Structural, cultural and personal barriers to healthcare for older adults in prison: insights from a qualitative study in New South Wales, Australia

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Studies investigating the complex nature of such barriers have been limited despite their identification being an important first step in addressing this challenge. The purpose of this study was to provide an in-depth exploration of the barriers to healthcare for older adults in prison. Methods We conducted interviews with 23 prison staff and 14 older incarcerated adults in 3 prisons in NSW, Australia. Thematic analysis was used to analyse the data. Results The study identified three main themes—structural, cultural, and personal—along with nine sub-themes of barriers: competing priorities of custody and health , resources and capacity , prison bureaucracy , relational coordination , power relationships , punitive practices , perceived stigma , fear of retribution , and deprived autonomy . These barriers impact service timeliness, choice and control, care seeking, risk of harm/discomfort, and the reach and scope of healthcare for older incarcerated adults. Conclusions The findings revealed a diverse and interrelated set of barriers indicating the considerable influence of custody on the delivery of prison healthcare to older incarcerated adults. Addressing these barriers requires working through custody and health policies, enhancing relational coordination, empowering older incarcerated adults and implementing efficient approaches to offset the rising cost of delivering health services to the cohort. Prison incarceration older adult access quality health care barriers INTRODUCTION Older incarcerated adults and their growing and complex needs The rapid increase in the number of older incarcerated adults in recent years has become a challenge for correctional and healthcare systems in Australia and internationally ( 1 , 2 ). Between 2009 and 2023, the older incarcerated adult population in Australia increased by 105% ( 3 , 4 ). In New South Wales (NSW), the most populous state in Australia, where this study was conducted, the proportion of this population increased by 325% between 2002 and 2021, compared with only a 47% increase among the older general population during the same period ( 5 , 6 ). The older incarcerated adult population has unique and complex health, social and custodial needs ( 7 , 8 ). Compared with both younger incarcerated adults and older adults in the community, they present multiple and significantly greater rates of chronic illness and disability, drug- and alcohol-related diseases, cognitive impairment, and increased levels of physical and mental health conditions ( 8 – 10 ). For example, 90% of older incarcerated adults in Northwest England prisons had a physical health disorder, and 35% of older adults entering prison in Australia in 2018 reported poor or fair physical health, whereas 22% of younger entrants reported poor or fair physical health ( 8 , 11 ). Older incarcerated adults require assistance with mobility and personal hygiene and with identifying their physical and mental health needs ( 12 ). Difficulties with accommodations, program activities and daily routines in prisons, which are not age-appropriate to suit their needs, have been frequently reported ( 7 , 8 ). Access to and quality of health care for older adults in prison Given their complex and unique needs, older incarcerated adults require proper access to high-quality prison health care. The World Health Organisation defines access to health care as: “The continuing and organised supply of care that is geographically, financially, culturally, and functionally within easy reach of the whole community. The care has to be appropriate and adequate in content and in amount to satisfy the needs of people, and it has to be provided by methods acceptable to them” ( 13 ). On the other hand, quality of health care signifies the ability of health services to adequetly meet individuals’ and population’s desired health outcomes, characterised by key attributes of effectiveness and efficiency, patient-centredness, timeliness, safety and equity ( 14 ). Access to and quality of health care for incarcerated adults in general are poor. In the United States, a cross-sectional analysis of decades of national surveys revealed that incarcerated adults lack access to health services ( 15 ). Among the 40% of respondents reporting ever having a mental health condition, more than one-third had received no mental health treatment during incarceration ( 15 ). Incarceration is also a known reason for worsening health status ( 16 , 17 ). For example, an Italian study reported that 60% of incarcerated adults perceived that their health status was worse after they entered prison ( 16 ). Similarly, in other countries, such as the United Kingdom, Australia and Iran, incarcerated adults and prison staff face numerous obstacles to accessing and ensuring the quality of health care in prisons, including security, the prison regime, staffing, and transport issues ( 17 – 20 ). Conversely, prisons can offer an opportunity for improved health status among some groups of incarcerated adults. For example, a study among 111 incarcerated adults in England indicated improvements in physical and mental health services for people who had limited access in the general community before their entry to