commission on Human Rights (CHR) has been

monitoring conditions in jails and detention centers, majority of the facilities covered by the


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visits were found not fit for human confinement. The CHR report (2004) stressed that these

jails are observed and described as unlikely to rehabilitate, but certain to punish. Inspections

made by CHR regional offices revealed that more than 50% of the jails covered by the visits

needed a gargantuan amount of reconditioning and restoration, the report further stated. The

most common problem encountered by prisoners, according to the report was insufficiency or

lack of food provision due to the delay in release of food allotment and inadequate or unsanitary

food preparation. Another major problem is shelter/living space of detainees. Old and

dilapidated buildings, defective comfort rooms, lack of sleeping paraphernalia, undersized cells

with poor ventilation, defective water system, and poor or no lighting facilities characterize the

confinement areas of prisoners. The absence of sufficient medical supplies and laboratory

facilities in correctional systems is also a major concern. Due to these, disease transmission

among prisoners in these setting is fast and outbreaks of skin diseases, diarrhea, tuberculosis,

sexually transmitted infections, and other infectious illnesses have been reported, the report

concluded.

Prisoners, as they may be branded, are still endowed with the same basic rights

inherent in every individual. Their dignity as a person should always be upheld. The provision of

basic rights and needs of prisoners as human being needs to be fulfilled first before any effective

rehabilitation program can be realized (Aday, 1994). One of these basic rights is the right to

health. The inmates are also entitled to the quality health care as every free man deserves and

enjoys.

However, according to Gupta et al (2001), prison health is always a neglected and

forgotten area. Most studies indicate that prisoners suffer from problems such as severe drug

abuse, alcoholism, homicide, suicide, infectious diseases, among others. Those who are

incarcerated represent a medically underserved population and considered at high risk of medical

disorders. The lack of concern, meager facilities, and inadequate heath personnel further

aggravate the health of inmates. Unless their intricate problems on health and other concerns are

addressed, prisoners will always remain as a group of useless, unproductive and irrelevant

individuals. With this condition, the real purpose of these correctional facilities, of rehabilitating

those who defied the law once in their life is forfeited.


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Marquet et al (2000) (as cited in Loeb and Steffensmeier, 2006) stated that although

issues related to health care for inmates have captured the attention of correctional healthcare

professionals and the larger correctional community, only a modest amount of research has

examined these issues.

Few comprehensive researches on health conditions of inmates of Philippine correctional

facilities have been published. Hence, this paper was conceived with a view of looking into the

health condition of inmates at San Ramon Prison and Penal Colony, the oldest and third largest

correctional facility in the Philippines, located in Zamboanga City.

Statement of the Problem

The following were the key research questions pursued in this research.

1. What are the health concerns of inmates of San Ramon Prison and Penal

Colony?

2. What are the health facilities and services available to the inmates?

3. Do inmates utilize the health services made available for them?

Objectives of the Study

The general objective of the study was to determine the health concerns and healthcare

delivery system in San Ramon Prison and Penal Colony. It had the following specific objectives:

1. to determine the health concerns of inmates;

2. to determine the past illnesses based on medical records;

3. to describe the health facilities and services available at the penal colony; and,

4. to describe the utilization of inmates of the health services made available to

them.


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Significance of the Study

The findings of this study have important policy implications. This research study can

provide valuable systematic information to policymakers regarding the actual health picture of

inmate population of San Ramon Prison and Penal Colony. With the information at hand,

policymakers will be guided accordingly on the future health programs and policies that will

reliably address the multifaceted health needs of the inmate population. It is also the goal of this

paper to amplify the awareness of the general public on the actual health conditions of this

neglected and forgotten segment of the society.

Scope and Delimitation

This study limited itself to the population of inmates incarcerated at San Ramon Prison

and Penal Colony, particularly two groups (those 50 years old and above and those incarcerated

for ten years or more who are less than 50 years old). A delimitation of this study is that

prisoners` health concerns and health service utilization were exclusively assessed by self-report

(through the interviewer-administered questionnaire). Physical examination of inmates was not

done. Other factors which might affect the health services utilization among inmates were not

explored in this study. Result of this study is only true for the two groups of inmates- ages 50

years old and above and those less than 50 years old who have been incarcerated for ten years or

more. It may not also hold true for other population of inmates incarcerated at the penal colony

as well as for inmate population in other detention facilities in the city and the country as a

whole.

Operational Definitions

Emotional Health Parameters: This measures the emotional health of inmates. These included

questions which explore the following: difficulty in adjusting to being incarcerated, experience

of depression in the past four weeks, preference to be alone, problems in concentrating at work

or in other regular activities, suicidal intent, tendency to hurt self or involvement in a fight, and

experience of physical abuse by fellow inmates.


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Health facilities: This refers to the jail clinic, infirmary, dental clinic, and pharmacy.

Health personnel: This refers to the jail physician, two jail nurses, dentist, and pharmacist of the

prison colony.

Health services: This refers to the available health programs and screenings made available by

health personnel to inmates. This also refers to physical examinations/check ups, emergency

medical care, and ambulatory patient care.

Health service utilization: This refers to the participation/use of inmates of the health programs

and screenings available; number of consultations/visits done to the health personnel of the jail

colony (jail physician, nurses, and dentist) and/or hospital emergency room.

Living out prisoners: These are prisoners who are not confined to the main detention facility and

are granted the privilege of establishing their individual houses within the premises of the penal

colony.

Older male inmates: This refers to male inmates who are 50 years old and older.


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Conceptual Framework

Figure 1. Conceptual Framework of the Study

This study seeks to explore the various health concerns of inmates as well as their health

services utilization. Health services utilization could not be determined unless the health delivery

system of the penal colony is elucidated. The health delivery system was determined by

identifying the available health facilities as well as the health services rendered. The health

services include various health programs, screenings, and ambulatory patient care offered by

health personnel.

Health Concerns of Inmates

Health Delivery SystemIDENTIFICATION

OF

Health Services Utilization

TO DETERMINE

San Ramon Prison

and Penal Colony

Health Facilities

Health Services


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CHAPTER II

Review of Related Literature

Prisoners are not the same with the general population in their health needs. According to

Lester et al (2003), concerns about the health of prisoners are not new and many have expressed

that prison health services require urgent modernization.

Individuals incarcerated in correctional system facilities are thought to represent a

special population both with respect to their health status and also their medical care needs

(Novick, et al, 1977). Only few studies are available on the health status of populations of

prisoners despite numerous reports of prison health care systems in various states and localities

which described the numerous inadequacies and the meager support given to them.

In another study by Conklin, et al (2000) conducted in Hampden County Correctional

Center located in Western Massachusetts, obtained comprehensive health information from

newly admitted correctional inmates. Interviews were conducted with 1198 inmates on day three

of their incarceration. Results of this study include a high prevalence of chronic medical and

mental health issues, limited access to health care, high rates of infections and sexually

transmitted diseases, substantial substance abuse, other unhealthy behaviors and violence, and a

strong desire for help with health-related problems. The study concluded that there is a need to

apply the public health approach to correctional health care, including detection and early

treatment of disease, education and prevention to facilitate health and behavior change, and

continuity of care in the community.

Baillargeon, et al (2000) documented the disease profile of Texas prison inmates. The

present study examined the prevalence of major acute and chronic conditions of the said prison

system, considered to have one of the largest prison populations in the United States.

