The Unique Innovative Role of Information Technology in Advancing Health
Care Solutions for Incarcerated Women

Ces’ Cook, Senior Advisor, BCA
Health Services Research
Health Policy and Management
Incarcerated women represent a population clearly at risk for health problems,
including problems that may affect their children and eventually the general public. The period
of confinement presents an opportunity to provide treatment and support that should not be
missed. To the extent that health information technology improves health care quality,
differential adoption among providers that serve vulnerable populations may exacerbate health
disparities. Offering public health assistance and expertise to correctional facilities is an
important means for addressing the gaps in services and programs for women in the correctional
Key Words: Substance Abuse, Evidence-Based, Data-Driven, Information Technology,
Incarceration, Variability, Political Will, Social Determinants of Health, ACOs, CHCs,
Over the last 15 years, the number of incarcerated women in the United States has increased
dramatically. While the number of men in state and federal prisons has grown 67 percent since
1990, the number of incarcerated women has increased by 92 percentffenses related to
illegal drugs account for nearly 40 percent of this increase. Historically, offenses such as
larceny, forgery, embezzlement and prostitution accounted for the majority of women’s
sentencesAt the end of 1998, 84, 427 women were under the jurisdiction of State or Federal
correctional authority and as of June 30, 1998, 63,791 women were in local jailsToday
nationally, there are 183, 348 women in prisThese women were housed within a correctional system that includes 94 federal and 1,378 state
prisons, and 2,994 local jailsf the 94 federal institutions, four are female and male facilities
and nine are administrative facilitiesWomen entering the correctional system represent a
population already at high risk for communicable diseases, substance abuse and mental health
problemscause the number of incarcerated men historically has far exceeded that of
incarcerated women (women represented 6.5% of prison inmates at the end of 1998), limited
attention has been paid to the unique health concerns of this population.With increasing
2 Office of Justice Programs, U.S. Department of Justice, 1998 4 Pennsylvania Prison Society Working Group 2011 numbers of women entering and exiting the prison system, there is a compelling need to ensure
that mechanisms are in place that can adequately address these health issues.
Facts about the Over-Incarceration of Women
• Information from 2007 shows that with more than one million women behind bars or under the control of criminal justice system, women are the fastest growing segment of the incarcerated population increasing at nearly double the rate of men since 1985. (Facts about the Over-Incarceration of Women in the United States, December 12 2007, ACLU) • Nationally, there are more than eight times as many women incarcerated in State and Federal prisons and local jails as there were in 1980, increasing in number from12,300 in 1980 to 182,271 by 2002.
• Expanding at 4.6% annually between 1995 and 2005, women now account for 7% of the population in State and Federal prisons.
• Between 1977 and 2004, New Jersey’s female prison population grew by 717% with an average annual percent change of 8.8% per year.
• Throughout the period from 1977 to 2004, New Jersey’s female imprisonment rate was 33 female prisoners per 100,000 female residents.
• In 1977 there were 180 total female sentenced prisoners in New Jersey; in 2004, there were 1,470 female sentenced prisoners in New Jersey.
• Over the past 20 years the war on drugs has caused significant rise in the number of women incarcerated and their access to adequate drug treatment.
• 40% of criminal convictions leading to incarceration of women in 2000 were drug • 34% were for other non-violent crimes such as burglary, larceny, and fraud.
• 18% of women in prison have been convicted because of violent crimes.
• Many women in prison have experienced physical or sexual trauma at the hands of men.
• 92% of all women in California prisons had been “battered and abused in their lifetimes.
• Women of color are significantly over represented in the criminal justice system.
• African American women represent 30% of all incarcerated women in the United States although they represent 13% of the female population generally.
• Hispanic women represent 16% of incarcerated women, although they make up only 11% • Among female State prisoners, two-thirds are mothers of a minor child.
• Over 1.5 million children have a parent in prison.