prison ( 21 ). In another study in Italy, 72.8% of participants reported moderate or high satisfaction with their health status in prison ( 22 ). Health service provisions in prisons are quite variable among and within countries, and such variability contributes to the differences reported as improvements in or deterioration of health status (( 23 , 24 ). Older incarcerated adults consistently indicated dissatisfaction and poor access to prison health services ( 16 , 22 , 25 ). Some reported concerns with the quality of treatment they received, and others rated their experience in prison as poor ( 25 , 26 ). This is despite demographic making more visits to prison health services than the younger prisoner population does ( 16 , 27 , 28 ). Health care provision to older incarcerated adults is a complex phenomenon, as the group represents a dynamic cohort of varying health profiles and intersectional disadvantages related to socioeconomic status, gender and imprisonment history, requiring targeted, closely monitored, and highly specialised services ( 10 , 25 ). In Australia, health care provisions in prisons are largely the responsibility of state and territory governments, with a wide range of variability in the scope and quality of services across jurisdictions. In New South Wales, Corrective Services New South Wales manages most correctional centres in the state, and in 2023, the state had 42 adult correctional centres with different security levels both within and between facilities ( 29 ). The Justice Health and Forensic Mental Health Network is the agency responsible for providing healthcare to people who come in contact with forensic mental health and the criminal justice system. In 2023, the agency managed more than 30,000 patients annually in custody, court, and community and inpatient settings in metropolitan, regional and rural areas of the state ( 30 ). Most studies conducted on incarcerated adults in Australia and internationally have focused on describing prevalence, identifying risk factors and prevention and treatment approaches for mental illness and substance abuse ( 31 ). While there is emerging evidence on data specific to older incarcerated adults, the emphasis has been on assessing needs and investigating general challenges; thus, investigations of systemic factors that demonstrate the complex nature of health service provision to older incarcerated adults have previously been recommended ( 28 ). The purpose of this study was to provide an in-depth exploration of the barriers to access and quality of healthcare for older incarcerated adults. METHODOLOGY Sampling and recruitment of study participants The study involved maximum variation purposive sampling to select the prisons and study participants. This process considered several comparator factors, including typical cases (of mainstream prisons), the gender of older incarcerated adults, and diversity in the main function or purpose of correctional centres to identify and include three prisons. With the aim of gaining multistakeholder perspectives, the study involved healthcare professionals, Corrective Services staff and older incarcerated adults in individual in-depth interviews. The inclusion criteria for staff were having one or more years of experience working as a correctional officer or prison health staff, being aged 18 years and above, and being willing to provide informed consent. Similarly, for interviews with older incarcerated adults, the inclusion criteria were being aged 50 years and above (45 years and above if Indigenous), experiencing incarceration (either currently imprisoned, being released or on parole in a NSW correctional centre or parole unit), being able to conduct the interview in English, being willing and able to participate in an interview and being able to provide written informed consent. The age cut-off of 50 years (45 years if Indigenous) was used to align with the commonly used definition of older status of the cohort ( 32 ). Data collection Following ethics approvals (see Declaration section) and site-specific permission to conduct interviews, the research team approached Corrective Services staff with whom we had established communication during previous studies. The staff members liaised with security managers in each centre, who served as the focal points to grant access to each centre, screen and recruit interview participants (older incarcerated adults and Corrective Services staff). The security managers also provided contact details of the Nursing Unit Managers (NUMs) at each centre, who then assisted in recruiting Justice Health staff for interviews. The research team shared an invitation to participate in the study and the Participant Information Statement and Consent Forms with both the security managers and the NUMs of the three correctional centres. This occurred before the actual schedule of interviews. The data were collected from December 2020 to May 2021 via a combination of face-to-face, phone and audio‒visual links to suit the easing and tightening of COVID-19 restrictions during the study period. Data were collected as part of the first author’s PhD study, where three interview guides were developed to conduct interviews with older incarcerated adults and Corrective Services and Justice Health staff (Supplementary Material 1_Interview Guides). The interview guides for staff members focused on communication and