Running head: THE EFFECTS OF INCARCERATION ON MIDDLE AGED ADULTS

The Effects of Incarceration on Middle Aged Adults: A Multinational Study

Ciera Chang, Jordan Cochran, and Kayla Diehl
Missouri State University
Noora Parkkila
Satakunta University

The Effects of Incarceration on Middle Aged Adults

The word "health" is a rather ambiguous term. There is no isolated definition of health,
and there is no solitary representation of health worldwide. From the concept of a lack-of-illness
defining health for some, to a more holistic approach addressing abstract needs such as
spirituality, it can be seen that the idea of health varies greatly for all. The World Health
Organization defines health as, "A state of complete physical, mental, and social well-being and
not merely the absence of disease or infirmity." However, the idea that complete and total wellbeing can be simultaneously achieved in all three primary facets of health is highly debated.
Regardless, this more holistic approach is becoming more widely accepted as a proper, inclusive
way of viewing health and providing healthcare.
Further refining the interpretation of health from the eudemonistic approach taken by the
WHO, health can also be viewed within the scope of a role-performance model. For the middle
aged population, social roles are vital. Many middle aged adults experience a period of
development expressed by the theorist Erikson as the generativity or self-absorption phase
(Eliopoulus, 2014). This phase goes hand in hand with role-performance as it becomes evident
that while incarcerated, the inmate's role of parent, spouse, provider, or any number of things

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becomes displaced. The incarceration forces self-absorption upon the middle aged adult and
relationships and role strain becomes apparent. A loss of fulfillment in social roles can lead to a
loss of health in the eyes of the incarcerated individual. With these concepts in mind, health
becomes a truly multi-faceted concept involving the individual's physical, mental, and social
well-being.

Identifiers of Health
In order to display the effects of incarceration on the typically middle aged adult, one
must break down the complex idea of health into its parts. Identifiers of health include mortality
and morbidity rates, risk factors, utilization of health resources and services, and health system
resources (Harkness & DeMarco, 2016). A Finland-based study on the mortality rates of inmates
seven years after release stated that there is an increased risk for early mortality in the
incarcerated population. 13.2% of the study's population died within the seven year window;
5.2% died from natural causes, 4.1% from accidental death, and 2% from suicide (Joukamaa,
1998). This population is vulnerable for many reasons including their limited rights and support.
While their rights are present, incarcerated adults are at the mercy of their care providers and
institutions to uphold them. Their support systems are strained, and there is undue stress on the
prisoners because of a lack of privacy and antagonistic relationships with guards and other
prisoners (Pridemore, 2014). All of these findings contribute to the risk factors that the middle
aged adult population faces while incarcerated. Close living quarters place the individual at risk
for contracting various communicable diseases. Prison violence and risky behaviors such as
tattooing, piercing, and sharing hygiene products also contribute to a risk of illness in the

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population (Pridemore, 2014). Adults within the African American and Latino populations are
considered to have increased risks while incarcerated. Many studies note that incarceration
affects these two groups disproportionately. Additionally, there is a generalization that all
inmates have at least one chronic disease and there is an increased rate of HIV and transmission
in the prison system (Wilper, et al., 2009). In fact, many of the inmates in prison show higher
rates of chronic diseases such as diabetes, hypertension, asthma, and HIV than that of the general
population (Kulkarni, Baldwin, Lightstone, Gelberg, & Diamant, 2010). Also, tuberculosis and
hepatitis C infections are also significantly higher in incarcerated adults than those of the general
population (Pridemore, 2014).
It is also important to understand the differences gender makes on risk factors in this
population. According to a study cited in Colbert, Sekula, Zoucha, & Cohen (2013), women are
more likely than men to experience medical and psychiatric problems specifically anxiety,
depression, and PTSD. According to a study by Zlotnick (as cited in Colbert et al., 2013),
Women inmates are five to eight times more likely to abuse alcohol than women in the general
population, ten times more likely to abuse drugs, and 27 times more likely to use cocaine (p.
410). In the study by Colbert et al., (2013), women discuss their barriers to care such as skipping
medications to save money because of the lack of health care available. Also, women have
difficulties obtaining the proper food they needed while incarcerated because healthy choices are
not available. This can be extremely difficult for a woman managing her diabetes because
vending machines become their only option if it is not a specific meal time (Colbert et al., 2013).
These are just another few of the numerous factors that play into the risks for incarcerated middle
aged adults.