In order to assure that the unique health needs of incarcerated women are met, it is important that correctional facilities are equipped with appropriate information, staff and resources. Providing incarcerated women with comprehensive and appropriate health care services can be challenging because women represent such a small proportion of jail and prison inmates. Despite these challenges, the period of incarceration, however long or short, provides a window of opportunity for improving the health status of this populatiuccessful collaboration between correctional and public health agencies can ensure that opportunities are taken. State and local Maternal and Child Health professionals and other health professionals may be able to assist in this regard through partnerships to plan and/or provide health services within correctional facilities as well as to arrange for follow-up in the community upon a woman’s release 9 Katherine McCaa Baldwin and Jacquelyn Jones Characteristics of Incarcerated Women
The median age of women in Federal, State and local facilities is 36, 33, and 31 years
respectivelyore than half of women in the correctional system have at least a high school
education and are not marrieore than two thirds of women have children under the age of
18, most of who are living with a grandparent or other relativesWomen of color are
disproportionately represented in the prison system in 1998, and women of color represent
approximately 26% of women in the United States, but represented 64%, 67% and 71% of
women in jails, State prisons and Federal prisons respectivelyoverty and addition appear to
frequently motivate criminal acts by women in prison and almost 75% of women in jail are
unemployed upon arrest and one in four women prisoners state they committed their offense to
finance drug purchasesrug-related crimes represent the most common offenses by women in
Federal and State prisons (Federal72%, State 34%) and the second most common offenses by
women in local jails (30%). The most common offenses by women in local jails are property
offensesWomen entering State prison are less likely than men to have a violent
criminal history. Women are more likely than men to have no previous sentence (28% v 18%).
In their 1997 NIC Report, Brennan and Austin described seven unique attributes of female
• Vocational, Educational and Economic needs In order to provide appropriate health care services for incarcerated women, it is important that these attributes be considered by correctional systems and facilities as they develop and/or implement health care standards and protocols.
Although the facilities within the Federal prison system are accredited and routinely surveyed by the Joint Commission Accreditation in Health Care Organizations (JCAHO), national uniform standards are not applied across all State and local correctional facilities and community incarceration programs. As a result, health care services offered to incarcerated women (and men) outside the Federal prison system vary significantly.
Given the multiple issues surrounding communicable diseases, reproductive health and the prevalence of substance abuse and mental health problems among incarcerated women, it is necessary to direct special attention to these areas. Screening for sexual transmitted diseases (STDs) in correctional facilities is difficult because of the large number of persons admitted each
day and the frequent shortage of medical staff and examination spaceThis is of particular
concern because the prevalence of STDs and other communicable diseases is known to be high
among women entering correctional facilitiesWhile each female inmate is to receive a
complete physical examination, the syphilis serology appears to be the only STD for which
women are most consistently screened. Other infectious disease testing is conducted if clinically
indicateFollowing a treatment protocol based on clinical indication is not adequate because most women
with Chlamydia and gonococal infections are asymptomaticeft untreated, these two
infectious diseases can lead to pelvic inflammatory diseases, ectopic pregnancy, infertility or
chronic pelvic pain in women. They also are associated with increased risk for contracting the
human immunodeficiency virus (HIVHIV and acquired immunodeficiency syndrome (AIDS) are more prevalent among incarcerated
women than incarcerated mesponses to a 1997 survey indicated that more than half (27 of
51) reporting State prisons test for HIV among high risk groups, inmates with symptoms, or
upon inmate request. According to this survey, HIV therapies are available in most correctional
systems with more than 90% of responding prison and jail systems reported availability of such
therapies as protease inhibitors, combination therapy, Bactrim, and AZT for pregnant women.Despite the appearance that most correctional systems offer these treatments; it should be noted
that financial constraints as well as the lack of uniform standards may inhibit access to them.