relationships, tensions that arise during service provision and recommendations to improve current practices in the care and management of older incarcerated adults. Questions for older incarcerated adults included their experience and evaluation of the health service they receive in prison during entry through to pre-release (see supplementary material for interview guides). The first author (AKH) conducted the interviews, with each interview lasting for a maximum of one hour. Through purposive sampling, a total of 23 interviews were conducted with Corrective Services and Justice Health staff at three correctional centres. Similarly, AKH interviewed 14 older incarcerated adults from two of the three prisons. The study participants provided written consent before each interview, and all except six face-to-face interviews with older female incarcerated adults were audio-recorded. Permission to audio-record the six face-to-face interviews was not granted, and the interviewer took notes instead. A transcription company transcribed the audio-recorded interviews. Data analysis The study employed and systematically applied the six steps of thematic analysis approach ( 33 ). First, interview transcripts were uploaded into qualitative data analysis software (NVivo Version 12, QSR International) for coding and data management. The first author, who also conducted the interviews, read and re-read the transcripts to further immerse themselves in the data. This was followed by immersive reading into the first transcript and developing initial codes inductively. The initial list of codes was further examined, and differences in meanings were critiqued to develop a revised list of codes. At this stage, the analysis process was further checked against the audio recordings of the interviews to ensure that these represent participants’ voices while progressing from semantic coding to latent or interpretive coding. The revised codes were then applied to the analysis of the rest of the transcripts and further refined and expanded to capture participants’ perspectives. This iterative process continued with observing shared meanings and emerging patterns across the codes and grouping similar codes to generate themes. Once the themes were drafted, the naming and meaning of each theme and their relationships were assessed to check if they still represented the data, had a central concept and that these stood by themselves. This led to the naming and defining of the themes and the production of the report for the study. FINDINGS I. Characteristics of study participants Interview participants included 14 older incarcerated adults (P1–P4), 10 Corrective Services staff (CS1–CS10) and 13 Justice Health staff (JH1–JH13). Older incarcerated adults had a median age of 61 years, with an age range of 53–67 years. Most staff participants were female nurses (48%) and male correctional officers (26%). Table 1 below describes the demographic characteristics of study participants. Table 1 Demographic characteristics of study participants. Demographic characteristics n (%) Participants (n = 37) Older Prisoners 14 (38%) Corrective Services Staff 10 (27%) Justice Health Staff 13 (35%) Median Age of Prisoners (Range) 61 (53–67) Gender Prisoners (n = 14) Male 8 (57%) Female 6 (43%) Staff (n = 23) Male 7 (30%) Female 16 (70%) Staff profession/role (n = 23) Nurse 9 (39%) Nursing Unit Manager 2 (9%) General Practitioner 2 (9%) Correctional Officer 6 (26%) Senior Correctional Officer 2 (9%) Functional Manager 2 (9%) II. Themes Three organising themes ( structural, cultural and personal ) and nine sub-themes of barriers to prison healthcare emerged from the analysis of the data. Table 2 below provides a summary of the organising themes and sub-themes. Table 2 Summary of the themes and sub-themes of barriers to prison healthcare for older incarcerated adults. Organising themes Sub-themes Description Structural Competing priorities of custody and health Differing policies and working procedures between custody and health. Resources and capacity Workforce and monetary resources that are incommensurate with older incarcerated adults’ growing health care needs. Prison bureaucracy Stringent prison procedures and rules that delay access or compromise quality of care. Cultural Relational coordination Limitations to shared knowledge and mutual understanding between custody and health during provision of health care to older incarcerated adults. Power relationships Power asymmetry between custody and health in making decisions about healthcare provision. Punitive practices Measures targeted at limiting access to healthcare merely due crimes committed. Personal Perceived stigma Undesired feelings due to negative attitudes others hold towards incarcerated adults. Fear of retribution Anxiety over potential retaliation for actions committed while accessing health service in prison. Deprived autonomy Incarcerated adults’ limited control and choice over their health care. 1. Structural barriers Structural barriers refer to (inter)organisational and systemic challenges in prison that limit access to and quality of prison healthcare for older incarcerated adults. The study identified three structural barriers: competing priorities of custody and health , resources and capacity , and prison bureaucracy. Competing priorities of custody and health Competing priorities are differing policies and working procedures between