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For uptake of health services, studies state that 13.9% of federal inmates and 20.1% of
state inmates received no care for their persistent medical problems after their incarceration. It
was also found that 26.3% of federal inmates and 28.9% of state inmates quit taking their
medications after incarceration. (Wilper, et al., 2009) In relation to access to care and the
system's provision of resources for this population, it has been found that, "following serious
injury 7.7% of federal inmates, 12.0% of state inmates, and 24.7% of local jail inmates were not
seen by medical personnel" (Wilper et al., 2009). In addition, it has been shown that previously
incarcerated adults tend to have less access to health insurance, have high rates of poor discharge
planning, and struggle with interruptions in care following the release period (Kulkarni, Baldwin,
Lightstone, Gelberg, & Diamant, 2010).
Global Health Care and Health Care System Models
Before one can address the aforementioned issues within the prison systems, one
must understand the models of healthcare and what healthcare looks like in an individuals
nation. First and foremost, it is important to identify what the goals for health are on a global
level. According to the World Health Organization (2015), some of the Millennium
Developmental Goals are eliminating poverty and hunger, achieving primary education for all,
promoting gender equality and empowering women, combating HIV/AIDS among other
diseases, and developing a global partnership for development. These are some very important
aspects of the MDGs that need to be addressed in our population. Every country has its own set
of beliefs and models used to establish health care norms and practices and address these health
care goals. There are four primary models that make up the health care systems in the majority of
nations: the Beveridge Model, the Bismarck Model, the National Health Insurance Model, and

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the Out-of-Pocket. Each of these models will be discussed in relation to their application in their
respective countries.
Finland.
Finlands health care system is a free and reduced-cost program designed by the
government under the scope of the nations taxation laws. The programs coverage is not just for
residents, but for tourists in time of emergency or accident as well. The overall goal of this
system is to provide financially-fiscal care with little to no wait on access. Consumers are
expected to have their own personal insurance as well and to cover the cost of transportation for
health services (HealthGov.Net, 2012). This concept of a government-owned health care system
paid for by taxation relates strongly to the Beveridge Model. Named for Britains William
Beverage, this model advocates for taxes to cover a public health care system. Systems under
this model tend to have less expensive medical care despite the increase in taxation rates. The
Social Insurance Institution has many national insurance institution assignments private health
care medical expenses, outpatient drug benefits, sickness allowances (Huttunen, 2014).
Other nations that have been derived from this model include Spain, New Zealand, and Cuba
among others (Physicians for a National Health Program, 2010). However, in addition to this
model, there is a similarity to the Bismarck model in regard to the occupational health care
system. In addition to public sector health care services, theres also health care services
produced by private companies. Fees are collected from employers and employees (KELA =
KELA is an independent social insurance institution supervised by Parliament, earnings
insurance), and services are purchased mainly from private service providers (Huttunen, 2014).
United States of America.

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Most nations, like Finland, utilize one of the four models of health care systems
individually. In the United States, however, the health care system was created using a plethora
of ideas from other health care system predecessors. For example, the Bismarck Model of health
care systems was created in Europe and named after Chancellor Otto von Bismarck (Physicians
for a National Health Program, 2010). This system was designed to utilize payroll deductions
and insurance programs; however, the similarities to the American system generally end with the
concept privately-owned insurance plans. In addition to the Bismarck Model, the American
health care system pulls ideas from the Out-of-Pocket Model when discussing those without
insurance coverage. Bills for those without coverage are due at the time of treatment in most
instances (Physicians for a National Health Program, 2010).
To really complicate things, the United States takes aspects from Canadas National
Health Insurance Model when caring for individuals over the age of 65. Medicare is a federal
insurance program that is offered to individuals aged 65 years and older. There are many parts of
Medicare that an individual can add onto their typical coverage such as Part D for
pharmaceutical assistance. This selective-service coverage concept is not foreign to the National
Health Insurance Model. This model utilizes selective coverage as a means of regulating
expenditures (Physicians for a National Health Program, 2010). Overall, the health care system
in the United States is a conglomerate of other programs worldwide.
Prison Health Care Systems
Finland.
Finland underwent a drastic prison reform in the last thirty years. This reform has led to a
decreased in incarceration rates. According to the Ministry of Justice in Helsinki, there were a
little more than 2,700 prisoners in Finland a decade ago. In a country of 5.2 million people, this

