Contextual and Organizational Factors

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The structure of U.S. jails and prisons offers different opportunities for health promotion. Jails incarcerate individuals who are awaiting adjudication, those sentenced to terms of a year or less, and parole and probation violators (James, 2004). Because of the high volume, short lengths of stay, and rapid

Box 13.1 Definitions of health promotion activities in jails and prisons

Counseling describes one-on-one or small group interactions between health, mental health, social service, or correctional staff and incarcerated or recently released individuals that takes place inside a correctional facility or after release. It provides tailored guidance, emotional support, and information to help individuals address health, psychological, and social problems.

Health education has been defined as "any combination of learning experiences designed to facilitate voluntary actions conducive to health" (Green, Kreuter, Partridge, & Deeds, 1999). Health education is expected to be evidence-based, culturally and linguistically appropriate, and can include multiple modalities such as individual education, peer education, lectures, and role-play.

Chronic disease management assists individuals to manage diseases such as asthma, hypertension, or diabetes. It includes regular screening, counseling and education, skills development, and access to appropriate medical care in the correctional setting and after release.

Community follow-up includes prerelease planning for medical care and social services and postrelease contact to reinforce health education, ensure medical care access and adherence to prescribed regiments and to assist in meeting emerging needs. The interval for community follow-up varies from days to a year or more.

Collaboration describes intersectoral cooperation and coordination among a variety of public and private organizations including correctional, parole and probation, health, mental health, housing, welfare, employment, and other agencies.

Addressing other social needs such as housing, employment, legal assistance, substance use treatment, access to entitlements and family reunification, describes activities designed to assist people returning from jail or prison to create the life circumstances that allow them to make health a higher priority.

Policy advocacy describes activities designed to identify policies that facilitate or impede successful and healthy community reentry after incarceration and to strengthen those policies that assist reentry and modify those that block success.

turnover, jails provide unique opportunities to reach many vulnerable individuals within low-income communities, to link them to community health promotion efforts after release, and, because jails unlike prisons are usually located within high-incarceration communities, to engage family members in health promotion activities (Freudenberg, 2001; Glaser & Greifinger, 1993; Lindquist & Lindquist, 1999; McLean, Robarge, & Sherman, 2006; Rogers & Seigenthaler, 2001). On the other hand, the high turnover, security concerns, dynamic environment, and external demands from elected officials, the media, and the public on jails make them a difficult environment for health promotion This setting requires health staff to have patience, modest goals, and a willingness to balance their desires to address health issues with the custody and control priorities of correctional officials.

Prisons typically house people sentenced to more than a year and include individuals who will never be released from the facility. Longer lengths of stay and a more secure and stable environment sometimes enable prisons to have more opportunities for planned health activities and to have the intensity and duration of contact needed to achieve health goals. On the other hand, prisons have more limited interactions with families and communities, reducing their potential to have an impact on population health (Austin & Hardyman, 2004).

Correctional systems also vary in their support for and commitment to health services. Some jurisdictions have established model programs and CHS, and

Table 13.1 Approaches to health promotion in existing standards and guidelines for correctional health care.


Health education

Chronic disease management

Community follow-up

APHA (2003)

Individual-level patient education by medical staff for chronic illness and risk behavior for infectious disease

Culturally and linguistically appropriate health education provided by trained facilitator for those with chronic/infectious disease and for smoking, nutrition, exercise; use of peer-based, lecture, discussion, and role-play

Medical care (screening, clinic visits, treatment education) for those with long-term conditions for which self-care is significant

Prerelease planning and referrals to medical care; postrelease contact for reinforcement of health education and access to medical care and entitlements like Medicaid

NCCHC (2003,2001)

Individual-level patient education by medical staff

Culturally and linguistically appropriate health education provided by trained facilitator for those with chronic/infectious disease and for smoking, nutrition, exercise; use of in-house video channels

Quality screening, treatment management, and education for chronic/infectious disease (STIs, tuberculosis, HIV, hepatitis, asthma, high blood cholesterol and pressure, diabetes)

Collaboration with commu-nity-based organizations to provide prerelease planning for those with chronic/ infectious disease

Re-Entry Policy Council _(2005)_

Individual-level patient education by medical staff and community-based organizations

Culturally and linguistically appropriate health education provided by trained facilitator for those with chronic/infectious disease, smoking, nutrition, exercise, medication adherence, STIs

Presence of standardized clinical protocols for evaluation, treatment, and education for those with chronic disease

Use services and relationships with community-based organizations prerelease to coordinate care postrelease; seamless and protected medical record transfer

HIPP (Gatherer et al., 2005; Whitehead, 2006; WHO, 2002,2004,2006)

Education and skill development that emphasize rewards rather than sanctions

Quality care provided; address chronic/infectious disease (tuberculosis, HIV) by addressing overcrowding in prisons and using harm reduction approaches


Table 13.1 (continued)


Other social needs

APHA (2003)

Collaboration with local health departments, government agencies, and community-based organizations to provide corrections-based services and services on reentry

NCCHC (2003,2001)

Collaboration with local health departments, government agencies, and community-based organizations to provide corrections-based services and services on reentry

Re-Entry Policy Council _(2005)_

Engagement of community providers to provide effective corrections-based counseling, health education, chronic disease management, and community follow-up

Part of transition planning services, especially for those diagnosed with multiple disorders, which can impede successful reentry

HIPP (Gatherer et al., 2005; Whitehead, 2006; WHO, 2002,2004,2006)

Collaboration among WHO, national departments of justice and health to create a prison health service in participating countries

Creating alternatives to standard incarceration as part of mental health promotion; use of corrections-based harm reduction services for drug users; focus on rehabilitation


Mandatory policy reports from each participating country to be disseminated widely wardens, sheriffs, or commissioners/directors are forceful advocates for health (Lincoln et al., 2006; Sinclair & Porter-Williamson, 2004; White et al., 2003). Others, however, view health as a distraction from more traditional custody and control issues and take on health issues mainly in response to litigation (Nathan, 2004). Obviously, health professionals in a supportive environment will have an easier time adding a health promotion perspective into existing CHS, while those in more traditional settings face greater obstacles. Even in challenging environments, however, litigation, new state or federal mandates, or forceful advocacy can stimulate interest in more comprehensive approaches to health, including health promotion.

A third contextual variable of interest is the extent to which existing officials in local or state correctional or health departments or in local or state government as a whole support intersectoral, multilevel approaches to reentry and improved health. The approach to health promotion described here works best if officials, providers, and advocates from multiple systems and agencies are willing to come together to articulate a shared vision , identify and solve problems, exchange resources , and plan comprehensively. Having a high level official who supports and is willing to lead such an effort significantly increases the likelihood of success.

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