the effects of incarceration on middle aged adults: a multinational study

Running head: THE EFFECTS OF INCARCERATION ON MIDDLE AGED ADULTS 1

The Effects of Incarceration on Middle Aged Adults: A Multinational Study

Ciera Chang, Jordan Cochran, and Kayla Diehl

Missouri State University

Noora Parkkila

Satakunta University

THE EFFECTS OF INCARCERATION ON MIDDLE AGED ADULTS 2

The Effects of Incarceration on Middle Aged Adults

The word "health" is a rather ambiguous term. There is no isolated definition of health,

and there is no solitary representation of health worldwide. From the concept of a lack-of-illness

defining health for some, to a more holistic approach addressing abstract needs such as

spirituality, it can be seen that the idea of health varies greatly for all. The World Health

Organization defines health as, "A state of complete physical, mental, and social well-being and

not merely the absence of disease or infirmity." However, the idea that complete and total well-

being can be simultaneously achieved in all three primary facets of health is highly debated.

Regardless, this more holistic approach is becoming more widely accepted as a proper, inclusive

way of viewing health and providing healthcare.

Further refining the interpretation of health from the eudemonistic approach taken by the

WHO, health can also be viewed within the scope of a role-performance model. For the middle

aged population, social roles are vital. Many middle aged adults experience a period of

development expressed by the theorist Erikson as the generativity or self-absorption phase

(Eliopoulus, 2014). This phase goes hand in hand with role-performance as it becomes evident

that while incarcerated, the inmate's role of parent, spouse, provider, or any number of things

becomes displaced. The incarceration forces self-absorption upon the middle aged adult and

relationships and role strain becomes apparent. A loss of fulfillment in social roles can lead to a

loss of health in the eyes of the incarcerated individual. With these concepts in mind, health

becomes a truly multi-faceted concept involving the individual's physical, mental, and social

well-being.


Identifiers of Health

In order to display the effects of incarceration on the typically middle aged adult, one

must break down the complex idea of health into its parts. Identifiers of health include mortality

and morbidity rates, risk factors, utilization of health resources and services, and health system

resources (Harkness & DeMarco, 2016). A Finland-based study on the mortality rates of inmates

seven years after release stated that there is an increased risk for early mortality in the

incarcerated population. 13.2% of the study's population died within the seven year window;

5.2% died from natural causes, 4.1% from accidental death, and 2% from suicide (Joukamaa,

1998). This population is vulnerable for many reasons including their limited rights and support.

While their rights are present, incarcerated adults are at the mercy of their care providers and

institutions to uphold them. Their support systems are strained, and there is undue stress on the

prisoners because of a lack of privacy and antagonistic relationships with guards and other

prisoners (Pridemore, 2014). All of these findings contribute to the risk factors that the middle

aged adult population faces while incarcerated. Close living quarters place the individual at risk

for contracting various communicable diseases. Prison violence and risky behaviors such as

tattooing, piercing, and sharing hygiene products also contribute to a risk of illness in the

population (Pridemore, 2014). Adults within the African American and Latino populations are

considered to have increased risks while incarcerated. Many studies note that incarceration

affects these two groups disproportionately. Additionally, there is a generalization that all

inmates have at least one chronic disease and there is an increased rate of HIV and transmission

in the prison system (Wilper, et al., 2009). In fact, many of the inmates in prison show higher

rates of chronic diseases such as diabetes, hypertension, asthma, and HIV than that of the general

population (Kulkarni, Baldwin, Lightstone, Gelberg, & Diamant, 2010). Also, tuberculosis and


hepatitis C infections are also significantly higher in incarcerated adults than those of the general

population (Pridemore, 2014).

It is also important to understand the differences gender makes on risk factors in this

population. According to a study cited in Colbert, Sekula, Zoucha, & Cohen (2013), women are

more likely than men to experience medical and psychiatric problems specifically anxiety,

depression, and PTSD. According to a study by Zlotnick (as cited in Colbert et al., 2013),

“Women inmates are five to eight times more likely to abuse alcohol than women in the general

population, ten times more likely to abuse drugs, and 27 times more likely to use cocaine” (p.

410). In the study by Colbert et al., (2013), women discuss their barriers to care such as skipping

medications to save money because of the lack of health care available. Also, women have

difficulties obtaining the proper food they needed while incarcerated because healthy choices are

not available. This can be extremely difficult for a woman managing her diabetes because

vending machines become their only option if it is not a specific meal time (Colbert et al., 2013).

These are just another few of the numerous factors that play into the risks for incarcerated middle

aged adults.

