**5.2. Individual (determinants of health)**

People within the correctional setting have poorer social, education and economic circumstances which impact on their determinants of health. For example, being in an environment not designed for older people with aged conditions, the socioeconomic indicators demonstrate most have a low education level, are homeless, generally unemployed and have substance misuse [20, 25, 54]. A person's lifestyle, geographical location, employment status and social connections strongly influence their health, with studies establishing the links between health, poverty and social exclusion [35]. Those incarcerated in a correctional setting are at a higher risk of developing dementia and/or related problems due to the isolation of the setting, being exposed to violence, at times being in overcrowded facilities as well as being separated from their families [33]. Older prisoner's health is vastly poorer than those of a comparable age residing in the community. It has been highlighted that, of prisoners in the over 60 years age group, 85% had chronic disease, and in particular a high incidence of mental illness, which was found to be five times greater than a comparable sample group in the community [18].

Those who become incarcerated have higher rates of substance misuse and chronic diseases, including those affecting mental health, and, if these are not recognised, treated and managed in the correctional environment before the prisoner is released, there will be an increased burden on the community [55]. There is also evidence of a cycle of reoffending caused by links between the determinants of health, such as employment and housing, once as person is released from prison, with a high number of these people becoming homeless [35].

Older prisoners entering a correctional setting, where the majority of inmates are young and can be quite violent, are becoming more vulnerable and at risk of violent episodes from those more physically fit [52]. Health disparities and poorer health outcomes occur where appropriate healthcare is not provided to individuals in the correctional environment, which not only affects the person with dementia but also the prisoners around them, as well as the community they will be released back into [55].

Health promotion is an important aspect of providing healthcare and has been a growing trend internationally. Health promotion activities are the foundation of the WHO guide to prison health which also encompasses the Ottawa Charter for Health Promotion and the Declaration of the Alma-Ata [56–58]. 'Peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity' are critical to a person's health and are the foundation for the Primary Health Care principles [57]. The principles acknowledge that the Health Promotion approach is not restricted to just the individual but also applies to the setting or environment, and highlights practices to reduce the impact of the 'wicked' problems within communities and/or populations [59].

facilities [53]. This penal harm also occurs when correctional staff feel that policies of the facility and security override the need for medical attention [53]. When this occurs the quality of the healthcare provided can deteriorate significantly and can be seen as standard care for the

Of prisoners aged between 50 and 54 years, about 50% had mental health problems, and only one third of these people would have adequate access to treatment during the time they were in prison [30]. Although there is a section in the US constitution protecting against cruel punishment, and supporting the rights of prisoners to appropriate medical care, many criminal justice system healthcare providers are not prepared to support the needs of older prisoners in a cost- effective way [32, 40]. Williams et al. [32] and Ahalt et al. [40] identified that healthcare systems within the prison setting increasingly need to provide healthcare for rising

People within the correctional setting have poorer social, education and economic circumstances which impact on their determinants of health. For example, being in an environment not designed for older people with aged conditions, the socioeconomic indicators demonstrate most have a low education level, are homeless, generally unemployed and have substance misuse [20, 25, 54]. A person's lifestyle, geographical location, employment status and social connections strongly influence their health, with studies establishing the links between health, poverty and social exclusion [35]. Those incarcerated in a correctional setting are at a higher risk of developing dementia and/or related problems due to the isolation of the setting, being exposed to violence, at times being in overcrowded facilities as well as being separated from their families [33]. Older prisoner's health is vastly poorer than those of a comparable age residing in the community. It has been highlighted that, of prisoners in the over 60 years age group, 85% had chronic disease, and in particular a high incidence of mental illness, which was found to be five times greater than a comparable sample group in the

Those who become incarcerated have higher rates of substance misuse and chronic diseases, including those affecting mental health, and, if these are not recognised, treated and managed in the correctional environment before the prisoner is released, there will be an increased burden on the community [55]. There is also evidence of a cycle of reoffending caused by links between the determinants of health, such as employment and housing, once as person is

Older prisoners entering a correctional setting, where the majority of inmates are young and can be quite violent, are becoming more vulnerable and at risk of violent episodes from those more physically fit [52]. Health disparities and poorer health outcomes occur where appropriate healthcare is not provided to individuals in the correctional environment, which not only affects the person with dementia but also the prisoners around them, as well as the commu-

released from prison, with a high number of these people becoming homeless [35].

facility even though it is well below what is provided in the general community [53].

chronic conditions as the population in correctional facilities becomes older.

**5.2. Individual (determinants of health)**

nity they will be released back into [55].

community [18].

128 Cognitive Disorders

For a prisoner to feel 'at peace' they need to be feeling safe and not be in fear or stressed about their wellbeing in the environment they are in [56]. Being in an environment where a person's circumstances create stress over an extended period can lead to feelings of insecurity, for prolonged periods of time can be both physically and emotionally harmful [60]. If a person has long periods of feeling insecure or anxious, accompanied by being socially isolated and with poor self-esteem, they will have an increased incidence of mental illness. Not only does this increase psychological problems, it also leads to increased death at an early age [60]. These problems are recognised in greater numbers across industrial countries in the section of the population classified as low socioeconomic, which includes the correctional population [60]. Therefore unless healthcare in the correctional setting is supported by using guidelines such as the World Health Organisation prison health guide, prisoners will not be able to achieve the Primary Health Care and Health Promotion approaches and principles such as achieving peace.

Social isolation will and has a great impact on a person's wellbeing and creates barriers to being in a place where they are feeling at peace [60]. Being excluded from social interactions and distanced from family and loved ones will also create stress and feelings of unease leading to health problems and premature mortality [60]. This social isolation can be harder on some sections of the community, including the older prisoner population, and even on release they remain quite vulnerable [60]. There is a greater risk of early death in people who are stigmatised by their position, such as being a prisoner, and being looked down upon, along with exclusion from society, can have a significant impact on a person's health [60]. Furthermore, if prison healthcare and management do not address these issues and develop policies for healthy prisons, there will be an increase in deaths within this particular population group.