custody and health encountered during the provision of health care to older incarcerated adults. Corrections and health staff recognised these differences as real and evident. “Our roles are just so different … it is like chalk and cheese.” (Corrections staff member, CS4) “There are sometimes a few setbacks but obviously everybody has got their own policies and procedures and sometimes the Justice Health procedures clash with the Correctional Officers’ Policy and Procedures.” (Justice Health staff member, JH2) Corrections prioritised preventing risk and ensuring safety and security to self and others, whereas Justice Health staff members were concerned with treating patients to save lives and adhering to treatment protocols to reduce harm or complications. Such competing priorities were reasons for delaying access and increasing the risk of harm , such as medication error. “When something bad happens, nurses have this sort of innate instinct to go over and help, whereas our innate instinct is to make sure we are protected first. So that is the time that there is a real sort of clash because they are like, ‘Well, come on, hurry up!’ ‘No, let me put my gear on.’ ‘’ (Corrections staff member, CS7) “So that is where our policies sort of clash. Like ours would be ‘Let us all just have a methadone so we can focus on the methadone’ because that is our policy, you know? Whereas the correctional officers were like, ‘Well no because we cannot cross these guys with these guys so we have to get them individually out.’ Then, you had to do like a methadone as well as a supervised pill back to methadone to a supervised pill to insulin to methadone. So there was a higher risk there of a medication error because you are actually swapping from one part to another.” (Justice Health staff member, JH2) Safety and security considerations took precedence over health care provisions, where the priorities of Corrections were either limiting access or causing services to be rushed because of time constraints in providing health care. “So, obviously, one of the barriers is having access, you know. Sometimes you can plan to do a clinic and then only see one person for various reasons. There might be a lockdown; there might be a union meeting on the side of Corrective Services.” (Justice Health staff member, JH7) “It is routine as well because we start at 7 o’clock and we have half an hour, only half an hour, to pack all the medications for the morning. So, it is really a time factor as well.” (Justice Health staff member, JH3). More attention was given to health care, primarily during a health emergency or when a patient’s condition deteriorated, further confirming the delay in access for non-emergency cases and the priority given to safety and security. “The only real time you get to see somebody in a short period of time is if there is an emergency of some description.” (Older incarcerated adult, P7) “I think you have to be on your death bed there to get any help. If you want to see a doctor you have got to be something major wrong with you.” (Older incarcerated adult, P4) Resources and capacity Corrections’ and Justice Health’s resources and capacity were insufficient to meet the health assessment needs of prison entrants and the increasing demand for secondary care and treatment of chronic conditions. Shortage of doctors and nurses and the high cost of escorting older incarcerated adults to referral hospitals were significant barriers to delivering the required health services. These barriers limit the reach and scope of some services (e.g., supervised medication and aged care assessment). “…you have to remember they are very understaffed at reception centres; they get a lot of new receptions. They do not have a lot of time to be spending doing a lot of age health assessments there and also because, you know, when you are assessing an older person, it just takes longer.” (Justice Health staff member, JH7) “Increased costs to the centre because we have to pay staff to go out to the hospital…sometimes we have to shut down a wing or an area to get the staff to take somebody to the hospital.” (Corrections staff member, CS10) “There is so many more that can probably be put on supervised medication…there is not the staff really available to be giving everyone supervised medications.” (Justice Health staff member, JH3) The constraints on resources and capacity were also evident from the prison clinics’ long waiting list and patients’ extended time to see a doctor. “…often by the time we actually called up to see the GP, we cannot remember why we are there, that is how long it is.” (Older incarcerated adult, P14) “Our GP list, for example, is extremely extensive, and so in order for patients to be seen, they have to wait.” (Justice Health staff member, JH10) Prison bureaucracy Correctional facilities’ stringent processes to ensure safety and security means that older incarcerated adults’ access to health care could be delayed . This was particularly evident during entry to prison, where validating patients’ pre-imprisonment medical history and diagnosis was required before commencing treatment. The process involved establishing contact with patients’ medical centre in the community, releasing information from a community general practitioner (GP), and reviewing and approving the information by prison GPs. “For someone who waits for too long it means if they are on medications