Respondents consisted of 170, 215 inmates. These inmates were incarcerated between August

1997 and July 1998. The institution-wide medical information system provided data on medical

conditions and socio-demographic factors. The most prevalent major disease category noted

among the inmates was infectious diseases (29.6%). Also included in the list were disease of the


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musculoskeletal system and connective tissue (15.3%), diseases of the circulatory system (14%),

mental disorders (10.8%), and diseases of the respiratory system (6.3%).Evidence of tuberculosis

infection without active pulmonary disease (20.1%) was found to be the most prevalent

condition. The other specific conditions examined include hypertension (9.8%), asthma (5.2%),

low back pain (5.1%) and viral hepatitis (5%). Prevalence rates for a number of conditions,

reported to be substantially higher among the prison population compared to those reported for

the general population. There is also a substantial variation noted for a number of diseases

according to age, race, and gender.

According to Glaser and Greifinger (1993), 1.2 million inmates in US correctional

institutions have a high prevalence of communicable diseases. These include HIV infection,

tuberculosis, hepatitis B virus infection, and gonorrhea. Most inmates have limited access to

health care, before incarceration. Coupled with poor compliance, make them difficult to identify

and treat in the general community.

The fastest-growing prison subgroup is men age 50 years and older, of whom 85% have

multiple chronic health conditions (Loeb and Steffensmeier, 2006). Gal, cited in Older Male

Prisoners: Health Status, Self-Efficacy Beliefs, and Health-Promoting Behaviors, (2002) is in

support of this finding as he pointed out that inmates age 50 years and older constitute the

fastest growing age cohort in prisons today. Older prisons are further classified by Becket,

Peternelj-Taylor, & Johnson, 2003, into three major groups: inmates with extended sentences,

repeat offenders, and first time offenders who commit crimes and/or are apprehended late in

life. Most studies reveal that older prisons are said to be major consumers of corrections health

services (Aday, 2003; Mitka, 2004).

Some of the more commonly reported health conditions among older inmates include

cardiovascular problems, arthritis, psychiatric conditions, substance abuse, respiratory diseases,

endocrine disorders, and sensory deficits (Loeb and AbuDagga, in press).

A study conducted by Loeb and Steffesmeier (2006) measured the participating health

promoting behaviors and related activities of older men in prison. This was a pilot study


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conducted at Pennsylvania Department of Corrections facility. The subjects were 51 older male

inmates. The survey instrument used included demographic items, the Older Mens Health

Program and Screening Inventory (OMHPSI; Loeb, 2003), items from the Health Promotions

Activities of Older Adults Measure (HPAOAM; Padula,1997), and questions developed by the

authors relevant to the study. For the health status, the two most common reported self-ratings

were good (56.9%) and fair (21.6%) with all participants having comorbidity. Vision problems

(84.3%) are the most common chronic condition. For self-efficacy for managing health, 60% of

respondents are very confident in managing their own health. For the past 12 months,

respondents attended from zero to nine health programs (M=2.55, Mdn=2.00). The most

commonly attended health programs are the following: immunization (68.6%), exercise program

(41.2%), and substance abuse programs (39.2%). Respondents availed of one to seven health

screenings in the past 12 months (M=4.53, Mdn=4.0). The three most common health screenings

include blood work (98.0%), blood pressure assessment (94.1%), and physical examinations

(94.1%). Colonoscopies were the least reported at 17.6%. Respondents also were asked to

indicate how likely they are to watch for various body function changes as they age (e.g., urinary

frequency and hearing). This was reported using a 4-point scale ranging from very unlikely to

very likely. Scores ranged from 34 to 56 (possible range of 14 to 56), with higher score

reflecting greater likelihood of watching for changes (M=49.34, Mdn=50).

Access to health professionals by US prisoners regardless of age is made possible without

too much effort. According to Feron et al (2005), prisoners make an average 17 visits to the GP

each year. This is 3.8 times more visits than the average prison in the community. However, this

study failed to show the breakdown of visits by age group.

Lindquist and Lindquist (1999) examined the utilization and evaluation of medical care

among jail inmates in a large county jail in a southern city of the United States. The study also

determined the physical health status of 198 male and female inmates. Using multiple regression

analysis, predictors of physical health status, utilization of medical care, and inmates`

evaluations of the accessibility and quality of health care were recognized. Gender and age are

the most consistent demographic predictors of health status and medical care utilization. Females

and older inmates have higher morbidity. Thus, these two groups have higher numbers of


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medical encounters. Inmates have unduly high levels of chronic and acute physical health

problems. This translates into increased utilization of health services in correctional institutions.

The experience of incarceration also affects the physical health of inmates. This is manifested by

an increase in self-reported chronic and acute physical health problems with increasing inmates

period of incarceration. Evaluations of jail medical care differ significantly by gender. Female

inmates reporting more difficulty accessing health services, yet they seem to have higher

satisfaction with the quality of services acquired. The outcome suggests a need for medical care

in correctional settings to adapt to the medical needs of older inmates and women, in addition to

improving treatment for chronic conditions and preventive services.

In an article entitled, The Health Care Needs Assessment of Federal Inmates Report

(2004), published in the Canadian Journal of Public Health, provides a comprehensive profile

of the health status and needs of federal inmates in Canada. This report noted a difference

between the health status of the general population and the inmate population. Inmates` health

status indicators are influenced by many social and economic factors. They are also considered a

high risk, high needs population. Socio-economic factors that negatively influence health of

the inmate population include lower levels of formal education, a history of unemployment,

previous unstable accommodation and lack of social support networks. Health behaviors indicate

that inmates are more than twice as likely to smoke and more likely to have alcohol or

substance abuse disorders. Inmates have higher chronic disease rate of diabetes, cardiovascular

conditions, and asthma. Inmates also have higher rates of infectious diseases compared to the

general population. They usually manifest a history of high-risk behaviors, such as injection drug

use, trade sex and unprotected sex with high risk partners. These place them at risk of infection

prior to their incarceration. Inmates are more than twice as likely to develop any mental disorder.

A substantial proportion of inmates have co-existing mental health disorders and substance abuse

needs.

Lester et al (2003) conducted a study entitled Health Indicators in A Prison Population:

Asking prisoners. The setting was Her Majestys Prison (HMP) Cardiff in Wales. Three

hundred men were administered a questionnaire which contents included qualifications, previous

occupation, drug, alcohol, and medical history, smoking, perceived threats, worries, diet,


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exercise, drugs in prison, access to services, and the Hospital Anxiety and Depression (HAD)

scale. Results were the following. Twenty five percent drank 90 alcohol units or more weekly

before prison and 68% used illegal drugs with 33% still drug user inside prison. Sixty eight

percent never had vigorous exercise and 62% ate less than three portions of fruit and/or

vegetables daily. Thirty five percent have normal HAD range for both anxiety and depression.