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rate breaks down to 52 for every 100,000 inhabitants. The comparable rate in the United States is
702 per 100,000. Even so, these rates have decreased more since then for Finland (Prison Policy
Initiative, 2012). With this new system, health follows the more inclusive definition as seen with
the World Health Organization. In 2006, the prison reform led to the creation of a new
constitution covering the fundamental rights of those within the prison system. Under subsection
7.2, those within the network are protected from being sentenced to death, tortured, or otherwise
treated in a manner violating human dignity (Lappi-Seppl, 2012, p. 341).
This being said, Finland is now known for having a more relaxed approach to
institutionalization for crimes. In about one-third of Finnish correctional facilities, there are no
large gates and fences as in the United States, and guards are generally unarmed (Hoge, 2003).
That is not to say that security is neglected. Prisons due utilize cameras and surveillance systems.
Trust in the system and the belief of treating the inmates as human beings leads to a more mental
health friendly institution. There is a strong belief that socialization plays a large role in
maintaining the health of an individual. Home leaves are available to many inmates near the end
of their sentences, and on-grounds home leaves are given to inmates near the middle of their
sentence. These leaves on prison grounds consist of the prisoner being able to stay in a house on
the grounds for up to four days with visitors children and other family in particular (Hoge,
2003).
Self-awareness and a focus on the potential for goodness in every individual leads
Finlands prison system to be one of the best in the world. The ultimate goal of the system is to,
increase the prisoners preparedness for a crime free life by furthering life handling skills and
adjustment into society as well as to prevent the committing of offenses during the term of the
sentence (Lappi-Seppl, 2012, p. 342). In addition to this holistic approach, there is a focus on

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the physical health as well. Each Finnish prison has at least one registered nurse, and a doctor
makes appointments at least once a week. Most prisons have facilities and equipment for dental
care. Prisoners have their state of health and ability to work checked as they enter the prison. At
the same time, they get a set of basic hygiene equipment such as dental care equipment and
disinfection tools (Rikosseuraamus, 2015).
The biggest downfall of this system is the lack of mental health treatment to all. Only a
small fraction of those that need these services are able to receive them (Lappi-Seppl, 2012).
While prisoners are supposed to be provided an opportunity for psychologist support and
treatment, this is not always available as need be. It has been found that worldwide, mental
disorders are more common in prisoners than in the general population (Viitanen, 2013, p. 28).
This leads the lack of inclusive mental health treatment to be a serious shortcoming. There is also
a noted weakness in the coordination of care after release from the prison system (LappiSeppl, 2012). With these flaws, nurses working within this system need to act within their roles
as case managers and advocates to push for continued policy both governmentally and
institutionally. Advocating for individuals within the Finnish prison network could lead to an
increase of mental healthcare in the long run.
United States of America.
In the United States, prison systems are very different from that of Finland. As stated on
the NAACPs website, the US holds a get tough on crime attitude (NAACP, 2015). This
attitude and the mentality of justice for ones wrongdoings, lead to a toughened, highly-guarded,
overfilled prison network. The population of incarcerated individuals in the US has quadrupled
since 1980 and accounts for 25% of the worlds imprisoned population (NAACP, 2015). As
mentioned previously, there is a 716:100,000 people incarceration rate in the US. The next

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closest contender is the United Kingdom at 147 prisoners out of every 100,000 individuals
(Prison Policy Initiative, 2012). Despite this, The United States acknowledges that prisoners are
still individuals with rights. The Health Insurance Portability and Accountability Act is a notable,
American law that protects the rights, safety, and identity of individuals seeking health care.
Incarcerated individuals are not excluded from these rights. Unless information about a patient
incarcerated or not is being used for providing health care to that individual, being used for the
safety of employees, other patients, and other inmates, or being used for informing institutional
law enforcement, it cannot be disclosed (Bednar, 2003).
The United States has special opportunities for individuals after release from
incarceration through the Affordable Care Acts governmental insurance program. Lower
premiums and out-of-pocket costs are just a few of the potential benefits for those looking for
assistance after leaving the prison system (HealthCare.Gov, 2013). Regardless of the type of
insurance chosen after incarceration, there is a 60-day window of opportunity for the individual
to find a plan before the penalty for not having insurance is enacted (HealthCare.Gov, 2013).
Despite this, there is still a shortage in planning for the individuals reintegration to his or her
community after release.
The other major flaws the US prison system are the increasing rates of incarceration and
a shortage of mental health services. Because of the overcrowded conditions of the US prison
system, communicable diseases make a huge, negative impact on prisoners. As advocates for
patients in this network, nurses can speak out for decreasing incarceration rates, increasing
communicable disease education, prevention, and treatment, increasing mental health treatments
for incarcerated middle aged adults, and increasing the planning for reintegration into society
(Wilper, 2009).