Unlike Hepatitis B, for which there is a vaccine that is increasingly available to inmates and staff
in correctional facilities, the prevalence of Hepatitis C continues to be a serious problem.The
Hepatitis C virus (HVC) is especially prevalent among persons infected with HIV and injection-
drugs users. Untreated women returning to the community following a period of incarceration
may place themselves and others at risk for future health complications.
Reproductive Health of Women Incarcerated
In addition to standard health care needs, pregnant women entering the correctional system have
health concerns specific to prenatal, postpartum and infant care. Approximately 6% of female
inmates are pregnant upon incarceratiThis percentage is probably imprecise because as of
1997, less than half of correctional systems routinely screen incoming female inmates for
18 Hammett et al, 1999; Puisis, Levine and Mertz, 1998 19 Profile of Female Offenders, May 1998; Hammett et al; MMWR, June 1998 pregnancyome studies report higher birth-weights among incarcerated pregnant women
compared with high risk pregnant women in the general population. A possible explanation for
this effect is that pregnant women in the correctional system have adequate shelter and nutrition,
have more limited access to alcohol, cigarettes and other drugs and are more likely than high risk
pregnant women in the general population to have access to routine prenatal careOf great concern, however, are those pregnant women who are infected with HIV. Women who
are pregnant and HIV positive require medical treatment and ZDV (AZT or Zidovudine)
prophylaxis to reduce the risk of HIV transmission to their infants and optimally manage their
HIV disease. There are also special needs for women who have decided to terminate the
pregnancy, such as provision of counseling, medical treatment and family planning services.
Although most pregnant incarcerated women would be considered at risk for complications,
access to specialists including obstetricians and gynecologists is often limited in correctional
systems because of cost and transportation issuesSubstance Abuse and Mental Health Problems
According to the Bureau of Justice statistics, 73% of female prisoners in State institutions and
47% in Federal institutions used drugs regularly prior to incarceratiorty percent of women
in State institutions and 19% in Federal institutions were using drugs at the time of offense.
Substance abuse or dependence, post traumatic stress disorder (PTSD), the most common mental
health problems for this population. Women in the correctional population report higher rates of
childhood abuse than women in the general populati Profile of Jail
Inmates, 1996, it was reported that almost 50% of jailed women had experienced physical and/or
sexual abuse at some point in their lives, but only 36% had ever received mental health services
and just 20% received mental health services after admissiClassification, Collaboration and Screening
The classification and screening process determines the location and type of facility in which an
offender is placed. Based on this placement, certain programs and treatment options may or may
not be available, such as support groups, women-oriented substance abuse treatment, or extended
visitation with childreThe difference in circumstances and needs between incarcerated men
and incarcerated women have implications for the classification process and subsequent
strategies for incarcerated women. Morash, Bynum and Koons (1998) found that although
female inmates have unique programming and housing needs, the methods used for inmate
classification tend to be identical for female and male offenders. Only three states reported using
a special classification instrument for women inmates. Thirty-nine states reported using the
27 Martin, et al, 1997; Cordero, et al, 1991 same instrument for women and men and seven states reported using an adjusted men’s
instrument for women.
Given the prevalence of substance abuse and mental issues among incarcerated women, quality
programs designed for women are needed in order to take advantage of the “window of
opportunity” provided by the period of incarceration. Correctional facilities may be under
increasing pressure to offer more comprehensive services without the benefit of additional
Interagency collaboration is needed and necessary to reduce the burden for correctional facilities
that are attempting to address the issues. Loss of entitlements to publicly funded insurance
coverage (such as Medicaid) when inmates enter into this system is why there is a need for
interagency collaboration. The absence of interagency collaboration can greatly compromise the
abilities of correctional institutions to develop appropriate discharge plans and facilitate
continuity of care arrangementsPolicy Framework to Strengthen Community Corrections
Many community corrections agencies lack a systematic approach to performance measurement
that would enable them and their key stakeholders and constituents to effectively judge how well
the agencies are accomplishing their goals. Interagency collaboration is only part of the solution
must the ability to measure how well an agency performs is required for tracking progress.
