Marginalized Women in Healthcare

To ensure the delivery of safe high quality care, primary care providers must be knowledgeable about the unique health care challenges of marginalized women. One marginalized group that will be encountered in the primary care setting that demands attention is past incarcerated women. According to the Department of Justice, there are currently over 2 million incarcerated individuals in the United States and with consistent reports over the last several decades demonstrating that women account for approximately 6%-8% of the total imprisoned population (Kaeble & Cowhig, 2018). This disproportionate mix of incarcerated individuals constitutes women as a marginalized group once outside the walls of the justice system. While imprisonment plays a vital role in curbing crime, incarcerated women reintegrating into society encounter significant economic struggles, substantial health care disparities, and several ethical issues. The purpose of this paper is to provide a brief overview of incarcerated women. The prevalence of incarcerated women at a national, state, and local level is included followed by the discussion of the economic inequality, health care disparities, and ethical concerns that encompasses the process of reentering society. Finally, a well-developed evidenced based health management action plan is offered that addresses these concerns and helps facilitate the delivery of safe, high quality patient care. 

Background

In the United States, incarceration is the main form of punishment for committing a crime or felony . Currently, women account for 6%-8% of the national incarcerated population (Kajstura, et al., 2017; Mignon, 2016). As outlined in the Department of Corrections yearly statistical report, 9% of the total population in the state of Michigan’s justice system are females and approximately 15% of the total population in the St. Clair County are females (Washington, 2017). Many women enter the justice system with remarkable histories of physical, mental, and/or sexual abuse, poor dentition, substance abuse or addictions, sexually transmitted infections (STIs), and depression (Rich, Cortina, Uvin, & Dumont 2013; Mignon, 2016). Hispanic and the African-American ethnicity constitutes the largest position of incarcerated women and majority of these women are single and often the primary caretaker of their children (Coughlin, Lewis, & Smith, 2016; Fertszt, Miller, Hickey, Maull, & Crisp, 2015). The age group typically is between 25-40  years of age and the most common punishable crimes are non-felony offenses such as property theft, larceny, fraud, drug trafficking and/or drug possession (FBI, 2015). The average sentence imposed is typically around 27 months in which women are then released back into the community and often without insurance coverage (USSC, 2014). Once released, women experience a heightened marginality and are faced with a variety of economic, social justice and ethical challenges. 

Economic Issues

After reintegration into society, women with a history of incarceration endure daunting economic obstacles. Incarcerated women generally have higher rates of learning disabilities, lower rates of literacy, and/or lack a high school diploma which severely positions them at an economic disadvantage (Nowotny, Masters, & Boardmen, 2016).In one large study involving 1,585 state prisons found that 41% of women entered prison with less than a GED level of education (Nowotny et al., 2016). This educational disadvantage is further compromised as many employers are often hesitant to hire individuals with past criminal records and states that allow employers to deny jobs to individuals with a past criminal records. It is also challenging to advance education as many educational opportunities through grants have been severely curtailed for incarcerated individuals.  Additionally, previously incarcerated women face rejection when applying for public housing, loans, professional or technical licensing, and even federally funded benefits such as nutritional assistance or food stamps. These economic challenges occur at a time when women are most vulnerable and are at the greatest need of aid. 

Social Justice and Health Care Disparities

Social justice in the health care system implies all people should have equal access to  health care regardless of social status. However, health care disparities are shown to be amplified in individuals with past incarcerations, poverty-stricken, substance users, or those with  stigmatizing conditions such as STIs, immunodeficiency syndrome (HIV), or depression (Varcoe, Browne, & Ponic, 2013). Many of these conditions and health aliments are highly prevalent in incarcerated women which increases the risk of social injustice. Social injustice is further complicated by the lack of preventative care and treatment provided during imprisonment and the notion that nearly 95% of women leave the justice system without health care insurance (cite).  Another social injustice surrounding previously incarcerated women is the stigma associated with imprisonment. Women who experience this stigmatization are less likely to disclose important details to their health to health care providers due to the fear of being ostracized, judged, or being denied services.

The health care disparities, lack of health care access, and stigmatization curtails social injustice and simultaneously leads to poor health care outcomes, most notably for STIs and depressive disorder. STIs and depressive disorder are two of the most common stigmatizing conditions found in women with a history of incarceration (Javabakht et al., 2014). Multiple studies within the imprisonment facilities consistently demonstrate a high prevalence of chlamydia at 7%-22%, gonorrhea at 1%-7%, and human immunodeficiency syndrome at 1.2% to 1.8% (Javanbakht et al., 2014). Depressive disorder is also highly prevalent for the incarcerated women population. A large systematic review consisting of the U.S. state prisons found that the diagnoses and/or symptoms of depressive disorder ranged for incarcerated women ranged from 9%-29% with a majority of women predicted to develop depressive disorder at some point during the incarceration (Prins, 2014). Dismissal into the community without adequate health care coverage potentiates these serious healthcare conditions and leads to life threatening outcomes.

