Oftentimes, social or economic disadvantages prevent a person from living their healthiest life. Last year, the American Diabetes Association (ADA) announced grant funding to support projects that focus on the impact of such health disparities on those with diabetes.
Louise Reagan, MS, APRN, ANP-BC, an assistant professor at the University of Connecticut School of Nursing, received one of those grants — called the Health Disparities and Diabetes Innovative Clinical or Transitional Science Award — as her research focuses on people with diabetes who are reentering society from prison.
Reagan says her team has found that people living with diabetes in prison lack critical knowledge and skills regarding managing their diabetes. As these individuals transition to the community, they are required to self-manage diabetes independently and are not prepared to do so.
Diabetes survival and self-management skills include knowing what foods to eat, how to control blood glucose (sugar), when to take insulin, how to manage sick days, and how to access health care. These skills are critical for incarcerated individuals, as their rate of diabetes diagnosis is almost 50% higher than the general population.
“I wanted to figure out what we could do to reach persons with diabetes at this critical transition period when they’re just getting out of prison and into the community, and how we could help them self-manage their illness,” Reagan says. “The Connecticut Department of Correction (CDOC), a community collaborator and advocate for the needs of persons transitioning from prison to the community, and my team don’t want citizens returning to the community from prison to end up in the emergency room being treated for hypoglycemia or dangerously low blood glucose when it can be prevented.”
Reagan worked as an advanced practice registered nurse in Hartford for 16 years, treating underserved populations with multiple comorbid diseases, including diabetes. This clinical work exposed her to the challenges that people released from prison or living in supervised community housing post-prison release face in self-managing their illness when reentering the community, and inspired her research.
She says many social barriers prevent patients from adequately caring for their own health. It can be challenging to provide diabetes education to recently released patients due to their multiple housing locations, desire for anonymity, and limited access to clinical care.
Additionally, she says, the priorities of people recently released from prison are often to avoid reentering prison, to find a job, and reestablish social and family relationships rather than manage their diabetes and other aspects of their health.
“Patients have many other competing needs when integrating into their societal roles,” Reagan says. “The Diabetes LIVE JustICE research provides an opportunity to help them with their health.”
Her study — called Diabetes Learning in Virtual Environments Just in Time for Community reEntry (Diabetes LIVE JustICE) — examines the feasibility and acceptability of a mobile app that provides diabetes education, support, and other resources in a virtual environment to people recently released from prison living in supervised community housing or on parole. Reagan’s goal is to improve health outcomes and reduce health inequities for this vulnerable population.
Reagan’s app, called LIVE Outside, contains live sessions with diabetes educators and instructive games to inform users about self-care.
Over the course of 12 weeks, Reagan will be measuring users’ diabetes knowledge, stress, and self-care after using LIVE Outside and comparing it to typical diabetes care education.
The mobile app is a culmination of projects Reagan has been working on since completing her postdoctoral fellowship at New York University. There, she served as a project director for an R01 study using a personal computer-based virtual environment called Diabetes LIVE, which promoted diabetes education to community-dwelling individuals.
Reagan’s proceeding research project with the CDOC, Diabetes Survival Skills (DSS), was an in-person intervention run within CDOC-managed correctional facilities. However, this project experienced attrition as individuals reentered society and could no longer participate, she says.
With collaboration and support from the Connecticut Department of Correction, Reagan anticipated taking in-person DSS interventions beyond prisons to supervised housing facilities to reach recently released individuals. This intervention, however, was put on hold due to the COVID-19 pandemic.
This forced Reagan to get creative with her work, leading to her innovation and the ADA grant.
“I was thinking about my work, and I wondered, ‘what if we use a virtual environment and adapt it to a mobile environment?’ ” Reagan says. “We could adapt the virtual app, use my program from the Diabetes Survival Skills, and blend them into a mobile app.”
Given the need for diabetes self-management education during the critical transition from prison to the community, the CDOC was excited to work with Reagan again to develop a remote mobile option for the people with diabetes under their care. Reagan then collaborated with her colleagues from Diabetes LIVE — Constance Johnson (UTHealth Houston), Allison Vorderstrasse (University of Massachusetts Amherst), and Stephen Walsh (UConn School of Nursing) — to combine DSS and Diabetes LIVE into a mobile app.
Diabetes LIVE JustICE was created and Reagan applied for the ADA grant to propel her innovation forward.
“My team and I had been talking about making this app mobile,” Reagan says. “The grant allows us to put all our work together to collaborate on this new idea.”