Fazel (2001) studied 203 men from 15 prisons which held at least 10 older prisons (over

60 years of age). These inmates were held within 100 miles of Oxford. Semi-structured interview

and inmates medical records provided the data. Data gathered from younger prisoners and

community older people were used as basis for comparison. The results revealed that 83% of

elderly prisoners reported long standing illness or disability, 19% had a new illness that had

started in the previous three months and 85% had a major illness or disability recorded in their

medical notes. These figures are relatively high compared to younger prisoners and older people

in the community. Ten percent of older prisoners interviewed stated that they were functionally

disabled in Activities of Daily Living. The illnesses recorded were psychiatric (92%),

cardiovascular (71%), musculoskeletal (48%), respiratory (31%), and genito-urinary (2%),

endocrine (20%), and gastroenterological (20%). The level of self-reported illness was similar,

except only 18% considered having psychiatric illness and 88% thought of having

musculoskeletal illness. Self reported illness in the younger prisoners (aged 18-49 years old) was

mainly musculoskeletal and respiratory.

The study of Fazel (2001) illustrates a marked difference in terms of the health of older

and younger prisoners as well as when comparing the health of older inmates to the older

community residents. The older prisoners are much more likely to suffer illness or disability,

except smoking related conditions. As younger prisoners age, this will also add to the older

prisoner problem.

Fazel (2001) compared the health of older prisons to younger prisons as well as to the

older community people living in Oxford. Prior to this, research results appeared conflicting.

There was a reduction in health care demands as prisoners age (Twaddle, 1976 in Fazel). There

was a noted increase in the utilization of health services with age (Lindquist et at, 1999).


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The main issues in prison health care, according to Watson and Hostick (2003), are

mental health, substance abuse, and communicable diseases. Health promotion and the health of

the community outside prisons are desirable aims of prison healthcare. The delivery of effective

healthcare to prisoners is dependent upon partnership between health and prison services.

Telemedicine is one of the identified modes of delivery of healthcare to prisoners.

Guthrie et al (1996) measured the health service satisfaction among female inmates in

New South Wales, Australia. Particular variables were analyzed for factors associated with

satisfaction with provision of health services. These variables include indigenous status, mean

age, age range, and education level. Analysis indicated that for the nine outcomes, correctional

center location was the only statistically significant indicator of satisfaction with various aspects

of health care provision. Three factors- correctional center location, indigenous status, and age

group-were associated with being satisfied with health care received during a womans last

prison doctor consultation. The studys most important finding was that the correctional center

was associated with inmates` satisfaction with health care services.

In another related study authored by Feron, et al (2005), revealed a substantial use of

primary care in prison. The study was conducted in all Belgian prisons (n=33). This is a

retrospective cohort study of a sample of prisoners` medical records. Main results were the

following. Prisoners consulted the GP 17 times a year on average. It is 3.8 times more than a

demographically equivalent population in the community. The most common reasons for

physician encounter were administrative procedures (22%), psychological (13.1%), respiratory

(12.9%), digestive (12.5%), musculoskeletal (12%), and skin problems (7.7%). Psychological

reasons for consultation (n=481) involved mainly feeling anxious (71%). The rest include sleep

disturbance and prescription of psychoactive drugs. Many other visits included common

problems that would not require any physician intervention.

A study conducted by Gupta et al (2001) entitled, Health Status of Inmates of a Prison,

was carried out at Central Prison, Yervada, Pune, India. This was a cross-sectional descriptive

study of 227 out of 1100 convicted prisoners. The sampling method used was stratified random


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sampling based on the sentence category. The inmates were interviewed and were also subjected

to physical examination. Medical records were also consulted to establish the inmates` past

medical illnesses. On interviewing the inmates, it was found out that about one half of the

inmates (44%) reported to be sick and 14.5% required hospitalization in the past one year. More

than half of inmates (58.15%) suffered from skin disorders. Scabies and fungal infections

showed a significant relationship with the duration of stay in prison. Tuberculosis is the

commonest illness, 25.15% of all respiratory disorders or a population prevalence of 7.5%. This

is about four times higher than the national figures of about 1.8% (Goyal et al cited in Gupta, et

al, 2001).

This present literature search found only one study describing the conditions of the

second largest jail in the country. In 2005, Narag published a book entitled Freedom and Death

inside the Jail: A Look into the Condition of Quezon City Jail. It is the first book ever written

about Philippine prison life. Using what social researchers call participatory research approach

(PRA) methods, the author documented the stories of inmates, their jail officers, and the visitors

and volunteers who frequent the detention center. The author engaged the subjects of the study in

interviews, focus group discussions, and they recanted their stories using tools like map-and

chart-making, and illustrations. Due to lack of financial support, facilities were so overcrowded;

a cell designed for only 20 inmates, houses 200 inmates. Inmates are reported to suffer from skin

disease, respiratory infections, and are likely to develop mental disorders in the course of their

detention. The jails health services are unable to cope with the number of inmates getting sick.

Each inmate is allotted only around P100 budget for medicines. Every month, anywhere from

two to five inmates die, the most common cause of mortality is cardiovascular disease.

This literature search highlights studies on inmate population and correctional systems of

other countries. Only one study was in the Philippine setting. These studies were mainly on the

health indicators of inmates as well as the health services utilization of prison population.

Equally, health concerns and health service utilization are the two concerns of this current


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investigation. The review reveals fairly widespread use of tobacco, alcohol, and illicit drugs

among prisoners, just as in this current study. The prisoners are also afflicted with numerous

infectious diseases and have multiple chronic conditions. One peculiarity noted among the

correctional systems of many countries is the relative neglect of health of inmates.


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CHAPTER III

METHODOLOGY

Research Design

This research employed cross-sectional descriptive research design. It included a survey

of the health concerns and health service utilization of a sample of inmates who are sentenced

prisoners at San Ramon Prison and Penal Colony. The availability of health facilities and

services for the inmates was determined by interviewing the health personnel. An account of the

available health facilities of the prison colony was prepared after ocular inspections were made.

The Study Site

The San Ramon Prison and Penal Colony in Zamboanga City is composed of a one-

hectare security compound and a 600 hectare- penal farm. It is approximately 45 minute drive

away from the city proper. As of recent count, there are 1022 prisoners detained in the penal

colony in different security status- maximum, medium, and minimum security. Among the

available structures of the colony are: an administrative building, worship areas, entertainment

building, medical infirmary, a medical clinic (which caters to the health needs of living out

prisoners only), pharmacy, mini-gym, among others. The colony also has a reception center and

disciplinary cells. The reception center houses inmates who are recently admitted in the colony

where they undergo a 60 day orientation program to prepare them in facing the long period of

incarceration. The disciplinary cells serve as temporary accommodation for those who violated

prison rules and regulations. The inmates` health needs are supervised by a team of five health

personnel, namely, a jail physician, two registered nurses working alternately in two straight 24

hour shifts, a dentist who visits the facility twice a week, and a registered pharmacist.


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Respondents

The respondents of this study were inmates and health personnel of the penal colony. The

sample population for inmates was determined using the most recent official list of inmates of

the Records Section of the prison colony. Based on the list, there were 90 inmates aged 50 years

old and above and 125 inmates less than 50 years old who have been imprisoned for at least 10

years or more.

Inclusion Criteria for Inmates

1. inmates 50 years old and above, regardless of length of stay

2. inmates, less than 50 years old and below with a length of stay of ten years or more

3. willing to participate in the study

Other groups of inmates incarcerated in the prison colony were excluded.

Inclusion criteria for health personnel

1. These included the five health personnel, namely, jail physician, two jail nurses,

dentist, and pharmacist.

Sampling Method

This study utilized total count sampling method. It included all of the inmates whose

names were found in the list furnished to the researcher by the chief of the records section, with a

sample size of 215. All of the five health personnel of the colony were interviewed.