For uptake of health services, studies state that 13.9% of federal inmates and 20.1% of

state inmates received no care for their persistent medical problems after their incarceration. It

was also found that 26.3% of federal inmates and 28.9% of state inmates quit taking their

medications after incarceration. (Wilper, et al., 2009) In relation to access to care and the

system's provision of resources for this population, it has been found that, "following serious

injury 7.7% of federal inmates, 12.0% of state inmates, and 24.7% of local jail inmates were not

seen by medical personnel" (Wilper et al., 2009). In addition, it has been shown that previously

incarcerated adults tend to have less access to health insurance, have high rates of poor discharge


planning, and struggle with interruptions in care following the release period (Kulkarni, Baldwin,

Lightstone, Gelberg, & Diamant, 2010).

Global Health Care and Health Care System Models

Before one can address the aforementioned issues within the prison systems, one

must understand the models of healthcare and what healthcare looks like in an individual’s

nation. First and foremost, it is important to identify what the goals for health are on a global

level. According to the World Health Organization (2015), some of the Millennium

Developmental Goals are eliminating poverty and hunger, achieving primary education for all,

promoting gender equality and empowering women, combating HIV/AIDS among other

diseases, and developing a global partnership for development. These are some very important

aspects of the MDG’s that need to be addressed in our population. Every country has its own set

of beliefs and models used to establish health care norms and practices and address these health

care goals. There are four primary models that make up the health care systems in the majority of

nations: the Beveridge Model, the Bismarck Model, the National Health Insurance Model, and

the Out-of-Pocket. Each of these models will be discussed in relation to their application in their

respective countries.

Finland.

Finland’s health care system is a free and reduced-cost program designed by the

government under the scope of the nation’s taxation laws. The program’s coverage is not just for

residents, but for tourists in time of emergency or accident as well. The overall goal of this

system is to provide financially-fiscal care with little to no wait on access. Consumers are

expected to have their own personal insurance as well and to cover the cost of transportation for

health services (HealthGov.Net, 2012). This concept of a government-owned health care system


paid for by taxation relates strongly to the Beveridge Model. Named for Britain’s William

Beverage, this model advocates for taxes to cover a public health care system. Systems under

this model tend to have less expensive medical care despite the increase in taxation rates. The

Social Insurance Institution has many national insurance institution assignments – private health

care medical expenses, outpatient drug benefits, sickness allowances (Huttunen, 2014).

Other nations that have been derived from this model include Spain, New Zealand, and Cuba

among others (Physicians for a National Health Program, 2010). However, in addition to this

model, there is a similarity to the Bismarck model in regard to the occupational health care

system. In addition to public sector health care services, there’s also health care services

produced by private companies. Fees are collected from employers and employees (KELA =

KELA is an independent social insurance institution supervised by Parliament, earnings

insurance), and services are purchased mainly from private service providers (Huttunen, 2014).

United States of America.

Most nations, like Finland, utilize one of the four models of health care systems

individually. In the United States, however, the health care system was created using a plethora

of ideas from other health care system predecessors. For example, the Bismarck Model of health

care systems was created in Europe and named after Chancellor Otto von Bismarck (Physicians

for a National Health Program, 2010). This system was designed to utilize payroll deductions

and insurance programs; however, the similarities to the American system generally end with the

concept privately-owned insurance plans. In addition to the Bismarck Model, the American

health care system pulls ideas from the Out-of-Pocket Model when discussing those without

insurance coverage. Bills for those without coverage are due at the time of treatment in most

instances (Physicians for a National Health Program, 2010).


To really complicate things, the United States takes aspects from Canada’s National

Health Insurance Model when caring for individuals over the age of 65. Medicare is a federal

insurance program that is offered to individuals aged 65 years and older. There are many parts of

Medicare that an individual can add onto their typical coverage such as Part D for

pharmaceutical assistance. This selective-service coverage concept is not foreign to the National

Health Insurance Model. This model utilizes selective coverage as a means of regulating

expenditures (Physicians for a National Health Program, 2010). Overall, the health care system

in the United States is a conglomerate of other programs worldwide.

Prison Health Care Systems

Finland.

Finland underwent a drastic prison reform in the last thirty years. This reform has led to a

decreased in incarceration rates. According to the Ministry of Justice in Helsinki, there were a

little more than 2,700 prisoners in Finland a decade ago. In a country of 5.2 million people, this

rate breaks down to 52 for every 100,000 inhabitants. The comparable rate in the United States is

702 per 100,000. Even so, these rates have decreased more since then for Finland (Prison Policy

Initiative, 2012). With this new system, health follows the more inclusive definition as seen with

the World Health Organization. In 2006, the prison reform led to the creation of a new

constitution covering the fundamental rights of those within the prison system. Under subsection

7.2, those within the network are protected from being “sentenced to death, tortured, or otherwise

treated in a manner violating human dignity” (Lappi-Seppälä, 2012, p. 341).