Reagan says she is grateful to have received this grant and for the strong collaboration with and involvement of the CDOC.
“When I received notice that the project was going to be funded, it was just an unbelievable feeling,” she says. “For me, this grant meant I had the opportunity to help underserved populations with their health, and I am so grateful for that. I feel so thankful that we can offer something to these people that sometimes don’t have anything.”
This research is supported by an American Diabetes Association grant #11-21-ICTSHD-05 Health Disparities and Diabetes Innovative Clinical or Translational Science Award. To learn more about the grant program, visit professional.diabetes.org. To learn more about the UConn School of Nursing, visit nursing.uconn.edu and follow the School on Facebook, Instagram, Twitter, or LinkedIn.
When you think of being a nurse, do you envision yourself wearing scrubs and treating patients in a hospital? Perhaps you think of taking patients’ vitals and administering medications, or moving between beds to care for the sick. While nursing often involves this discipline of bedside care, you might not have imagined working in a prison, despite the vital role nurses have in this field.
UConn School of NursingPh.D. student Anne Reeder, BSN, MPH is gaining expertise in this nontraditional area because she says she wants to help reduce inequities in the correctional health care system.
“I worked in a mid-sized jail in Colorado from 2011 to 2015, which was one of the most challenging, yet rewarding, experiences,” Reeder says. “I started asking questions about some of the inequities I saw and realized I wanted to study this topic formally and structurally.”
Reeder has a background in both nursing and public health. She earned her Bachelor of Science in Nursing in 2010 from Michigan State University, and then went on to earn her Master of Public Health in 2014 from the Colorado School of Public Health. Now, she is advancing her studies in both nursing and American Studies through UConn’s School of Nursing and The Graduate School, respectively.
“One of my primary goals is to elevate the voices of people who are incarcerated.”
Reeder’s research focuses on correctional health care, specifically mental health care, health services administration, and quality of care. She says there are often barriers when people who are incarcerated attempt to access health care inside correctional facilities. There is a lack of both physical and human resources, which makes high-quality, community-equivalent health care difficult, she says.
“One of the myriad reasons for the lack of access and quality disparity is the Medicaid Inmate Exclusion Policy, which significantly limits the use of Medicaid dollars for people who are incarcerated,” Reeder says. “Another reason is the stigma and social bias associated with incarceration.”
Reeder’s research aims to expose and decrease inequities in the correctional health care system by centering the material and social needs of people who are incarcerated.
“I am currently working on an integrative review that examines reentry programs for people with mental illness who are leaving U.S. jails,” Reeder says.
She has made two preliminary findings from the integrative review: there is a lack of conclusive evidence regarding the efficacy of existing jail reentry programs for people with mental illness and there is a disconnect between existing reentry models and the implementation research needed to demonstrate model efficacy.
As she continues to study the U.S. correctional health care system, Reeder hopes to implement research-based programs aimed at improving the quality of care for incarcerated individuals within its institutions.
“One of my primary goals is to elevate the voices of people who are incarcerated,” Reeder says, “so that they may more meaningfully direct their health care in correctional facilities.”
Using data from the Federal Bureau of Prisons, we discovered the infection rate among correctional officers drove the infection rate among incarcerated individuals. We also found a three-way relationship between the infection rate of officers, incarcerated individuals and the communities around prisons.
No stranger to outbreaks
Prisons, jails and other correctional facilities routinely deal with infectious diseases. Hepatitis Band C as well as tuberculosis are all incredibly common in prison populations.
Because of that, prisons have established policies and procedures for handling infectious diseases. Many of those policies are the same as those for preventing the spread of COVID-19 – such as medical isolation of individuals with active infections, increased cleaning and surveillance of the disease.
As early as March 2020, many prisons attempted to mitigate these conditions by granting early release and home confinement. Some also blocked all visitors and outside contractors. While helpful in some cases, ultimately these actions did little to stop outbreaks.
As the second and third waves of COVID-19 swept through the nation and the federal prison system, the mask mandate made only a small dent in slowing the uptick of infections among prisoners.
We found the relationship between COVID-19 infections among correctional staff and incarcerated individuals is also shaped by the incidence of COVID-19 in the community surrounding the prison. Because correctional officers move between the prison and the community at the beginning and end of each shift, they can carry COVID-19 between these two spaces.