Research Instruments

The research instruments used in this study were the following: a 53-item questionnaire,

previous medical records, and an interview guide used for health personnel.

1. Questionnaire to determine the Health Concerns and Health Services Utilization

of Inmates


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This was a 53-item interviewer administered questionnaire composed of three parts. The

bulk of the questions were taken from validated questionnaires utilized in previous studies

conducted out of the country to determine the health status of inmates. Questions one to 16

pertained to demographic data. Questions 17 to 28 determined the health concerns and questions

41 to 53 determined the health service utilization of respondents. The health concerns of

respondents were measured in terms of the following: state of health inside prison, changes in

health since incarceration, confidence in managing own health, self-rated lifestyle, self-reported

diseases in the past week, claimed illnesses suffered in the past year, health complaints/problems

experienced in the past year, current medications, tooth loss, and emotional health parameters.

Questions 17, 18, and 19 were adapted from the questionnaire used in the study by Loeb

and Steffensmeier (2006). Question 20 was modified from Older Mens Health Program and

Screening Inventory questionnaire by Loeb (2003). Questions 27, 28, 29, and 30 were modified

from the questionnaire utilized by Colsher, et al (1992). Questions 34, 35, 36, 37, and 38 explore

the status of the emotional health of the inmates. A local psychiatrist was consulted in the

construct of these questions. Some of the questions on health service utilization were modified

from health care utilization questionnaire of Stanford Patient Education Center (1996 edition).

Content validity was established through evaluation by the researchers thesis adviser and

inputs from a psychiatrist specifically for items on emotional health. The questionnaire was

translated in Filipino. The translation of the questionnaire to Filipino was done by a Filipino

professor of Western Mindanao State University, Zamboanga City.

The Filipino version of the questionnaire was pre-tested to 20 inmates of the Zamboanga

City Reformatory Center. After the questionnaire administration, the researcher met with the

inmates as a group in order to answer questions and issues raised as to the content and construct

of the questionnaire. The inmates suggested that the questionnaire is better understood and

completed when it is interviewer administered, rather than self-administered.


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The pre-tested questionnaire was translated in the Visayan and Chavacano dialects in

order to accommodate respondents with varied educational background. The full text of the

questionnaire is found in Appendix 1.

2. Previous medical records

Medical records of respondents served as source of information in order to determine the

past illnesses in the past year as diagnosed by the jail physician.

3. Interview guide questions to determine health services

This interview guide questions were structured to determine the health services and

facilities available. A full text of the interview guide is found in Appendix 3.

Pre-Data Collection

A list of inmates meeting the studys inclusion criteria was requested from the records

section chief of the correctional facility. Jail officers assigned to the prison visiting room used

the list to inquire from each of the qualified inmates if they would be willing to meet with the

researcher to discuss the research study. Inmates who expressed interest met with the researcher

individually with a correction officer present and were given letter describing the study.

Informed consent was provided to the respondents and was read aloud to them.

Data Collection

1. Administration of the questionnaires

The questionnaire to determine health concerns and health services utilization was

interviewer administered. The researcher was assisted by a research assistant. The questionnaire

was administered in the presence of a correction officer. It took 10 to 20 minutes for a

questionnaire to be administered. The respondents were told that any information they have

provided to the researcher would be medically confidential and this would in no way affect their

incarceration. The respondents were also told that information they have provided will form part


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of the medical record, would be used for policy drafting and planning purposes. The actual

administration of questionnaire lasted for three weeks.

2. Examination of individual inmates medical records

Inmates` records on past illnesses were requested from the jail clinic. The records were

retrieved with the supervision of a jail nurse. The data on the past illnesses were based on the

2007 records. The examination of individual medical records of respondents lasted for one week.

3. Determination of Health Facilities and Services Availability

Preparation of the questions was done before hand in order to guide the researcher on the

actual interview session. The health personnel of the prison colony were interviewed separately.

Refer to appendices 3 to 6 for the excerpts of the interview with the health personnel. The health

personnel were asked regarding the health facilities and services in the penal colony. Ocular

inspections were also conducted on three separate occasions in the entirety of the research

implementation in order to determine available health facilities/equipment.

Data Management and Analysis

Demographic profiles of respondents, results of the questionnaire on health concerns and

health services utilization were presented using frequency distributions and percentages. These

facilitated description of the sample population. Data on the past illnesses were also presented in

frequency distribution and percentages. Presentation of results for health facilities/services

available were done in a descriptive approach.


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CHAPTER IV

PRESENTATION AND INTERPRETATION OF RESULTS

This study was carried out to determine the health concerns, availability and utilization of

health services among inmates of San Ramon Prison and Penal Colony. Little is known about the

health status and what health services inmates require.

The results presented below are reflective of a total of 215 respondents included in the

study.

I. Profile of the Respondents

The age of the respondents ranged from 30 to 75 years old. The mean age of respondents

is 48.6465.

Most are Visaya, accounting for 54.9% of the respondents. The second most dominant

tribal group is Zamboangueo, 21.4% of the total respondents. The other three most dominant

ethnic groups are the Tausug (5.1%), Ilocano (4.2%), and Subanon (4.2%).

More than half of the respondents (113 or 52.6%) are married. Thirty one percent (68

respondents) are single. About 8% (18 respondents) are separated and 7.4% (16 respondents) are

already widowers.

More than 80% or 173 respondents have children while 19.5% (42 respondents) do not

have children.

Forty four percent of the total number of respondents has one to three children while

2.8% have more than ten children.


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Table 1. Educational Attainment

Educational Attainment Respondents

Frequency (%)

elementary level 122 (56.7)

high school level 25 (11.6)elementary graduate 22 (10.2)High school graduate 16 (7.4)college level 15 (7.0)no formal education 14 (6.5)college graduate 1 (0.5)Total 215 (100)

The educational attainment of the respondents is reflected in table 1. Majority of the

respondents did not finish elementary education (122 respondents or 56.7%). More than 6% or

14 respondents had no formal education. Twenty five respondents or 11.6% did not finish their

secondary education. Fifteen respondents or 7% reached tertiary education. Only one respondent

(0.5%) was able to graduate from college.

Table 2. Occupation Prior to Incarceration

Occupation Respondents

farmer 85 (39.5)

laborer 49 (22.8)government employee 19 (8.8%)jobless 17 (7.9)driver 16 (7.4)entrepreneur 10 (4.7)others 8 (3.7)security guard 4 (1.9)fisherman 3 (1.4)teacher 2 (0.9)Overseas worker 1(0.5)nurse, doctor 1 (0.5)

Total 215 (100)

Most of the respondents (85 out of 215) worked as farmers before they were incarcerated

(table 2), hence farming was the main source of income of 39.5% of the respondents. Close to

23% of the respondents were laborers before they were confined. Close to 9% worked in the

government before their imprisonment. About 8% were jobless before imprisonment.


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Table 3. Age of First Imprisonment

Age Group Respondents

< 30 66 (30.7)30 to 50 100 (46.5)

>50 49 (22.8)

Total 215 (100)

Age of first imprisonment is shown in table 3. Many of the respondents were imprisoned

at the age of 30 to 50 years old (100 or 46.5%). Close to 31% or 66 respondents were imprisoned

at age of less than 30 years old. There were 49 respondents or 22.8% who were incarcerated at

the age of more than 50 years old.