This being said, Finland is now known for having a more relaxed approach to

institutionalization for crimes. In about one-third of Finnish correctional facilities, there are no

large gates and fences as in the United States, and guards are generally unarmed (Hoge, 2003).


That is not to say that security is neglected. Prisons due utilize cameras and surveillance systems.

Trust in the system and the belief of treating the inmates as human beings leads to a more mental

health friendly institution. There is a strong belief that socialization plays a large role in

maintaining the health of an individual. Home leaves are available to many inmates near the end

of their sentences, and on-grounds “home leaves” are given to inmates near the middle of their

sentence. These leaves on prison grounds consist of the prisoner being able to stay in a house on

the grounds for up to four days with visitors – children and other family in particular (Hoge,

2003).

Self-awareness and a focus on the potential for goodness in every individual leads

Finland’s prison system to be one of the best in the world. The ultimate goal of the system is to,

“increase the prisoners’ preparedness for a crime free life by furthering life handling skills and

adjustment into society as well as to prevent the committing of offenses during the term of the

sentence” (Lappi-Seppälä, 2012, p. 342). In addition to this holistic approach, there is a focus on

the physical health as well. Each Finnish prison has at least one registered nurse, and a doctor

makes appointments at least once a week. Most prisons have facilities and equipment for dental

care. Prisoners have their state of health and ability to work checked as they enter the prison. At

the same time, they get a set of basic hygiene equipment such as dental care equipment and

disinfection tools (Rikosseuraamus, 2015).

The biggest downfall of this system is the lack of mental health treatment to all. Only a

small fraction of those that need these services are able to receive them (Lappi-Seppälä, 2012).

While prisoners are supposed to be provided an opportunity for psychologist support and

treatment, this is not always available as need be. It has been found that “worldwide, mental

disorders are more common in prisoners than in the general population (Viitanen, 2013, p. 28).


This leads the lack of inclusive mental health treatment to be a serious shortcoming. There is also

a noted weakness in the coordination of care after release from the prison system (Lappi-

Seppälä, 2012). With these flaws, nurses working within this system need to act within their

roles as case managers and advocates to push for continued policy both governmentally and

institutionally. Advocating for individuals within the Finnish prison network could lead to an

increase of mental healthcare in the long run.


In the United States, prison systems are very different from that of Finland. As stated on

the NAACP’s website, the US holds a “get tough on crime” attitude (NAACP, 2015). This

attitude and the mentality of justice for one’s wrongdoings, lead to a toughened, highly-guarded,

overfilled prison network. The population of incarcerated individuals in the US has quadrupled

since 1980 and accounts for 25% of the world’s imprisoned population (NAACP, 2015). As

mentioned previously, there is a 716:100,000 people incarceration rate in the US. The next

closest contender is the United Kingdom at 147 prisoners out of every 100,000 individuals

(Prison Policy Initiative, 2012). Despite this, The United States acknowledges that prisoners are

still individuals with rights. The Health Insurance Portability and Accountability Act is a notable,

American law that protects the rights, safety, and identity of individuals seeking health care.

Incarcerated individuals are not excluded from these rights. Unless information about a patient –

incarcerated or not – is being used for providing health care to that individual, being used for the

safety of employees, other patients, and other inmates, or being used for informing institutional

law enforcement, it cannot be disclosed (Bednar, 2003).

The United States has special opportunities for individuals after release from

incarceration through the Affordable Care Act’s governmental insurance program. Lower


premiums and out-of-pocket costs are just a few of the potential benefits for those looking for

assistance after leaving the prison system (HealthCare.Gov, 2013). Regardless of the type of

insurance chosen after incarceration, there is a 60-day window of opportunity for the individual

to find a plan before the penalty for not having insurance is enacted (HealthCare.Gov, 2013).

Despite this, there is still a shortage in planning for the individual’s reintegration to his or her

community after release.

The other major flaws the US prison system are the increasing rates of incarceration and

a shortage of mental health services. Because of the overcrowded conditions of the US prison

system, communicable diseases make a huge, negative impact on prisoners. As advocates for

patients in this network, nurses can speak out for decreasing incarceration rates, increasing

communicable disease education, prevention, and treatment, increasing mental health treatments

for incarcerated middle aged adults, and increasing the planning for reintegration into society

(Wilper, 2009).