Even when correctional officers test negative for COVID-19, they can still drive COVID-19 rates both inside and outside the prison via asymptomatic or pre-symptomatic spread. Our data showsthat when COVID-19 rates in the outside community get worse, so too do rates among the incarcerated population.
Prison policies aimed at stopping the spread of COVID-19 should be designed with an eye toward controlling the disease in the prison population, among correctional officers and in the community around the prison.
For example, prison systems should be just as concerned with vaccination rates in the communities around prisons as they are with vaccination rates among correctional officers. Both rates will have an impact on the spread of COVID-19 within a prison.
One November night in a Missouri prison, Charles Graham woke his cellmate of more than a dozen years, Frank Flanders, saying he couldn’t breathe. Flanders pressed the call button. No one answered, so he kicked the door until a guard came.
Flanders, who recalled the incident during a phone interview, said he helped Graham, 61, get into a wheelchair so staff members could take him for a medical exam. Both inmates were then moved into a covid-19 quarantine unit. In the ensuing days, Flanders noticed the veins in Graham’s legs bulging, so he put towels in a crockpot of water and placed hot compresses on his legs. When Graham’s oxygen levels dropped dangerously low two days later, prison staff members took him to the hospital.
“That ended up being the last time that I seen him,” said Flanders, 45.
Graham died of covid on Dec. 18, alarming Flanders and other inmates at the Western Missouri Correctional Center in Cameron, about 50 minutes northeast of Kansas City. His death reinforced inmates’ concerns about their own safety and the adequacy of medical care at the prison. Such concerns are a major reason Flanders and many other inmates said they are wary of getting vaccinated against covid-19. Their hesitancy puts them at greater risk of suffering the same fate as Graham.
Inmates pointed to numerous covid deaths they considered preventable, staffing shortages and guards who don’t wear masks. While corrections officials defended their response to covid, Flanders said he’s apprehensive about how the department handles “most everything here recently,” which colors how he thinks about the vaccines.
Reluctance to get a covid vaccine is not unique to Missouri inmates. At a county jail in Massachusetts, nearly 60% of more than 400 people incarcerated said in January they would not agree to be vaccinated. At a federal prison in Connecticut, 212 of the 550 inmates offered the vaccines by early March declined the shots, including some who were medically vulnerable, The Associated Press reported.
The Missouri Department of Corrections said March 12 that more than 4,200 state inmates had received the vaccine out of 8,000 who were eligible because they were at least 65 years old or had certain medical conditions. Officials were still working to vaccinate 1,000 additional eligible inmates who had requested the shots. The department had not begun vaccinating the remaining 15,000 inmates or surveyed them to determine their interest in the vaccines. So far, about 18% of the total prison population has been vaccinated, which roughly tracks with the overall rate in Missouri even though inmates are at higher risk for covid than Missourians generally and should be easier to vaccinate given they are already in one place together.
Missouri placed the majority of inmates in its lowest vaccine priority group. It is one of 14 states to either do that or not specify when they will offer the vaccines to inmates, according to the COVID Prison Project, which tracks data on the virus in correctional facilities.
Another is Colorado, where Democratic Gov. Jared Polis moved inmates to the back of the vaccine line amid public pressure. The emergence of a more contagious variant of the virus at one prison, however, forced officials to adjust their plans and instead start vaccinating all inmates at that facility.
Lauren Brinkley-Rubinstein, prison project co-founder and professor of social medicine at the University of North Carolina, said that disregarding health officials’ recommendation to prioritize people living in tight quarters might make inmates less trustful of prison staff “when they come around and say, ‘Hey, it’s finally your turn. Let me inject you with this.’”
States cannot mandate that inmates take the vaccines. But Missouri officials have tried to encourage them by distributing safety information about it, including a videodebunking myths featuring a scientist from Washington University in St. Louis.
But persuasion is proving difficult at Western Missouri, given inmates’ longtime distrust of prison management. Flanders, Graham and others were transferred there from neighboring Crossroads Correctional Center following a 2018 riot that caused an estimated $1.3 million in damage and led to its closure. Inmates were angry that staff shortages had reduced time for recreation and other programming.
Officials acknowledge that staff shortages have persisted through the pandemic. “Corrections is not the most popular place to work right now,” Missouri corrections director Anne Precythe said at an early March NAACP town hall on covid and prisons.
Flanders, who is serving a life sentence for first-degree robbery, said the prison didn’t have enough nursing staffers to check on him during a bout with mild covid in November. He said other sick inmates also didn’t receive appropriate medical attention. Karen Pojmann, a corrections department spokesperson, said she could not comment on specific offenders’ medical issues.
