Health and healthcare access among Zambia’s female prisoners: a health systems analysis

Abstract

BackgroundResearch exploring the drivers of health outcomes of women who are in prison in low- and middle-income settings is largely absent. This study aimed to identify and examine the interaction between structural, organisational and relational factors influencing Zambian women prisoners’ health and healthcare access.MethodsWe conducted in-depth interviews of 23 female prisoners across four prisons, as well as 21 prison officers and health care workers. The prisoners were selected in a multi-stage sampling design with a purposive selection of prisons followed by a random sampling of cells and of female inmates within cells. Largely inductive thematic analysis was guided by the concepts of dynamic interaction and emergent behaviour, drawn from the theory of complex adaptive systems.ResultsWe identified compounding and generally negative effects on health and access to healthcare from three factors: i) systemic health resource shortfalls, ii) an implicit prioritization of male prisoners’ health needs, and iii) chronic and unchecked patterns of both officer- and inmate-led victimisation. Specifically, women’s access to health services was shaped by the interactions between lack of in-house clinics, privileged male prisoner access to limited transport options, and weak responsiveness by female officers to prisoner requests for healthcare. Further intensifying these interactions were prisoners’ differential wealth and access to family support, and appointments of senior ‘special stage’ prisoners which enabled chronic victimisation of less wealthy or less powerful individuals.ConclusionsThis systems-oriented analysis revealed how Zambian women’s prisoners’ health and access to healthcare is influenced by weak resourcing for prisoner health, administrative biases, and a prevailing organisational and inmate culture. Findings highlight the urgent need for investment in structural improvements in health service availability but also interventions to reform the organisational culture which shapes officers’ understanding and responsiveness to women prisoners’ health needs.

The health system accountability impact of prison health committees in Zambia

“…Nonetheless, the opportunity for such in the Zambian prison settings is real. Recent work in Zambian male and female prisons, for example, has demonstrated a robust inmate hierarchy that frequently protects its own interests at the expense of other inmates [ 18 , 19 ]. Transcripts from both officers and inmates in this study demonstrated how more educated inmates and cell captains were more likely to be selected for membership.…”

“…Zambian Prisons are severely overcrowded [ 13 – 16 ], the inmate occupancy rate (convicted prisoners and remandees) between 2014 and 2016 hovered around 270% of the official holding capacity of 6100 inmates. Previous and current work has highlighted lack of adequate food and potable water within prisons as direct and indirect contributors to the poor health status of both male and female inmates [ 17 – 19 ].…”

A Scoping Review of Qualitative Research Methods Used With People in Prison

“…;Howerton et al (2007);Plugge, Douglas, and Fitzpatrick (2008);Shen (2016); andSmirnova and Owens (2017) Health database or records 8Chambers (2009);Hassan, Edge, Senior, and Shaw (2013);Khaw, Stobbart, and Murtagh (2007);Newman, Cashin, and Waters (2015); andTopp et al (2016) Program participation 19 Boothby (2011);Bourke et al (2012);Carlin (2005);Drapeau, Korner, Granger, and Brunet (2005); and Mahoney, Chouliara, and Karatzias (2015) Linked research, researcher contacts 11Alves, Maia, and Teixeira (2016); Copes et al (2013); Haley et al (2014); Harawa, Sweat, George, and Sylla (2010); Loeb and Steffensmeier (2011); Plugge et al (2008); Treloar, McCredie, and Lloyd (2015); and Wainwright et al (2017) Resident in certain prison section/unit 6 Bennett (2014); de Viggiani (2007); Gilham (2012); Harner and Riley (2013); Kenning et al (2010); and Ralphs, Williams, Askew, and Norton (2017) Response to flyers and posters 21 Blagden, Winder, and Hames (2014); Cobb and Farrants (2014); Condon et al (2007); Dinkel and Schmidt (2014); Easterling and Feldmeyer (2017); Enders, Paterniti, and Meyers (2005); Harner, Hentz, and Evangelista (2011); Oliver and Hairston (2008); and Pritchard et al (2014) Health-care provider 20 Baker, Wright, and Hansen (2013); Carlson, Sexton, Hammar, and Reese (2011); Feron, Tan, Pestiaux, and Lorant (2008); Guin (2009); Hassan et al (2013); Mangnall and Yurkovich (2010); Soffer and Ajzenstadt (2010); and Yap et al (2014) Prison staff 10 Hefler, Hopkins, and Thomas (2016); Pinheiro, de Araujo, de Vasconcelos, and do Nascimento (2015); Ralphs et al (2017); Todrys and Amon (2011); and Weldon and Gilchrist (2012) Prison manager/administration 3 de Guzman, Imperial, Javier, and Kawasaki (2017); Loeb et al (2013)(2014); DeHart (2008); Earle (2011); Einat (2009); Fogel et al (2014); Rahmah, Blogg, Silitonga, Aman, and Power (2014); Smirnova and Owens (2017); and Topp et al (2016) Attendees at nonaffiliated meeting/event 3 Hefler et al (2016); Schonberg, Bennett, Sufrin, Karasz, and Gold (2015); and Woodall et al , & Zamith-Cruz (2011); Carlson et al (2011); Easterling and Feldmeyer (2017); Haley et al (2014); Hatton et al (2006); Machado and Silva (2012); Mercer et al (2015); Schonberg et al (2015); Soffer and Ajzenstadt (2010); and Weldon and Gilchrist (2012) All participants in a program 9 Akerman and Geraghty (2016); Billington, Longden, and Robinson (2016); Boothby (2011); Drapeau et al (2005); Mahoney et al (2015); Miller, Tillyer, and Miller (2012); O'Grady, Rolvsjord, and McFerran (2015); and Walton and Duff (2017) Purposive for selected characteristic(s) 15 Baker et al (2013); Borrill, Snow, Medlicott, Teers, and Paton (2005); de Guzman et al (2017); Fogel et al (2014); Garrett (2010); Howerton et al (2007); Kennedy (2014); Marzano, Ciclitira, and Adler (2012); Newman et al (2015); Ralphs et al (2017); Schneider and Feltey (2009); and Sondhi et al (2016) Purposive for variation of characteristics or views 20 Alves et al (2016); Andrinopoulos et al (2011); Bowen e...…”