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NGO Involvement
The prison systems discussed receive attention from both governmental and
nongovernmental agencies. NGOs, or non-governmental organizations, are groups that acquire
resources from private sources in order to help other individuals (Harkness & DeMarco, 2016).
Some of these organizations play a role in addressing the issues with the prison systems to some
degree in both Finland and the United States of America.
Finland.
Traditionally non-governmental organizations have had a strong position in Finnish social
care and healthcare. NGOs have had a special national role in expertise, promoting well-being
and providing services for vulnerable groups such as individuals with disabilities, the homeless,
the unemployed, those suffering from drug or alcohol abuse, and released prisoners.
Furthermore, they act as advocating agents and organize voluntary work. In the past, NGOs
could have been called charity organizations, but during the last decade, the role of NGOs has
been deemed communities for public good.
KRITS or the Correctional Service Support Foundation is a Finnish NGO that strives
to improve the position and performance in society of those sentenced to prison and their
families. KRITS develops after-care and improves services, influences criminal policy, promotes
the interests of its target group, and supports voluntary work. KRITS aims to accomplish a
nationwide network of organizations producing support services in the field of after-care and to
participate in the co-ordination of the network and provision of resources (KRITS, 2015).
Portti Vapauteen is a website produced by KRITS and the Rehellist elm network.
The Portti Vapauteen service is meant to provide help for incarcerated, their families, and for

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those who are working in prisons and/or with the prisoners. The service aims to prevent and
reduce recidivism by helping criminals and their families cope in society. Portti Vapauteen works
with the Criminal Sanctions Agency, educational institutions and researchers, and with health
care professionals. The service is financed by RAY and KRITS (Portti Vapauteen, 2015).
United States of America.
One major NGO in the United States that plays a part in protecting the rights and health
of incarcerated middle aged adults is the American Civil Liberties Union (ACLU). ACLU has
created a National Prison Project that, is dedicated to ensuring that our nations prisons, jails,
and detention centers comply with the Constitution, domestic law, and human rights principles
(ACLU, Prisoners rights, 2015). This organization believes that the vulnerability seen in this
population because of its dependence upon authority figures to provide care places inmates in a
very dangerous situation. The ultimate goal of the medical aspect of ACLUs National Prison
Project is to ensure that individuals with chronic illnesses, emergencies, and serious mental
illnesses get the care that they need in order to relieve unnecessary suffering (ACLU, Medical
and mental health, 2015). If an individual is taken care of during incarceration, they will be in
better condition to be reintegrated into society following release.
One NGO striving to address this shortcoming as well is the Lionheart Organization. The
Lionheart Organization started a prison project called House of Healing. What originally started
as a program for younger inmates is now being integrated into prisoners of all ages. This
program initially addresses rehabilitation process by asking the important question of, Who are
you? Many individuals in the prison system are burdened by what they did, who they affected,
or rage and anger that it may be difficult to get to the core of what got them into prison in the
first place. This is a program similar to the introspective ideals of Finlands system that causes

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prisoners to examine themselves and start to find healing from the inside out. In addition, this
program, like others in the United States, gives tools, resources, education, and hope to inmates
to begin living a new life. Many substance abuse or assault programs may be offered to the
prisoners who wish to have the best well-being upon discharge (Lionheart Organization, 2015).
Nursing Involvement
Whether through the discussed NGOs or as a means of employment, nurses have a
unique body of knowledge and expertise that can be crucial to providing care for the middle aged
incarcerated population. The nursing role of provider of care is highly intertwined with the idea
of health promotion. There are three typical stages of intervention and health promotion for care
of an individual: primary, secondary, and tertiary.
An applicable nursing model for primary, secondary, and tertiary nursing
interventions with the middle aged adult population is that of the Neuman Systems Model by
Betty Neuman. This model has a focus on the wellness of the client system in relation to the
environmental stressors and the client systems reaction to stress (Masters, 2012). As mentioned
previously, the overcrowded environments of US prisons can have a negative impact on the
health of the individuals within. This is an example of the environmental stressor that affects the
client system. Neuman also states that the goal of this model and its designed interventions is to
reduce the potentiality or actuality of these stressors on the client (Masters, 2012).
The primary level of prevention as intervention aims to retain the current state of health
in an individual (Masters, 2012). A prime example of primary prevention is education. Educating
inmates and facility workers on the increased rates of disease in the incarcerated population and
how to prevent some of these diseases is an intervention that nurses can take advantage of in this
category. Secondary interventions are typically implemented when primary interventions fail or