Where performance measures exist, most are primarily case flow measures (new cases received,
cases discharged, cases remaining), activity counts (number of office or field contacts completed,
number of drug tests administered), point-in-time snapshots (average caseload size, types of
cases supervised) and other process measuresSuch measures provide information about the
agency workload, but fail to address the results achieved by the agency. The absence of outcome
handicaps policy makers and others who wish to assess the overall performance of the
agency and also limits the ability of corrections executives to effectively manage their staff and
resources plus meet their goals.
The solution to the problem mentioned above may require community corrections agencies to
implement a systematic performance measurement model which includes measures of outcomes
in key performance areas. A comprehensive performance measurement system would address
the many tasks that community corrections agencies are responsible for: tracking performance at
multiple levels (individual cases, staff, units, programs and the entire agency) and examining
both process and outcome measures.
The marketplace, however, should work for health care by focusing not on access, but on
outcomes. To reimburse for outcomes requires a system to measure health outcomes.
Reimbursement now is based on process because we have not focused on how to measure
outcomes. We could start by reimbursing as we now do, for process, and then add incentives for
improvements in outcomes. These outcome measures can also be applied to community
corrections agencies.
Key performance: Recidivism, employment, substance use, payment of victim restitution,
compliance with “no contact” orders, and the overall performance of supervised individuals as
measured by the type of discharge from supervision. These key performance and others must
now be “evidence-based practices” to convince policy makers that financial resources are needed
by the agency.
34 Pew Center on the States, Public Safety Performance Project (12-15-2012) On any given day in this country, over seven million offenders are under some form of
correctional supervision. About 2.3 million adults are in State and Federal prisons and jails;
more than 5 million are on probation, parole or some form of government supervision after
release from prison. About 4 in 10 probationers don’t successfully complete their period of
supervision, and half of those released from prison wind up back behind bars within three years.
This revolving door of offenders contributes to crime in our communities and the exploding cost
of correctionssearch and practice over the past 25 years have identified new strategies and
policies that can make a significant dent in recidivism rates. Implementing these research-
backed programs and procedures is called “evidence-based practices.”
The implementation of evidence-based practices results, in an average decrease in future crime
of between 10% and 20%, whereas programs that are not evidence-based tend to see no decrease
and even a slight increase in future crimeerventions that follow all evidence-based
practices can achieve recidivism reductionsany state statutes and administrative
regulations specify that certain correctional services and programs must be evidence-based. For
example, Oregon has taken a comprehensive approach by passing legislation requiring that at
least 75% of all state monies for programming be spent on programs that are evidence-baseVariability and Information Technology
W. Edwards Deming, the quality improvement pioneer who is credited with revolutionizing
manufacturing, most notably through his work with the Japanese auto industry, created a theory
to analyze and eliminate variability in quality improvement. The idea was used by Intermountain
Healthcare in Utah to analyze and use the theory to minimize variability. By sharing findings
about variability and best practices, practice patterns began to shift as physicians learned from
each otherMeasuring variations in care delivery that is based on W. Edwards Deming quality improvement
theory has shown that improving the outcomes of clinical processes, the cost of operations will
drop. This process can be applied in the corrections facilities with a clear defined focus (i.e.,
substance among incarcerated women), where the organization can develop standardized
protocols that will guide clinicians to deliver the highest-quality, most cost-effective care for
these inmates.
Information technology (IT) is leveraged in several ways and is the key to effectively
implementing quality improvement initiatives. IT provides timely and accurate data about
processes, costs, and outcomes which is the heart of quality improvement. It is used to automate
processes, present complex data in easy-to-understand formats, and improve communication
across the enterprise. The results are streamlined processes that eliminate waste and variability.
For example, Business Computer Applications, Inc. (BCA’s) Pearl is designed specifically for
large ambulatory healthcare organizations and today is one of the leading EHR systems in the
world that supports large outpatient healthcare delivery systems. Pearl combines all Practice
Management, EHR, Billing and Accounts Receivable, General Accounting, Management
36 Andrews, D.A. and Craig Dowden, et al 39 Brent, James; Marc Probst and Brandon Savage Information and interoperability functionality on a single system and database technology platform.