More than half of the respondents interviewed or 53.5% are confined in the colony for 10

to 20 years. This was followed by 68 respondents or 31.6% who are confined in the colony for

less than ten years. Another 10.7% have been in the colony for 21 to 30 years. Nine of the 215

respondents or 4.2% is confined for more than 30 years, the longest stay in the colony recorded

for this current study.

Tobacco and Substance Use

The percent of smokers among respondents is relatively higher compared to the national

rate of 33% as reported by Dans, et al (2004). This is shown in the first table on the next page.


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The respondents reported relatively extensive tobacco use at present and heavy drinking

before the time they were confined. According to Lester et al (2003), the widespread smoking

and use of tobacco are widely accepted as an integral to the prisoner culture.

Smoking contributes to cardiovascular and respiratory diseases, both found to be high

among the inmate population of San Ramon Prison and Penal Colony. Smoking cessation

programmes may therefore contribute to the better health of the inmates.

The results on substance use among respondents who were interviewed were similar to

the results reported by Conklin, et al (2000) showing that 11% of the respondents admitted to

having ever used illicit drugs. This study (which was conducted in 2000 among newly admitted

correctional inmates in Western Massachusetts) also reported extensive abuse of tobacco and

drugs before imprisonment. Three quarters were cigarette smokers with more than 70% of those

smoking a pack or more per day. Thirty six percent reported having a drinking problem. In a

similar study by Lester et al (2003) among prisoners in Wales, United Kingdom, 84% were

current smokers and 74% reported drinking alcohol before prison. Seventy percent used illegal

drugs before. The most frequently reported drugs before prison were cannabis (53%), heroin

(37%), and cocaine (27%). Bridgwood et al 1995 (cited in Fazel et al, 2001) stated that younger

prisoners have higher smoking rates compared to older prisoners.


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II. Health Concerns

Table 4. State of Health Inside Prison

Variables Respondents

Self-rated Health

Good 114 (53.0)Poor 44 (20.5)Fair 40 (18.6)excellent 17 (7.9)Changes in Health Since Incarcerationworsened slightly 75 (34.9)stayed the same 64 (29.8)improved slightly 34 (15.8)improved greatly 30 (14.0)worsened greatly 12 (5.6)Confidence in Managing Ones HealthSomewhat Confident 81 (37.7)Very Confident 74 (34.4)Somewhat NotConfident

37 (17.2)

Not very Confident 23 (10.7)

Table 4 shows the state of health of respondents. More than half (114 or 53%) reported a

good state of health. Forty respondents or 18.6% reported their health status as fair. Forty four of

215 respondents (20.5%) stated that their health is poor. Only 7.2% (17 respondents) believe that

they are in excellent state of health.

In a related study by Conklin et al (2000), half of the male inmates rated their health as

only good, fair, or poor. In another study by Lester et al (2003), 41% of inmates rated their health

as good, 29% as very good or excellent, and 47% as fair or poor.


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The question: How do you rate your own health? provides intuitively satisfying

information about the health of others and is generally a reliable indicator of ones health (Loeb

and Steffensmeier, 2006).

Although there were favorable self ratings on the current health status, more than half of

respondents interviewed, either stated their health worsened slightly (75 or 34.9%) or stayed

the same (64 or 29.8%), since incarceration. Close to 16% or 34 respondents reported that their

health improved slightly while 14% stated that their health improved greatly. Close to 6%

stated that their health worsened greatly.

Nearly 38% of inmates interviewed stated that they are somewhat confident in managing

their own health. Thirty four percent are very confident while 10.7% are not very confident

in managing ones health.

Table 5. Self-reported Lifestyle

Lifestyle Respondents

Healthy sometimes 87 (40.5)Healthy most of the time 49 (22.8)Healthy all the time 44 (20.5)

Not healthy all the time 35 (16.3)Total 215 (100)

The lifestyle of respondents is seen in table 5. Nearly half of the population who were

interviewed (87 or 40.5%) stated that their lifestyle is healthy sometimes. While 16% or 35

respondents reported that their lifestyle is not health all the time. Forty four respondents or

20.5% claimed that their lifestyle is healthy all the time while 22.8% or 49 inmates have

healthy lifestyle most of the time.

The number of respondents claiming to be sick in the past year is relatively higher

compared to the number of respondents who claimed to have fallen sick in the past week. The

figure on the next page discusses this in more detail.


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Figure 3. Sick in the Past Week and Year

32.660

67.440

0

20

40

60

80

100

Sick in

the past

week

Sick in

the past

year

No

Yes

Nearly 33% or 70 respondents claimed to be sick in the past week. Those who have

reported to be sick in the past week, the most commonly self reported sicknesses and its

prevalence rates were upper respiratory tract infection (25%), hypertensive urgency (6.5%) and

pneumonia (0.9%).

Sixty percent or 129 respondents reported to be sick in the past year. There were 17

claimed diseases in the past year as reported by 215 inmates during the administration of thequestionnaire. Claimed illnesses suffered in the past year are presented in the subsequent table.

In a study by Gupta et al (2001) conducted among 227 inmates at Central Prison, Pune,

India, about half the inmate (44%) had reported sick in the preceding year. Twenty eight percent

of inmates suffered respiratory diseases, close to the 22% reported for the current study.

Pulmonary tuberculosis contributed to the 17 cases with overall prevalence of 7.5% (lower than

the 10.7% prevalence of TB for the current investigation). Acute respiratory tract infections

recorded a 9.7% prevalence rate (slightly higher than the 7.9% recorded for this present

investigation). The prevalence rate of skin diseases recorded for this present research is 9.9%,

very much lower compared to the recorded prevalence of 26.5% among the inmate population

included in the study by Gupta et al (2001). Skin disorders were the commonest ailments

encountered in the above mentioned study.


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Table 6. Claimed Diseases Suffered in the Past Year

Claimed Diseases in the

Past Year

50 years

old and above

49 years old

and below

Total

n=215

Arthritis 5 (5.6) 1 (0.8) 6 (2.8)Essential Hypertension 20 (22.2) 4 (3.2) 24 (11.2)PTB 4 (4.4) 19 (15.2) 23 (10.7)Skin diseases 7 (7.8) 13 (10.4) 20 (9.9)URTI 8 (8.9) 9 (7.2) 17 (7.9)Wounds of all kinds 3 (3.3) 9 (7.2) 12 (5.6)Asthma 2 (2.2) 5 (4) 8 (3.7)Ulcer 3 (3.3) 2 (1.6) 5 (2.3)Emphysema 3 (3.3) 0 3 (1.4)Acute Gastroenteritis 2 (2.2) 1 (0.8) 3 (1.4)STD 0 2 (1.6) 2 (0.9)Diabetes 2 (2.2) 0 2 (0.9)Stroke 1 (1.1) 0 1 (0.5)Beriberi 1 (1.1) 0 1 (0.5)Hepatitis A 0 1 (0.8) 1 (0.5)UTI 0 1 (0.8) 1 (0.5)Myocardial infarction 0 1 (0.8) 1 (0.5)

Table 6 shows the different claimed diseases suffered in the past year. The most common

claimed disease in the past year is essential hypertension with a prevalence of 11.2% (as reported

by 24 of the 215 respondents). Twenty two percent had respiratory disorders. Pulmonary

tuberculosis was the highest claimed respiratory illness (10.7%). This was followed by URTI

(7.9%) and asthma (3.7%). Also included in the top five are skin diseases (9.9%) and wounds of

all kinds (5.6%).