Ethical Issues

Incarceration has many collateral consequences that leads to the infringement of the basic ethical principles. First, incarcerated women may face discrimination from health care providers which encroaches upon the ethical principle of justice (Back, Duncan, Sherlaw, Brall, & Czabanowska, 2014). Health care providers have a duty to treat all patients equally, fairly, and impartially but when unfairness is imposed due to a criminal background, this principle is violated. Another ethical issue that may be infringement upon is confidentiality. As a healthcare provider, it is common code of conduct to maintain a patient’s privacy. However, Michigan Disease Surveillance System (2018) mandates the reporting of specific communicable disease are reported . As noted, STIs are highly prevalent in the incarcerated women most notably chlamydia, gonorrhea, and HIV  and must be reported (Javanbakht et al., 2014). Chlamydia and gonorrhea require partner treatment which becomes an ethical issues for health care providers that must ensure the safety of the sexual partner(s) while simultaneously maintaining the confidentiality of the patient. In addition, the CDC (2018) recommends that HIV positive patients notify partner(s). Currently, there are 24 states that mandate an HIV positive individual disclose this information to a sexual partner (CDC, 2018). This situation also creates an ethical issues for health care providers that again must ensure the safety of the sexual partner while simultaneously maintaining the confidentiality of the patient while also abiding to state laws.

Action Plan

An evidenced based action plan that specifically targets an incarcerated women’s health care needs is critical for the delivery of high quality, safe, ethical care. Because STIs and depressive disorder are highly prevalent in past incarcerated women, these health ailments were selected as a crucial component to the action plan. First, all women must be offered screening for chlamydia, gonorrhea, and HIV as these STIs  have serious life threatening effects if left untreated. A positive result for any STI requires a treatment plan. The chlamydia outcome will be measured by a test-of-cure culture after 2 weeks of therapy to detect treatment effectiveness (CDC, 2014).  Gonorrhea test for cure is not recommended unless symptoms persist (CDC, 2018). Education must be given for a positive culture of either STI so that recent sex partners within 60 days obtain a culture for gonorrhea and chlamydia and appropriate treatment as indicated (CDC, 2014). Consensual HIV screening will be offered so that referral and treatment are initiated in a timely manner.

Another plan of action is to provide the PHQ-9 scale as a component of the initial exam. The PHQ-9 is a patient health questionnaire that is utilized for screening, diagnosing, monitoring, and measuring the severity of depression. The nine questions of the PHQ-9 are based directly on the nine diagnostic criteria for major depressive disorder in the DSM-IV (Beard, Hsu, Rifkin, Busch, & Bjorgvinsson, 2016). The PHQ-9 is a powerful tool that assists clinicians with diagnosing depression and monitoring treatment response. It has excellent validity and reliability in the primary care setting as a method for the measurement of depression (Beard et al., 2016).  The clinician will conduct a clinical interview to confirm the results. This outcome will be measured by follow up appointments with repeat measures of the PHQ-9 screen and a goal of 25% or more reduction from the baseline score (Sui, 2016).

The final plan of action is to ensure reintegrated women offenders receive counseling and social support services. Early intervention of counseling services helps women identify options for the future, set realistic goals and enhances physical, psychological, and emotional well-being while support groups are valuable as these groups bond women who are experiencing similar struggles. Support groups and counseling may reduce rates of depression and is thought to attribute to reduced rates of reoffending (Prins, 2014). This action will also be measured through the use of patient-healthcare provider collaboration as well as the PHQ-9 screening tool.

 In addition to this action plan, it is imperative to uphold ethical principles of confidentiality while following state and local laws for communicable disease reporting as well as upholding the duty to treat all patients equally, fairly, and impartially. Healthcare will be provided in a nonjudgmental proactive method that promotes high quality, safe delivery of care.

Conclusion

Following incarceration, many women experience devastating economic, social, and ethical challenges making the successful reintegration a daunting journey. It is imperative for the health care provider to be sensitive to the unique needs of incarcerated women and have a well-developed evidenced based action plan in place. The high prevalence of STIs and depressive disorder found in past incarcerated women and the imperativeness of upholding the basic ethical principles helped direct the action plan. Amidst the economic, social, and ethical challenges, this action plan will assist the incarcerated women’s successful journey of reintegration into the community.

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