IT is a totally integrated product that supports nearly all clinical, operations, financial and administrative functions of a large scale multiple specialty healthcare practice. This reduces the product integration time required during implementation. Pearl can be easily customized to support all ambulatory specialty practices through the use of preferences, forms building, alerts, templates and tags many of which are standard with the system, since it was developed from a provider’s point of view for commercial multispecialty healthcare providers.
In Pearl, health data is presented to the user from the perspective of the patient’s chart. This allows users to easily navigate the patient’s clinical information from any point in the system without exiting the chart. User access and constraints are controlled by Pearl’s internal security system which defines navigation based upon user roles and responsibilities. This is vital, in general, for correctional facilities but, in particular, for incarcerated women.
BCA understands that integration with external systems is a risk area in any EHR implementation. Every BCA EHR Project integrates its software with other health information systems and the established processes will reduce this risk to an acceptable level. BCA has experience integrating Pearl with other EMRs and a number of pharmacies, laboratory, radiology and other ambulatory management information systems. This will be an initial challenge for the staff and the organization in a traditional women’s correctional institution because there is no indication that the systems are now in place. BCA have integrated its systems with Medicare and Medicaid, insurance companies, managed care, Federally Qualified Community Health Centers and other community-based clinics. Pearl have also been integrated with medical devices and equipment, as well as, State and local government disease registries such as immunizations, diabetes, hypertension and other public health surveillance and monitoring systems. Pearl is designed to operate, and interoperate, on the principle of allowing data to be entered into the system only once from any data entry point and shared through the system when needed. Thereby eliminating duplicate work and minimizing cost. The system’s multi-facility, multi-specialty, multi-department, multi-provider database design allows continuity of care.
A complete lifetime longitudinal patient record allows users to view all patient clinical information at any point in the system regardless of where care is provided. The system’s “one patient one chart” design allows multiple users to work in the patient chart simultaneously and view and share patient information in a collaborative fashion from anywhere in the healthcare delivery system or throughout the world. To protect against data becoming corrupt, Pearl’s records management logic allows any record in the patient’s chart to be updated by only one user at a time while allowing other users to view the record with notification of its current locked status. Authorized users can view patient records including laboratory results, culture results, medications, allergies, problem list, procedures/diagnosis, vital signs (which can be displayed graphically), referral information and physician orders. BCA have a CCHIT and HHS Office of the National Coordinator (ONC) certified EHR system.
Adoption of Health Information Technology in Community Health Centers
Enhanced health information technology—and EHRs in particular—may indeed provide new
leverage points for addressing health disparities, but this will occur only if patients from
traditionally underserved groups (e.g., incarcerated women) have access to the clinical benefits
associated with health IT. Conversely, slower adoption of health IT enhanced health care among
providers of care to historically underserved populations could exacerbate existing health disparities for thatAdoption of health information technology (HIT) among community health centers (CHCs) is an important addition for safety net provider. It is more important for potential women inmates seeking quality health care when released from incarceration.