NGO Involvement

The prison systems discussed receive attention from both governmental and

nongovernmental agencies. NGOs, or non-governmental organizations, are groups that acquire

resources from private sources in order to help other individuals (Harkness & DeMarco, 2016).

Some of these organizations play a role in addressing the issues with the prison systems to some

degree in both Finland and the United States of America.

Finland.

Traditionally non-governmental organizations have had a strong position in Finnish

social care and healthcare. NGOs have had a special national role in expertise, promoting well-

being and providing services for vulnerable groups such as individuals with disabilities, the


homeless, the unemployed, those suffering from drug or alcohol abuse, and released prisoners.

Furthermore, they act as advocating agents and organize voluntary work. In the past, NGOs

could have been called “charity organizations,” but during the last decade, the role of NGOs has

been deemed “communities for public good.”

KRITS – or the Correctional Service Support Foundation – is a Finnish NGO that strives

to improve the position and performance in society of those sentenced to prison and their

families. KRITS develops after-care and improves services, influences criminal policy, promotes

the interests of its target group, and supports voluntary work. KRITS aims to accomplish a

nationwide network of organizations producing support services in the field of after-care and to

participate in the co-ordination of the network and provision of resources (KRITS, 2015).

Portti Vapauteen is a website produced by KRITS and the “Rehellistä elämää” network.

The Portti Vapauteen service is meant to provide help for incarcerated, their families, and for

those who are working in prisons and/or with the prisoners. The service aims to prevent and

reduce recidivism by helping criminals and their families cope in society. Portti Vapauteen

works with the Criminal Sanctions Agency, educational institutions and researchers, and with

health care professionals. The service is financed by RAY and KRITS (Portti Vapauteen, 2015).


One major NGO in the United States that plays a part in protecting the rights and health

of incarcerated middle aged adults is the American Civil Liberties Union (ACLU). ACLU has

created a National Prison Project that, “is dedicated to ensuring that our nation’s prisons, jails,

and detention centers comply with the Constitution, domestic law, and human rights principles”

(ACLU, Prisoners’ rights, 2015). This organization believes that the vulnerability seen in this

population because of its dependence upon authority figures to provide care places inmates in a


very dangerous situation. The ultimate goal of the medical aspect of ACLU’s National Prison

Project is to ensure that individuals with chronic illnesses, emergencies, and serious mental

illnesses get the care that they need in order to relieve unnecessary suffering (ACLU, Medical

and mental health, 2015). If an individual is taken care of during incarceration, they will be in

better condition to be reintegrated into society following release.

One NGO striving to address this shortcoming as well is the Lionheart Organization. The

Lionheart Organization started a prison project called House of Healing. What originally started

as a program for younger inmates is now being integrated into prisoners of all ages. This

program initially addresses rehabilitation process by asking the important question of, “Who are

you?” Many individuals in the prison system are burdened by what they did, who they affected,

or rage and anger that it may be difficult to get to the core of what got them into prison in the

first place. This is a program similar to the introspective ideals of Finland’s system that causes

prisoners to examine themselves and start to find healing from the inside out. In addition, this

program, like others in the United States, gives tools, resources, education, and hope to inmates

to begin living a new life. Many substance abuse or assault programs may be offered to the

prisoners who wish to have the best well-being upon discharge (Lionheart Organization, 2015).

Nursing Involvement

Whether through the discussed NGOs or as a means of employment, nurses have a

unique body of knowledge and expertise that can be crucial to providing care for the middle aged

incarcerated population. The nursing role of provider of care is highly intertwined with the idea

of health promotion. There are three typical stages of intervention and health promotion for care

of an individual: primary, secondary, and tertiary.


An applicable nursing model for primary, secondary, and tertiary nursing

interventions with the middle aged adult population is that of the Neuman Systems Model by

Betty Neuman. This model has a focus on the “wellness of the client system in relation to the

environmental stressors and the client systems reaction to stress” (Masters, 2012). As mentioned

previously, the overcrowded environments of US prisons can have a negative impact on the

health of the individuals within. This is an example of the environmental stressor that affects the

client system. Neuman also states that the goal of this model and its designed interventions is to

reduce the potentiality or actuality of these stressors on the client (Masters, 2012).

The primary level of prevention as intervention aims to retain the current state of health

in an individual (Masters, 2012). A prime example of primary prevention is education. Educating

inmates and facility workers on the increased rates of disease in the incarcerated population and

how to prevent some of these diseases is an intervention that nurses can take advantage of in this

category. Secondary interventions are typically implemented when primary interventions fail or

were not provided. The goal of these interventions is to attain wellness and prevent the further

spread of illness (Masters, 2012). Screening is the typical example for secondary interventions.