Tim Cutt, executive director of the Missouri Corrections Officers Association, said he’s seen no evidence that Western Missouri even had a plan to contain covid. “They were quarantining for a while,” he said, “but it was a haphazard attempt.”
Also fueling skepticism of prison health care, inmates said, is the failure of many staff members to follow the corrections department’s mask mandate. Byron East, who is serving a life sentence for murder at South Central Correctional Center, two hours southwest of St. Louis, said in a phone interview that he has begged officers — many of whom live in conservative, rural areas where masks are less common — to wear face coverings.
“As an employee, your job is to protect, and we are not able to protect ourselves,” said East, 53. “You can catch something and then come in here and spread it to us.”
Amy Breihan, co-director of the Missouri office of the Roderick & Solange MacArthur Justice Center, a nonprofit civil rights law firm, said she didn’t see a single officer wearing a mask on Feb. 10 when she visited a correctional facility in Bonne Terre, Missouri.
Corrections Department Deputy Director Matt Sturm confirmed Breihan’s account at the NAACP town hall and said it has been addressed. He said the department expects staff members in all prisons to wear masks while inside when they can’t stay 6 feet apart from others.
“Right from the beginning, the Department of Corrections in Missouri has taken covid extremely serious,” Sturm said. The department deployed “everything we could get our hands on to help either prevent or contain covid,” including equipment for ventilation and disinfection.
Still, Missouri has reported at least 5,500 covid cases and 48 deaths among inmates at the state’s adult correctional institutions during the pandemic. The department doesn’t break down covid deaths by prison, but data from the advocacy group Missouri Prison Reform showed Western Missouri had 21 total deaths from covid or other causes last year, more than any other state prison even though its population isn’t the largest. Statistics on deaths in the previous year were not immediately available.
An automatic email reply from Eve Hutcherson, a former spokesperson for Corizon Health, which manages health care in Missouri prisons, directed a reporter to Steve Tomlin, senior vice president of business development, but he didn’t respond to questions. The company, one of the country’s largest for-profit correctional health care providers, faced more than 1,300 lawsuits over five years, according to a 2015 report from the financial research firm PrivCo. In Arizona, Corizon paid a $1.4 million fine for failing to comply with a 2014 settlement to improve inadequate health care for inmates.
Despite concerns about prison health care, however, some inmates have agreed to get the shot. East, who is Black, said he initially decided against it because he didn’t trust prison health and thought about the legacy of the Tuskegee experiments from 1932 to 1972, when researchers withheld treatment for Black men infected with syphilis. But he changed his mind after reading about how safe the vaccines are.
Flanders, meanwhile, is still weighing whether to get vaccinated as he mourns the death of his longtime cellmate Graham, a convicted murderer whom he considered a friend and father figure.
Flanders’ mother, Penny Kopp, said Graham helped Flanders manage his finances and kept him from gambling and getting involved with “inmates who are troublemakers.” Kopp, a former corrections officer in Indiana and Colorado, said she understands the challenges of working in a prison but wonders if enough was done to save her son’s cellmate.
Flanders said getting the shot would mean putting himself at the mercy of prison staffers, as Graham did — and that’s something he’s not ready to do.
Border detention facilities that house immigrants have been in the news recently because of their policy of not providing influenza vaccinations to their detainees, sparking high-profile protests. Why would an immigration detention facility, tasked among other things with providing comprehensive medical care to its detainees, refuse to provide them with flu vaccines?
To answer this question, it might be instructive to ask how influenza vaccinations are handled at other prisons and jails in the U.S. It depends on what type of facility you are in and how long you will be there. All prison systems I know of offer influenza vaccinations to their inmates. On the other hand, most jails (short-term detention facilities) do not have a routine flu vaccination program, though there are exceptions.
Vaccinations in Prisons
Inmates are sentenced to prison for a minimum of one year and usually longer. As a result, prison populations are stable. Almost all of the inmates in a particular prison now will still be there next year. Also, prisons are tasked with providing comprehensive medical care to their inmates. This includes influenza vaccinations, but also other recommended vaccinations and boosters. Of course, just like in the community at large, not all inmates want to be vaccinated. The percentage of prison inmates who get vaccinated depends on how vigorously the prison pushes the program.