CHCs have been an important safety net provider for more than forty yearsThey have provided medical, dental, and behavioral health care for low-income people, uninsured people, migrant farmers, the homeless, and others in need of medical assistanceearly two-thirds of CHC patients are racial or ethnic minorities, and 30 percent are not fluent in English.ince 1999, the number of patients served by CHCs has increased more than 50 percentowever there are barriers to health information technology adoption in the CHC community. To better understand the primary barriers to health IT adoption among CHCs, 633 CHCs that did not have a functional EHR to rate the importance of several potential barriersNine-tenths of respondents noted the lack of capital to invest in EHRs as an important or very important barrier to adoption, four-fifths cited the inability to integrate the EHR with the center’s current billing or claims submission system, and three-fourths cited concerns about the loss of productivity or income during the transitine the other major barrier in the adoption process is the importance of patient mix. CHCs high proportion of uninsured and poor patients reflects their fragile revenue streams and financial vulnerability, as well as the increased complexity of the patients they serve. CHCs that serve the highest proportion of poor and underserved patients, and thus have comparatively lower third-party revenues, are significantly less likely to have an EHR systemCommunity health center’s heavy financial dependence on public grants and Medicaid payments, which in combination account for nearly 70% of all operating revenues, means that public financing for health IT adoption and operational support effectively will determine the extent to which these providers and their patients are able to benefit from these technological advances. CHCs will need major up-front investment to facilitate initial adoption, as well as ongoing assistance to support IT staffing and ongoing maintenanceHealth IT capacity and health disparities have shown reduction in health disparities among the population of patients served by CHCs. The impact of reduced health disparities achieved by CHCs in such key areas as infant mortality, prenatal care, tuberculosis rates, and age-adjusted 41 M.E. Lewin & S. Altman, eds.
42 National Association of Community Health Centers 43 J. Taylor, “The Fundamentals of Community Health Centers.
44 DHHS, Health Resources and Services Administration, 1999-2005 45 Adoption of Health Information Technology, Health Affairs 2007 47 R. Hillestad et al Health Affairs, 2007 48 McAlearney, “The Financial Performance.” death rates has been associated with a reduction in health disparities statewide.These
successes are consistent with health center’s mission to provide high-quality care that is
customized to fit the needs of the largely minority communities they serve. Given that CHCs
serve approximately 14% of the nation’s uninsured people, 11% of Medicaid enrollees, and 10%
of minorities, investing in expanding CHC’s health IT capacity seems a valuable strategy for
further reduce health disparities for a substantial number of financially vulnerable patients.The study that produced the above numbers must be viewed with study limitation within the
context of study limitations. Survey data were self-reported and were not audited. Despite these
limitations, this study provides the first national estimates of EHR adoption and barriers to
adoption among CHCs and useful information for developing policies to ensure that access to
improved quality and safety of health care will not be denied to those patients served by this
critical group of safety-net providers Monitoring the diffusion of health IT among providers that
disproportionately care for underserved populations must be a central part of any comprehensive
strategy to reduce health disparities in the United States.
Advancing Accountable Care Organizations for Medicaid Patients
Health professionals who care for people with Medicaid coverage are struggling to deliver high-
quality, efficient care to their most vulnerable patients. Low-income patients with complex
conditions often cycle in and out of the hospital because they don’t have good primary care, have
unmet mental health needs, and lack critical social supports, such as stable housing, that are
essential for good health. At the same time, many health care practices and clinics that care for
low-income Medicaid patients often lack the infrastructure, resources, and staff to ensure that
these patients receive targeted interventions from community-based teams that are familiar with
patients’ outcomes, poor coordination of care across different providers, and wasteful spending
from avoidable hospital use.
The health reform act provided for Accountable Care Organizations (ACOs) for Medicare
patients but they are also being considered by States for Medicaid patients. Under this model,
financial incentives are used to encourage better coordinated care delivery across providers, and
accountability for patients shifts from health plans down to the practice level, where providers
are better positioned to assess and help address patient’s needs. The experience of Medicaid
ACOs is particularly timely given the Medicaid expansion that will occur in 2012, which may
cover and additional 11 million to 16 million Americans. This could also include incarcerated
women if their health care coverage could be restored as well as coverage for their children.By building on complementary state innovations such as patient-centered medical homes—a
primary care delivery model that offers easy access to coordinated care and puts patients’ needs
first—and collaborations among medical, behavioral health, and social service providers. The
ACOs approach presents and opportunity to better serve the most vulnerable low-income
populations. To accelerate States’ effort, The Center for Health Strategies (CHCS) is launching
Advancing Medicaid ACOs: A Learning Collaborative with other support. The initiative will
help seven States develop and launch ACO models. CHCS will work with Medicaid agencies in
Maine, Massachusetts, Minnesota, New Jersey, Oregon, Texas and Vermont. These seven States