Only 17.2% of respondents are taking medicines at present. Essential hypertension and

pulmonary tuberculosis are the two most common reasons for medication, accounting for 11.1%

of the total population. Six respondents or 2.8% claimed to take medicines for upper respiratory

tract infections. The other medications taken are for asthma (1.9%), diabetes mellitus (0.9%), and


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for beri-beri (0.5%). Self-reported health complaints in the past year are presented in the

subsequent table.

Table 7. Health Complaints in the Past Year

Health Complaints in the Past Year Respondents

Cough 84 (39.1)Hearing Problems 80 (37.2)Dental Problems 80 (37.2)Visual Problems 71 (33.0)Foot Pain 56 (26.0)Skin Problems 46 (21.4)

Sleep Difficulties 37 (17.2)Callus 28 (13.0)Joint Pains 27 (12.6)Difficulty of Breathing 15 (7.0)Hemoptysis 15 (7.0)Wakes up very early 21 (9.8)Nail Problems 7 (3.3)Other Foot Problems 5 (2.3)

Health complaints in the past year are presented in table 7. As can be gleaned in the table,

cough was the most commonly reported symptom (39%). Not far behind are dental and hearing

problems (37.2% each). Visual problems were reported by 33% of respondents while skin

problems were reported by 21.4%.

In a study by Conklin et al (2000), the most frequently reported health concerns among

the inmates were teeth/gums, bone/joints, back/neck, and emotional/mental problems. The

number of inmates reporting teeth/gums symptoms is comparable with the current investigation.

Another health concern that was asked among respondents was dental problem. More

than 50% (108 respondents) reported loss of some teeth while close to 37% (79 respondents)

reported no tooth loss.


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Table 8. Parameters of Emotional Health

Parameters of Emotional

Health

Respondents

Experienced depression 69 (32.1)Hurt self/ involved in fight 11 (5.1)Hurt by fellow inmates 10 (4.7)Tried to commit suicide 8 (3.7)Difficulty adjusting 1 (0.5)

Surprisingly, only one out of 215 respondents (0.5%) reported difficulty in adjusting to

the confined life in the penal colony, as illustrated in table 8. However, 32% (69 respondents)

experienced depression in the past four weeks. Five percent has been involved in a fight or hurt

self. Close to 5% was hurt by fellow inmates. Six percent tried to commit suicide.

III. Diseases Recorded in the Past Year

The most common major illnesses recorded in the medical records of inmates in a study

by Fazel et al (2001) were psychiatric, cardiovascular, musculoskeletal, and respiratory. The

most common diagnoses recorded in the prison medical notes were angina or ischemic heart

disease (19.7%), osteoarthritis (13.3%), hypertension (13.3%), diabetes mellitus (8.4%), chronic

obstructive pulmonary disease (6.9%) and asthma (5.4%). In another study authored by Lester et

al (2003), the most common illnesses reported in a Welsh prison include depression (40%),

anxiety (20%), asthma (17%), bronchitis, arthritis, epilepsy, and hepatitis ( 5 to 10% each, and

angina/chest pain, heart attack, stroke and hypertension (each less than 5%).

In the San Ramon Penal Colony, however, the most common physician-diagnosed illness

in the past year was upper respiratory tract infections with a prevalence of 26%. The high

prevalence rate of respiratory tract infections, including pulmonary tuberculosis as well as skin

diseases may be attributed to the crowded detention cells found in the penal colony. A detention

cell which is supposed to accommodate only about 20 inmates at the maximum, houses 40

inmates or more. The overcrowded condition as well as inadequate ventilation for the detention

facilities may facilitate rapid disease transmission. There were 25 respondents diagnosed to have


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essential hypertension with a prevalence of 22%. Included in the list are skin diseases (20.3%),

pulmonary tuberculosis (19.5%), and wounds of all kinds (12.7%). The table below shows the

details on these illnesses.

Table 9. Top Five Past Illnesses based on Inmates Medical Records

Diseases Respondentsn=215

1. Upper Respiratory TractInfections (URTI) 30 (13.9)2. Essential hypertension

25 (11.6)3. Skin diseases (dermatitis)

24 (11.2)4. Pulmonary tuberculosis

23 (10.7)5. Wounds of all kinds

15 (6.9)

IV. Health Facilities and Services

The results on the health facilities available were based on ocular inspection and

interview with the health personnel. Data on health services were based on the interview of the

five health personnel of the prison colony.

The available health facilities include a jail clinic, a pharmacy, and an infirmary. The jail

clinic, pharmacy, and dental room are housed in a one storey structure located approximately 15

meters away from the main maximum security detention facility (a one hectare security

compound, the perimeters of which is fenced with steel and barbed wires). This concrete

structure has a floor area of approximately 100 square meters. Dilapidated windows and ceilingscharacterize the age of the structure housing these health facilities. However, it is relatively

uncluttered as living-out prisoners are tasked to clean and maintain the area regularly. The

structure is enclosed with a wooden fence and a vegetable garden maintained by living out

inmates is found in front of this building housing the clinic, pharmacy and dental room.


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The jail clinic is composed of two adjacent rooms. The relatively bigger room is the

office of the jail physician. This is where the physician accepts living out prisoners seeking

consult. A stretcher made of steel with rubberized foam on top is found in the room, where

inmates are made to lie down during physical examination performed by the jail physician.

Health posters can be seen posted on the walls. The smaller room adjacent to the jail physicians

office is the workplace of the two jail nurses. Two cabinet drawers about two meters high serve

to stockpile the inmates` medical records. The jail clinic has a standard weighing scale, a

medicine cabinet made of glass and steel, four stethoscopes, four sphygmomanometers, two

functional oxygen tanks, two face masks for the oxygen tank, and two nebulizing machines. A

small holding area is situated outside these two rooms where inmates can wait for their turn for

consult.

The pharmacy is a small room adjacent to the jail clinic. Displayed on its shelves are

different kinds of IV fluids and boxes of medicines. This room also serves as the office of the

jail pharmacist.

A room which serves as the dental clinic is found right in front of the pharmacy. A

relatively old but functional dental chair is found inside the jail dental room. The dental room

was currently on renovation at the time it was inspected. The equipments for tooth extraction are

personal properties of the jail dentist.

A 10 bed capacity jail infirmary is located inside the main security facility. The infirmary

caters to admissible inmates requiring medical care and management. Inmates who have been

newly diagnosed of having pulmonary tuberculosis are also placed in this area, thus the infirmary

also serves as an isolation unit. The descriptions of the infirmary in the succeeding paragraph

were the accounts of the jail nurse and inmates. The researcher was not allowed to have an ocular

inspection of the infirmary for security reasons and limitations.

According to the jail nurse, the 10 bed capacity infirmary is a 100 square meter concrete

structure that is well ventilated and well lighted. Aside from ten stretchers with rubberized foam,

the infirmary has no other health equipment. The maximum length of stay of admissible patients

at the infirmary is only one day as these patients are immediately referred to Zamboanga City


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Medical Center for further evaluation and management. According to the inmates, the infirmary

is relatively clean and well kept as inmates are mandated to keep the area clean.