If a prison advertises the availability of the flu vaccine and actively encourages its inmates to be vaccinated, the acceptance rate can be greater than 50% (compared to about 33% of adults in the community who get vaccinated). Most prisons have a “big push” campaign to encourage flu vaccines once a year in the fall. However, if a prison does not advertise the availability of the flu vaccine, the percentage of inmates vaccinated can be very low. It makes economic sense for prisons to actively encourage their inmates to be vaccinated. Every dollar spent on influenza vaccinations will save more than a dollar down the road trying to deal with influenza outbreaks.
Vaccinations in Jail
Influenza programs in jails are
different for several reasons. The first issue is that the inmate population in
a jail is not stable. The average length of stay in the average jail in the
U.S. is around 2-3 weeks and many are released within days. If a jail offers
influenza vaccinations in October, most of the inmates vaccinated will be gone
by November. The jail will now be filled with new, unvaccinated inmates. If you
vaccinate the November inmates, most (again) will be gone by December. So, to
be effective, influenza programs in a jail must last the length of the
influenza season — making jail influenza programs more difficult and expensive
to administer than a prison program.
As an example, remember that one
must order influenza vaccines well in advance. In order to have influenza
vaccines ready in the fall, a prison or a jail has to order them at least six
months earlier. A prison will know how many influenza doses it will need based
on its population and previous acceptance rate. But how many doses will a jail
need with inmates coming and going over the course of an entire flu season?
That can be hard to get right in a jail! It is expensive and maddening to order
too many vaccines only to throw the unused doses away at the end of the flu season.
Also, jails vary greatly by size and
sophistication of the medical services they provide. There are many small jails
in the U.S. (think 10 beds) where no medical personnel ever come to the jail
for routine medical care. If their inmates need medical attention, the deputies
have to load them into a van and take them to a clinic or ER in the community.
Such a jail is unlikely to offer influenza vaccinations to their inmates. On
the other hand, bigger jails (say, more than 1,000 beds) with a full-time medical
staff may indeed have an influenza vaccination program.
“Kicking the Can Down the Road”
The most successful jail influenza
programs that I have seen are done in cooperation with the local health
department. The health department is tasked with providing vaccinations to the
community at large, which includes jail inmates. When asked, health departments
often will come to the local jail once a month to provide influenza
vaccinations to any inmate who requests one. (This is also a good way to
provide screening for sexually transmitted diseases in asymptomatic inmates.)
Even small jails can approach their local health department about providing
immunizations to inmates, though few do.
Customs and Border Patrol reportedly
defended its policy of not providing influenza vaccinations during border detention
by saying that immigrants are only there for a few days and are expected to get
the flu vaccine later, when they are moved to a long-term facility. Where I
grew up, this was called “kicking the can down the road.” To my mind,
deferring vaccinations until later makes little medical or financial sense.
Since none of these detainees is going to be released, and since you are going
to vaccinate them later anyway (as reported), why not do it as part of their
initial medical screening?
Jeffrey E. Keller, MD, FACEP, is a
board-certified emergency physician with 25 years of experience before moving
full time into his “true calling” of correctional medicine. He now
works exclusively in jails and prisons, and blogs about correctional medicine
at JailMedicine.com.
This post was originally published in MedPage Today.
Sherry Cameron, a medical recruiter for correctional facilities across the US, recently wrote a post for DailyNurse as the first part in this Three-part series. (For part Two, see What to Expect as a Correctional Care Nurse). Now, she’s starring in the latest DailyNurse podcast, “What is it like to be a Correctional Nurse?”
Sherry Cameron, correctional facility recruiter for CoreCivic
Nurses in correctional facilities work so closely with other members of the healthcare team that Sherry describes it as a “family-oriented environment.” Often looking after inmates who have never received regular medical care, these nurses perform the usual nursing tasks such as administering medications, blood sugar checks, and tending to injuries incurred in the kitchen or carpentry shop.
Also, correctional facilities offer the opportunity to experience one of the most gratifying aspects of nursing. Corrections nurses act as educators for people who have rarely had any sort of relationship with a healthcare provider. Sherry recalls, “one nurse said to me that ‘it’s a very special moment when you see a patient come to tears because someone took the time to finally talk with them and educate them about their health.’ That to me is a true nurse at heart”.
In this episode of the DailyNurse podcast, you will hear Sherry discuss the character traits that she looks for in potential correctional nurses, the concerns they have when they first consider a career as healthcare providers in a correctional facility, advice for those interested in correctional nursing, and much more.