50 Adoption of Health Information Technology.
51 Tricia McGinnis, The Commonwealth Fund, August 15, 2012 are pursuing a wide range of ACO models including communitywide ACOs, provider-led ACOs,
and hybrids that hold both health plans and providers accountableThey are all applying core ACO concepts, such as value-based purchasing, wherein payment is
directly tied to improved health outcomes and lower costs; case management targeted to high-
risk patients that use health services at an avoidably high rate; and data sharing (e.g., integration
and coordination of physical, behavioral, and dental health care). There is also the “super-
utilizer” approach, in which community-based teams work to stabilize patients who are high
utilizers of patient services.
Designing and implementing ACO programs is challenging, requiring Medicaid agencies to
develop new payment approaches, certification criteria, quality improvement strategies, data
sharing and analytic capabilities, and new roles and responsibilities for their health plans.
Provider innovation and collaboration, stakeholder input and buy-in, and CMS approval are all
linchpins to success. CMS innovations recently announced State Innovation Models Initiative
which should be valuable to broader efforts. This will allow States the opportunity to test multi-
payer payment and delivery models to achieve high-quality health care. Multi-payer approaches
promise to be particularly effective in engaging providers as care models and payment methods
similarity across most, if not all, of a practice’s patient populatiAs Medicaid ACO models advance alongside commercial and Medicare efforts, it is anticipated
that all payers will begin to leverage the strengths of each respective approach and that multi-
payer opportunities will rapidly follow. By creating incentives for patient-centered coordination
across a broad array of physical health, behavioral health, and social services providers, ACOs
will shift the way health care is delivered to vulnerable populations. ACOs offer tremendous
opportunity to dramatically improve not only the way care is delivered for low-income patients,
but also provide solutions to a complex array of health care needs. Supporting and accelerating
the development of ACOs in Medicaid is an important step on the path to achieving high-
performance health care for vulnerable population.
Social Determinants of Health
The domain of public health has expanded dramatically in the last 60 years. This expansion
makes it clear why public health is now able to address problems as basic as the social
determinants of health. For example, the real causes of many deaths are social determinants such
as illiteracy, fatalism, gender bias, racial bias, unemployment, and poverty. When the term
fatalism is used, it refers to the belief that a person cannot change his or her future it is the
opposite of empowerment and a major determinant of poor health. Poverty is the single biggest
factor contributing to adverse health outcomes, and health outcomes worsen as poverty becomes
more severeWhat is needed in the new approach to health reform is a sensible metric to measure outcomes.
Developing this metric for health outcomes make it possible to incorporate prevention as part of
medical practice, and practitioners would be reimbursed for preventive medicine because that is
how outcomes improve. With experience, (e.g., information technology) adverse social
determinants could be added, and health care reimbursement would have direct impacts on those
determinants. With CDC developing health outcome criteria and devising a surveillance system
54 Foege, WH., Social Determinants of Health. Public Health Reports, 2010 Supplement to monitor and reward programs successfully using prevention to improve outcomes, the
expansion of public health would have reached the ultimate position of coordinating public
health and healthcare delivery systems for the improvement of both individual and aggregate
healtPrisons and Social Determinants of Health
Among many vulnerable populations prisons are evolving as one of the social institutions that
determine their health status and health outcomes. As places or neighborhoods in which
individuals are physically confined and deprived of a range of personal freedoms, prisons have
been shown to operate as structural factors that may influence health status and outcomes
independently of individual-level attributestructural factors include those physical, social,
cultural, organizational, community, economic, legal, or policy aspects of the environment that
impede or facilitate efforts to avoid disease transmission.ocial factors include the economic
and social conditions that influence the health of people and communities as a whole, and
include conditions for early childhood development, education, employment, income and job
security, food security, health services, and access to services, housing, social exclusion and
stigmaally, the impacts of prison neighborhoods on health status should be analyzed in
relation to upstream social determinants of health (SDH) in the larger societyew of the
close links between prison settings and surrounding communities, as well as the fact that more
than 95% of inmates will eventually reenter the general community.Prison settings are commonly associated with high risk of infectious diseasesDHs are about
the quantity and quality of a variety of resources that a society make available to its members.