“…(2009);Blagden et al (2014);Condon et al (2007);Decorte (2007);Giertsen, Nylander, Frank, Kolind, and Tourunen (2015);Kenning et al (2010);Topp et al (2016);Tzvetkova et al (2016); andWoodall (2010) Random or quasi-random 6Cobb and Farrants (2014); DeHart(2008); Einat (2009); Fogel et al (2014); Rahmah et al (2014); and Topp et al (2016) Unclear 7 Recruitment strategies (excluding self-response to advertisement) Researcher presented to group (including meetings for other purposes) 8 Aday, Krabill, and Deaton-Owens (2014); Harawa et al (2010); Harner and Riley (2013); Lewin and Farkas (2012); Saraiva et al (2011); Staton-Tindall et al (2007); and Woodall, Dixey, Green, and Newell (2009) Individual invitation by researchers (including researchers in dual roles) 22 Alves et al (2016); A. N. Chambers (2009); Earle (2011); Fogel et al (2014); Gilham (2012); Haley et al (2014); Howerton et al (2007); Kennedy (2014); Khaw et al (2007); Mjaland (2015); Pedlar, Yuen, and Fortune (2008); Plugge et al (2008); Reading and Bowen (2014); Schneider and Feltey (2009); and Treloar, McCredie, and Lloyd (2016) Health-care provider invitation/facilitation 16 Baker et al (2013); Carlson et al (2011); Castro Madariaga, Gó mez Garcés, Carrasco Parra, and Foster (2017); Einat and Rabinovitz (2013); Elisha, Idisis, and Ronel (2012); Guin (2009); Hassan et al (2013); Havnes et al (2014); Lee et al (2006); Mangnall and Yurkovich (2010); Ritter and Elger (2013); Soffer and Ajzenstadt (2010); and Yap et al (2014) Prison program leader/worker invitation 7 Billington et al (2016); Borrill et al (2005); Kerley and Copes (2009); O'Grady et al (2015); and Sondhi et al (2016) Prison staff invitation/facilitation 11 Decorte (2007); Harner and Riley (2013); Havnes et al (2014); Muessig et al (2016); Oliver and Hairston (2008); Ralphs et al (2017); Todrys and Amon (2011); Tzvetkova et al (2016); Yap et al (2014); and Zamani et al , Martell, Pyne, and Keenan (2016); Hatton et al (2006); Howerton et al (2007); Lewin and Farkas (2012); and Smirnova and Owens (2017) Refreshments/cosmetics/clothes 5 Fogel et al (2014); Oliver and Hairston (2008); Plugge et al (2008); Schonberg et al (2015); and Zamani et al (2016); Alves et al (2016); Enders et al (2005); Facchin and Margola (2016); and Harner et al (2011) Not stated 84…”

Prison conditions for women facing the death penalty

“…In Zambia, prisoners must wash menstrual cloths with inadequate or no detergent, since the prison does not supply soap. 17 The lack of menstruation care is compounded by the lack of privacy and washing and bathing facilities in most prisons. Moreover, sanitary napkins, when provided, are sometimes withheld as punishment.…”