**5.1. Prisoners access to healthcare is a human right**

The question has been raised about whether it is appropriate to continue to hold someone in prison if they no longer remember their criminal act due to dementia [47]. Dementia can contribute to a prisoner having no knowledge about his/her wrong doing and the loss of the ability to understand this [31]. There is also the situation where a prisoner was initially aware of their guilt when admitted to the correctional facility, however in time they no longer have an understanding of this or their surroundings [31]. In all of these situations there is no opportunity for rehabilitation, which is the main reason for incarceration prior to release back into society [31].

Compassionate release from prison revolves around four different points: 'the chance of recidivism, the rights of the victim, the costs involved in continued incarceration versus the cost of external healthcare, and the continued welfare of the prisoner with dementia' [31]. This raised the question of the ethics of keeping a prisoner, whose psychological and physical needs cannot be met, in prison [31].

Older prisoners are more costly as they require resources that are more expensive compared to prisoners who are younger and generally healthier [48]. One of the increased resources needed is increased healthcare generally due to a lack of healthcare throughout their lives [48]. Older prisoners have a higher incidence of physical and mental health issues than those in the community who are the same age and therefore need ready access to healthcare services [48, 49].

Prisons were initially designed for young people, with narrow staircases and cement buildings and floors which can be harsh on old bodies [50]. Prison healthcare systems were initially designed for young and healthy men, therefore older females and males from marginalised backgrounds and/or minority groups, who have higher incidences of chronic conditions, have different healthcare needs which can challenge the traditional models of care [51].

Many older prisoners have chronic medical conditions. Approximately 95% of prisoners will eventually be released back into society, therefore proper management of these conditions in the correctional setting will reduce the costs and the impact on communities when prisoners are released [32]. Even though being incarcerated could be the optimal time to identify and mange health problems, this is not occurring adequately or consistently across correctional facilities internationally [49]. The guidelines of many countries state that healthcare provision to prisoners should be to the same standard as the general population, however this has not occurred in many prison healthcare services, with frequent lapses in care [19, 49].

As the correctional population is becoming older, increasingly release is through death, and therefore there is a growing need for end of life options in this environment, making it difficult for correctional services to meet the special needs of the ageing population while remaining humane [52]. In some countries there is a movement toward penal harm which means that disciplinary measures, which extend to the healthcare clinic, are the focus in correctional 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 facility even though it is well below what is provided in the general community [53].

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'

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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

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.

Prisoners within the correctional setting are seen as being in communities which are isolated and self-contained, away from the general population and the public health umbrella [61]. As a consequence, many opportunities for health improvement have been missed for both the individual and the community inside and outside the prison [61]. The health status of prisoners does not match their counterparts in the community for physical, social and mental

**5.3. Correctional healthcare services (incorporation of health performance** 

wellbeing, resulting in a much poorer health status and outcomes [17, 18, 54].

problems within communities and/or populations [59].

peace.

**framework)**

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 chronic conditions as the population in correctional facilities becomes older.