Canada, for example, through the Public Health Agency of Canada, lists nine (9) SDH: income,
employment and working conditions, food security, environment and housing, early childhood
development, education and literacy, social support and connectedness, health behaviors, and
access to health care. Although several recent articles have highlighted prisons as social or
structural determinants of health, limited information currently exists on how prisons socially or
structurally influence the health status and outcomes of the incarcerated. Research suggest that
prisons serve as SDH by mediating the vicious cycle of concentration, amplification,
deterioration, dissemination or overburdening, and post-release morbidity and mortality.Individuals with inferior health status are overrepresented among those in contact with the
criminal justice systemrisons exacerbate health inequities between individuals in contact
56 Awofeso, Niyi., Prisons as Social Determinants, Public Health Reports, 2010 Supplement 57 Dean, H and Fenton, K., Public Health Reports, 2010 Volume 125.
59 Roux, AVD; Am J Public Health 2001; 91:1783-9 60 World Health Organization, Geneva: WHO; 2008 61 Baillargeon J, Black SA, Pulvino J, Ann Epidemiology 2000; 10:74-80 62 Freudenberg N. Am J Public Health 2002; 92:1895-9 with the criminal justice system and the general community. Front-end policy choices that may
facilitate reductions in the numbers of incarcerated individuals include alternatives to
imprisonment for less serious offenders, as well as targeted use of drug courts to break the cycle
of addiction, crime, and incarceration. Policies related to facilitating improved health of released
inmates include pre-release screening to detect new health problems, documentation of existing
health problems, and arrangement for community-based treatment, as well as social inclusion
strategies, such as access to unemployment benefits, housing, and skills trainiReducing the adverse impact of prisons on the health of the incarcerated and the general
community requires a cooperative effort among all stakeholders. Development of quality
benchmarks for core aspects of prison health care is an important component of this effort. Each
prison has a potential in the healthy setting, provided there is political will and technical
competence on the part of governments and custodial authorities to address the social, physical,
spiritual, and mental well-being of inmates. Prison reforms have a strong potential to benefit not
just inmates, but also the wider community, into which most inmates will return in the fullness of
timeMoving Forward: Integrating Information Technology in SDH and Prison Reform
While Satcher issues a call to elevate the profile of SDH in public health, he also suggests a
proactive, collaborative, inclusive, and deliberate process to advance the use of social-
determinants approach to reducing health inequities among and between populations.The
report from a national public health consultative partners meeting at the CDC looking at social
determinants of HIV/AIDS and other STDs, a list of suggested priorities for public health policy,
improving data collection methods, enhancing existing and expanding future partnerships, and
improving selection criteria and evaluation of evidence-based intervention.What is now needed is a paradigm shift in the willingness of prevention partners at national,
state, and local levels to adopt this more inclusive approach which would bring the potential of
data-driven interventions provided by health information technology using electronic health
records on the front-end during assessment of a woman prior to incarceration. This evidence-
based approach will also provide the environment for metrics to be generated to track the extent
to which the incarceration experience that impacts the health care of the individual inmate and
the aggregate community of incarcerated women will be measured before and during pre-release
of these inmates. To protect the wider community the pre-release assessment will provide the
documentation in the EHR to make intelligent policy decisions about prevention and wellness of
this vulnerable population.
66 Satcher D. Public Health Report 2010; 125 Supplement 4:8-10 67 Sharpe TT et al Public Health Report 2010; 125 Suppl 4:11-5 References
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