A typical prison clinic should have a trauma room, examination rooms, a laboratory,

radiological suite pharmacy or medication room, and dental facilities. There must also be

administrative areas for meetings and counseling (Correctional Healthcare. 2008). San Ramon

Prison and Penal Colony does not satisfy the requirements of a jail clinic based on international

standards as recommended by Correctional Healthcare, a US based scientific journal on

Corrections. To the knowledge of the researcher, there are no accepted national standards as to

what facilities and equipment should be available in jail clinics of correctional facilities for the

country. The limited facilities in the penal colony suggest that it is inadequate in diagnosing

illnesses other than what may be considered common. Under reporting of diseases may also be

possible. This may also imply that there are under diagnosed and under treated cases among

inmates in the colony.

The health services available for inmates at San Ramon Prison and Penal Colony include

the following:

Physical examinations and regular consult for health complaints conducted

by the jail physician; admissible patients are admitted at the jail infirmaryfor hospital care under the service of the jail physician and jail nurse on

duty.

Free medicines for common health complaints such as fever, headache,

musculo-skeletal pains, and cough and colds. Anti-hypertensive medicines

are also available but its supply is limited.

Regular blood pressure monitoring is also performed by the jail nurse.

Directly Observed Treatment Short Course (DOTS) program include

direct supervision by jail nurse of the actual intake of anti-TB drugs by

inmates enrolled in the DOTS program; collection of sputum (or

examination for acid fast bacilli at Ayala Health Center) from inmates

who are TB suspects. The sputum collection is supervised by the jail

nurse.


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Tooth extraction is the only dental procedure performed by the jail dentist.

The health delivery system at the San Ramon and Prison Colony follows the correctional

health delivery system of western countries like the United States. According to Aday (1994),

the typical correctional health delivery system provides basic ambulatory care on site and

makes arrangements with community providers for secondary and tertiary care. Most facilities

use a reactive sick cell model (patterned after the military) to provide services, rather than a

proactive preventive care model. In San Ramon Prison and Penal Colony, the jail physician

attends to regular consult from inmates- both living out prisoners and those who are held at the

main security facility. Referrals are also made by the physician to the Zamboanga City Medical

Center when such need arises. Generally, inmates (detained at the main security facility) who

have health complaints sign up for sick call. A health attendant (who is also an inmate) forwards

these complaints to the jail nurse. Their requests are serviced and triaged by the jail nurse and

they are then called in to be seen by the appropriate health provider (jail physician or dentist)

once the schedule of consult is agreed upon by the health provider and the jail nurse.

V. Utilization of Health Services

The result as to the number of visits made by the respondents to the jail physician (onlyone visit for the past six months for majority of the respondents) is in immense contrast with the

finding obtained by Feron (2005) which revealed that inmates detained in 11 Belgian prisons

consulted the physician 17 times on average per year. The following table shows the number of

visits made by inmates to the jail physician.

Table 10. Consulted Jail Physician

Consulted JailPhysician

Respondents

did not consult 96 (44.7)once 48 (22.3)twice 38 (17.7)>3x 17 (7.9)thrice 16 (7.4)Total 215 (100)


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Fifty five percent (199 of 215 respondents) consulted the jail physician in the past six

months, while 44.7% (96 respondents) had no consult (table 10). Twenty two percent (48

respondents) had a single contact with the jail physician. This was followed closely by those who

consulted the jail physician twice (38 or 17.7%).

In a study conducted by Feron, et al (2005), the most common reason for encounter with

the jail physician were administrative procedures (22%), psychological (13.1%), respiratory

(12.9%), digestive (12.5%), musculoskeletal (12%), and skin problems (7.7%). However for this

present study, the most common reasons for consult are due to skin problems (13%), cough and

colds (9.8%), head ache (8.4%), fever (4.1%) and bronchial asthma (3.7%).

Table 11. Consulted Jail Nurse

Consulted Jail Nurse Respondentsdid not consult 84 (39.1)once 43 (20.0)twice 41 (19.1)thrice 25 (11.6)>3x 22 (10.2)

Total 215 (100)

Sixty percent (131 of 215 respondents) consulted the jail nurse (table 11). Twenty percent

of the 215 inmates who were interviewed had at least one opportunity in consulting the jail

nurse, 19% consulted twice, and 12% consulted for three times. Twenty two respondents or

10.2% consulted the jail nurse more than three times.

The most common reasons of contact with the jail nurse are for medication (46%) and for

blood pressure assessment (15%). Respondents were also asked if they avail the services of the

jail dentist and their answer is reflected in the succeeding table.


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Table 12. Consulted Jail Dentist

Consulted Dentist Respondentsdid not consult 164 (76.3)twice 24 (11.2)

once 21 (9.8)thrice 6 (2.8)Total 215 (100)

Twenty three percent of respondents had the opportunity to avail of the services of the

dentist in the past six months (table 12). Eleven percent of the total inmate population

interviewed visited the dentist twice while close to 3% had the opportunity to visit the dentist

thrice.

In the past six months, inmates did not have the opportunity to consult at the emergency

room of a nearby hospital. However, a few of the respondents were hospitalized in the past six

months. Only 2.3% or five respondents gave a history of hospitalization in the past six months.

The two reasons for hospitalization for the first time were hypertensive urgency and pulmonary

tuberculosis. For the two inmates who have been hospitalized twice, pulmonary tuberculosis and

ulcer were the reasons for hospitalization. The available health programs and screenings

available to inmates are discussed in the next table.

Table 13. Health Programs and Screenings Attended

Health Programs andScreenings

Respondents

Health ProgramsExercise programs 82 (38.1)Physical Examination 81 (37.7)Medication educationclasses

69 (32.1)

DOTS program 22 (10.2)Health ScreeningsBP monitoring 82 (36.1)Psychological testing 43 (20)CBC, blood chemistry 25 (11.6)Sputum Exam for AFB 22 (10.2)Urinalysis 15 (7.0)


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Table 13 shows the health programs and screenings attended by respondents in the past

12 months. Thirty eight percent of inmates attended exercise programs. The second most

attended health program is physical examination. DOTS program was the least attended health

program, participated by 10.2% of respondents. Blood pressure monitoring is the most common

health screening, available to 38% of respondents. The least commonly available health

screening is urinalysis, only accessible to 7%. Complete blood count and urinalysis are only

made available to inmates who are admitted at the infirmary or those who are referred to the

Zamboanga City Medical Center (ZCMC). Blood and urine samples are sent to the ZCMC

Laboratory for examination, since the penal colony does not have laboratory facilities.

However, in a study by Loeb and Steffensmeir (2001), it was revealed that the most

commonly attended health programs were on immunization (68.6%), exercise (41.2%), and

substance abuse programs (39.2%). The study also revealed that the most common health

screenings received by inmates were blood works (98%) and blood pressure assessment (94.1%).

Despite the relatively high consultation rates noted among the respondents to health

personnel at the penal colony as well as the availability of health programs and screenings,

respondents` satisfaction of the health services is not noteworthy. This is made known by the

table below.

Table 14. Satisfaction on Health Services Rendered

Satisfaction on health

Services Rendered

Group 1 Group 2 TOTAL

satisfied all the time 23 (25.6) 18 (14.4) 41 (19.1)satisfied most of thetime

30 (33.3) 13 (10.4) 43 (20.0)

satisfied sometimes 29 (32.2) 68 (54.4) 97 (45.1)not satisfied 8 (8.9) 26 (20.8) 34 (15.8)

Total 90 (100) 125 (100) 215 (100)

Forty five percent (91 of 215 respondents) are satisfied sometimes of the health

services made available to them. Nineteen percent or 41 respondents that they are satisfied all


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the time for the health services they are receiving. Close to 16% (34 respondents) are not

satisfied with the services that they receive from the health personnel (table 14).