Screening for HIV – a disease with increased numbers in the middle aged incarcerated group – is

one example of secondary interventions that can be implemented (Wilper, et al., 2009). The final

group of interventions, tertiary, is for wellness maintenance or rather, returning to wellness after

treatment (Masters, 2012). Rehabilitation for drug abuse situations is an essential tertiary

intervention for this vulnerability group given that there is an increased potential to have a

history of or future use of illicit drugs in the population in comparison to the general population

(Wilper, et al., 2009). \


Rehabilitation

Further discussing the aspect of tertiary interventions, rehabilitation has similarities and

differences between Finland and the United States. Merriam Webster (2015) defines

rehabilitation in two ways. The first definition is, “to bring (someone or something) back to a

normal, healthy condition after an illness, injury, drug problem, etc.” The second definition is

more applicable to the vulnerable population and states, “to teach (a criminal in prison) to live a

normal and productive life.”

Finland.

As discussed already, Finland’s prison system does a wonderful job of incorporating

aspects of rehabilitation into the structure of the system itself. In Finland, the public attitude

toward crime is civil in that the focus is toward rehabilitating offenders and using gentle justice

(Ekunwe, Jones, & Mullins, 2010). The purpose of prisons in Finland is to try to solve the

biggest problems in the incarcerated adults’ life to reduce the risk of repeated crimes once they

are released. A survey by Ekunwe (2007) found that 80 percent of respondents believe that

criminals should be rehabilitated and 85 percent of the participants were willing to pay extra

taxes to improve the existing system (Ekunwe et al., 2010). Finland’s open prison system has

focused on providing work, study, and various activities to help them cope make them

productive members of society.

Finland has a program called Criminals Returning into Society (CRIS), which

assists incarcerated adults with complete abstinence from drugs and alcohol when they are

released (Ekunwe & Jones, 2011). They receive support from ex-convicts who understand their

situation and can provide social networks to assist with their sobriety. Also, incarcerated adults

in Finland are able to earn a wage while in prison and when they are released, “they are entitled


to housing subsidies and unemployment insurance” (Ekunwe & Jones, 2011, p. 457). This

provides the resources needed to be able to support themselves as they re-enter into society.


In the United States, correctional facilities are making large strides in trying to improve

the preparation of incarcerated individuals in order to make the inmates successful as they begin

to live their lives outside of prison. However, it is unfortunate that in the United States,

deterrence and incapacitation are still the goals of imprisonment rather than rehabilitation

(Phelps, 2011). The United States has harsh punishment laws and is the only country in the

Western world to continue using the death penalty and life sentences without the possibility of

parole (Ekunwe et al., 2010). However, in 2005, the Re-entry Enhancement Act was passed

which provides resources for drug addiction and mental health treatment, job training, housing,

and education for those returning into society after incarceration (Verro, 2010).

In the United States, there is a program called the Federal Bureau of Prisons Life

Connections Pilot Program. This is an 18-month program that helps inmates with ethical

decision-making, anger management, and victim resolution according to their own religious

beliefs with the end goal being recidivism reduction (United States Department of Justice, n.d.).

Male and female inmates must be within 24 months of release or more and they have to complete

500 hours of community service, 150 hours of addiction programming, participate in Victim

Impact Programs, and keep a journal with re-entry goals and action steps (USDOJ, n.d.).

Another initiative is the President's Prisoner Re-entry Initiative (PRI), which incorporates

resources from faith-based community organizations to provide newly released prisoners with

job training and placement, traditional housing, and voluntary mentoring support (USDOJ, n.d.).


With all of this combined, there is conflicting evidence as to whether or not the United States is

improving the concept of tertiary interventions within the idea of incarceration.

Conclusion

Management of health care varies greatly depending on the region in which the care is

being delivered. Furthermore, health care to vulnerable populations such as middle aged

incarcerated adults can vary significantly from that of the rest of the region’s general population.

While Finland has a wonderful prison system with low incarceration and re-incarceration rates,

there are still aspects of care that need to be addressed. Likewise, the United States’ prison health

care system is advancing in health care practices, but still has long strides to make before the

needs of these individuals are truly met. At this time globally, more can be done to address

prisoners as humans with existential rights; however, the advancement of rights within

vulnerable populations are constantly being expanded worldwide.


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the effects of incarceration on middle aged adults: a multinational study

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