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were not provided. The goal of these interventions is to attain wellness and prevent the further
spread of illness (Masters, 2012). Screening is the typical example for secondary interventions.
Screening for HIV a disease with increased numbers in the middle aged incarcerated group is
one example of secondary interventions that can be implemented (Wilper, et al., 2009). The final
group of interventions, tertiary, is for wellness maintenance or rather, returning to wellness after
treatment (Masters, 2012). Rehabilitation for drug abuse situations is an essential tertiary
intervention for this vulnerability group given that there is an increased potential to have a
history of or future use of illicit drugs in the population in comparison to the general population
(Wilper, et al., 2009). \

Rehabilitation
Further discussing the aspect of tertiary interventions, rehabilitation has similarities and
differences between Finland and the United States. Merriam Webster (2015) defines
rehabilitation in two ways. The first definition is, to bring (someone or something) back to a
normal, healthy condition after an illness, injury, drug problem, etc. The second definition is
more applicable to the vulnerable population and states, to teach (a criminal in prison) to live a
normal and productive life.
Finland.
As discussed already, Finlands prison system does a wonderful job of incorporating
aspects of rehabilitation into the structure of the system itself. In Finland, the public attitude
toward crime is civil in that the focus is toward rehabilitating offenders and using gentle justice
(Ekunwe, Jones, & Mullins, 2010). The purpose of prisons in Finland is to try to solve the
biggest problems in the incarcerated adults life to reduce the risk of repeated crimes once they

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are released. A survey by Ekunwe (2007) found that 80 percent of respondents believe that
criminals should be rehabilitated and 85 percent of the participants were willing to pay extra
taxes to improve the existing system (Ekunwe et al., 2010). Finlands open prison system has
focused on providing work, study, and various activities to help them cope make them productive
members of society.
Finland has a program called Criminals Returning into Society (CRIS), which
assists incarcerated adults with complete abstinence from drugs and alcohol when they are
released (Ekunwe & Jones, 2011). They receive support from ex-convicts who understand their
situation and can provide social networks to assist with their sobriety. Also, incarcerated adults
in Finland are able to earn a wage while in prison and when they are released, they are entitled
to housing subsidies and unemployment insurance (Ekunwe & Jones, 2011, p. 457). This
provides the resources needed to be able to support themselves as they re-enter into society.
United States of America.
In the United States, correctional facilities are making large strides in trying to improve
the preparation of incarcerated individuals in order to make the inmates successful as they begin
to live their lives outside of prison. However, it is unfortunate that in the United States,
deterrence and incapacitation are still the goals of imprisonment rather than rehabilitation
(Phelps, 2011). The United States has harsh punishment laws and is the only country in the
Western world to continue using the death penalty and life sentences without the possibility of
parole (Ekunwe et al., 2010). However, in 2005, the Re-entry Enhancement Act was passed
which provides resources for drug addiction and mental health treatment, job training, housing,
and education for those returning into society after incarceration (Verro, 2010).

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In the United States, there is a program called the Federal Bureau of Prisons Life
Connections Pilot Program. This is an 18-month program that helps inmates with ethical
decision-making, anger management, and victim resolution according to their own religious
beliefs with the end goal being recidivism reduction (United States Department of Justice, n.d.).
Male and female inmates must be within 24 months of release or more and they have to complete
500 hours of community service, 150 hours of addiction programming, participate in Victim
Impact Programs, and keep a journal with re-entry goals and action steps (USDOJ, n.d.).
Another initiative is the President's Prisoner Re-entry Initiative (PRI), which incorporates
resources from faith-based community organizations to provide newly released prisoners with
job training and placement, traditional housing, and voluntary mentoring support (USDOJ, n.d.).
With all of this combined, there is conflicting evidence as to whether or not the United States is
improving the concept of tertiary interventions within the idea of incarceration.
Conclusion
Management of health care varies greatly depending on the region in which the care is
being delivered. Furthermore, health care to vulnerable populations such as middle aged
incarcerated adults can vary significantly from that of the rest of the regions general population.
While Finland has a wonderful prison system with low incarceration and re-incarceration rates,
there are still aspects of care that need to be addressed. Likewise, the United States prison health
care system is advancing in health care practices, but still has long strides to make before the
needs of these individuals are truly met. At this time globally, more can be done to address
prisoners as humans with existential rights; however, the advancement of rights within
vulnerable populations are constantly being expanded worldwide.

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