This present study revealed that the respondents have numerous health concerns. Thirty

two percent reported to be sick a week before the questionnaire was administered. Sixty percent

of them claimed to be sick in the past year. Numerous health complaints were also reported by

the respondents. Relatively high levels of acute physical problems and relatively high prevalence

rate of chronic diseases such as hypertension can be observed. The current health conditions may

explain the relatively high number of respondents who have consulted the jail physician and the

jail nurses for the past six months. However, fewer respondents consulted the jail dentist for the

past six months. This may be due to the fact that the jail dentist only visits the penal colony for

only twice a week. Since the penal colony does not have a laboratory, only few respondents were

able to avail of laboratory screenings such as blood works and urinalysis in the past year. For the

past year, less than half of the respondents availed of the different health programs and

screenings available.


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CHAPTER VI

CONCLUSIONS AND RECOMMENDATIONS

The various health concerns and health services utilization of 215 inmates of San Ramon

Prison and Penal Colony were determined using an interviewer administered questionnaire. Past

medical records of inmates were utilized to determine the past illnesses. The five health

personnel of the penal colony were interviewed to determine the available health facilities and

services. The following findings highlighted this study:

Health Concerns

Fifty three percent of the respondents reported good state of health at present. About

21% rated their health as poor. Close to 35% stated that their health has worsened slightly

since incarceration and 29.8% reported that it remained the same. About 38% of the

respondents stated that they are somewhat confident in managing their own health while 34%

are very confident. When asked about their lifestyle, 40.5% reported it as healthy

sometimes and 22.8% has a lifestyle that is considered healthy most of the time. Thirty three

percent reported to be sick in the past week while 60% stated they have fallen sick in the past

year. The most commonly self-reported physician-diagnosed diseases in the past year (and their

prevalence rates) are essential hypertension (11.2%), pulmonary tuberculosis (10.7%), and

various skin diseases (9.9%). The most common health complaints in the past year are cough

(39.1%), dental problems (37.2%), hearing problems (37.2%), visual problems (33%), and foot

pain (22%). Fifty percent reported losing some teeth and 13% losing some teeth in the past year.

Thirty two percent experienced depression in the past four weeks. The top five recorded past

illnesses based on medical records of inmates include upper respiratory tract infections (26.3%),

essential hypertension (21.2%), skin diseases (20.3%), pulmonary tuberculosis (19.5%), and

wounds of all kinds (12.7%).


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Health Facilities and Services

The health facilities of the prison colony include a jail clinic, infirmary, dental room, and

a pharmacy. The jail clinic has a standard weighing scale, a medicine cabinet, four stethoscopes,

four sphygmomanometers, two oxygen tanks, two face masks for the oxygen tank, and two

nebulizers. The health services available include physical examinations, blood pressure

monitoring, and admission at the infirmary for those admissible for medical care, Directly

Observed Treatment Short Course for TB patients, tooth extraction, free medicines for common

health complaints, and dental extraction.

Health Service Utilization

Fifty five percent consulted the jail physician in the past six months. The most common

reasons for consult were due to skin problems (13%), cough and colds (9.8%), and headache

(8.4%). Close to sixty one percent consulted the jail nurses in the past six months. The reasons

for consult were for medication (46%) and for blood pressure monitoring (14.9%). Twenty four

percent of the inmates availed of the services of the jail dentist. Only 2.3% or five inmates gave a

history of hospitalization for the last six months. The two reasons for hospitalization for the first

time were hypertensive urgency and pulmonary tuberculosis. For the two inmates who have been

hospitalized twice, pulmonary tuberculosis and ulcer were the reasons for hospitalization.

The health programs available to the inmates in the past year included exercise programs

(38.1%), physical examination (37.7%), medication education classes (32.1%), and DOTS

program (10.2%). Health screenings attended in the past year were blood work (11.6%),

urinalysis (7%), blood pressure monitoring (36.1%), psychological testing (20%), and sputum

exam for AFB (10.2%).

Recommendations

This study does not take into consideration other factors or health determinants which can

be used to have a more accurate account of the health condition of inmates. The population size

of the study is only limited to two groups of inmates. Factors affecting health services utilization

among inmates are not included in the study. Thus, the author recommends the following:


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1. Another study with a greater number of inmates be conducted in order to increase

the power of this study and to determine if the results obtained from this study are

reflective of the general population of inmates.

2. Another study exploring the health status of inmates using physical examination

and other determinants of health.

3. Another study using a research instrument that will be able to explore factors

affecting health service utilization among inmates.

4. Smoking cessation programs should be implemented as this study reveals a high

smoking rate and respiratory illnesses among respondents.

5. Health education classes on hypertension, pulmonary tuberculosis, and common

skin diseases to increase the awareness of inmates regarding these diseases.

These are the three most prevalent diseases noted among the respondents.


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Appendix 1.

Health status and health service utilization questionnaire

Date: __________________

Name: _________________ID Number: _____________

Age: _____

Height: ________

Weight: ________

Part I. Demographic data

1. What is your level of educational attainment?

( ) no formal education( ) elementary level

( ) elementary graduate( ) High school level

( ) High school graduate

( ) College level

( ) College graduate( ) others: _____________

2. What is your marital status?

( ) single/ never married( ) married( ) divorced/legally separated

( ) widowed

3. What is your ethnicity?

( ) Visayan

( ) Zamboangueno( ) Tausug

( ) Ilocano

( ) Waray( ) Subanin

( ) Yakan

( ) Ilonggo( ) Maranao

( ) Samal

( ) Kalibugan

( ) others: _____________________________


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4. What is the status of employment prior to incarceration?

( ) unemployed

( ) employed part time

( ) employed full time

5. What was your work before entering the prison?

( ) government employee

( ) laborer, construction worker, utility worker

( ) teacher( ) doctor, nurse, other related health services

( ) farmer

( ) entrepreneur, businessman

( ) driver, gardener, other related services( ) others (Please specify.): __________________________

6. At what age did you first enter the prison system?

( ) < 20

( ) 20-25( ) 26-30

( ) 31-35

( ) 36-40

( ) 41-45( ) 46-50

( ) 51-55

( ) 56-60( ) 61-65

( ) >65

7. What is the reason for your incarceration (considering only the current sentence)?

( ) murder

( ) rape( ) homicide

( ) theft

( ) drug trafficking( ) human trafficking

( ) rape, attempted rape, acts of lasciviousness

( ) others (Please specify.): ________________________________


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8. How many years have you been incarcerated (considering only the current sentence)?

( ) < 1

( ) 1-5

( ) 6-10

( ) 11-15( ) 16-20

( ) 21-25( ) 26-30

( ) 31-35

( ) 36-40( ) 41-45

( ) >45

9. How many times have you ever been incarcerated?

( ) once( ) twice( ) thrice

10. Are you a smoker at present?

( ) Yes (Note: For those who answered Yes, please proceed to question number 11.)

( ) No (Note: For those who answered No, please proceed to question number 13).

11. Were you a smoker before?

( ) Yes, but stopped for _________ now.

( ) < 1year

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