that are not approved by our pharmacy and then they have to see the doctor and then….And then even the doctor reviews the medication we send to pharmacy, the pharmacy might say “Not approved”, so that goes back and then the doctor will try to find the alternative…” (Justice Health staff member, JH4) “Release of information [from community GP] is done by the nurse and then we fax it off. It goes to the community doctor and then we wait for them to send the information back.” (Justice Health staff member, JH3) For older incarcerated adults, the bureaucracy involved in ascertaining patients’ details often resulted in considerable delays in starting the medication they used to take before they came to prison. “I waited for two months to get the medication I was taking before coming into prison... They had to get authorisation from my family doctor… My brain was about to explode when I was not able to get the medication” (Older incarcerated adult, P13) “The problem is timing – one month to get a medication is long. I also know an inmate who has been waiting for two weeks for psych medication….” (Older incarcerated adult, P12) Prison bureaucracy also occurred beyond the initial entry period and persisted during routine health care services in prison. Older incarcerated adults reported several instances where their immediate need for a service was deferred to set procedures that they must follow before they can access care. “I have seen it where an incarcerated adult has cut his finger and he was walked out and all he wants was a Band-Aid. Stood there and you can see through the window a stack of Band-Aids on the trolley and ‘No, not going to see you. Just fill out a request form for a Band-Aid. Hold the finger with a bit of tissue.” (Older incarcerated adult, P5) “Just to get Nurofen or Panadol, you cannot just go up. You have to go through a whole rigmarole. By the time you get your Panadol the headache is over.” (Older incarcerated adult, P2) 2. Cultural barriers Cultural barriers arise from (inter)organisational values, norms and attitudes that are explicitly or inexplicitly exercised during routine healthcare provision to older incarcerated adults. These barriers include relational coordination , power relationships , and punitive practices . Relational coordination This sub-theme describes limitations to shared knowledge and mutual understanding between custody and health during the provision of healthcare to older incarcerated adults. These limitations increased the risk of harm or safety concerns to patients and were a reason for conflicts between Corrections and Justice Health staff. For example, Corrections staff’s inadequate understanding of the process of care involved in managing a patient presented a challenge to providing the appropriate level of care to older incarcerated adults. “So if they [Corrections staff] phone up or they ask us ‘She complains of a headache and you just give her a Panadol.’ No, it requires assessment. They do not understand what is involved.” (Justice Health staff member, JH12) “…So sometimes they [Corrections staff] do not understand you know why we do that extra mile for that patient where you know, ‘Just give them a Band-Aid and let them go back’ kind of thing.” (Justice Health staff member, JH2) Corrections staff’s limited understanding of the medical conditions of patients also resulted in conflicts between Corrections and Justice Health staff while potentially posing a risk of harm/discomfort to patients when staff use force. “They [Corrections staff] think that the patient was trying to go to be violent, to be aggressive towards other people. But it is just a medical condition. And the officer in one case would be just going in and try to use force to stop the patient, and her patient had no idea. So, you know, it caused conflicts between the health staff and officer.” (Justice Health staff member, JH8). Reciprocally, Justice Health staff’s inadequate attention to safety and security procedures posed a safety concern among Corrections staff and led to conflicts between the two coworkers. “A lot of the nurses often forget. So they will make mistakes like leave a needle on the bed and it is up for us. That is why we go in. ‘No, you cannot leave the needle there.’ ‘But why?’ ‘No, you cannot leave a needle right next to an inmate because he can grab it and stab you with it.’ So it is little things like that. People do not realise unless you are working in the industry.” (Corrections staff member, CS7). Justice Health staff might also not fully understand the behaviour of some incarcerated adults and thus could undermine the level of safety and security required to keep everyone safe. “I think a lot of them [nurses] come in a little bit blind and do not realise the sort of people that we are dealing with day to day” (Corrections staff member, CS3) “They [Justice health staff] sometimes cannot see the sense in handcuffs and things like that, but we rarely get any big dramas.” (Corrections staff member, CS9) Power relationships Corrections, as the host of Justice Health’s operations and holding the authority of managing correctional centres, had the upper hand in influencing patient care decisions, impacting timely access to care and creating unease among Justice Health staff. Justice Health staff members’ reflections on their interactions with Corrections staff during the routine care of older incarcerated adults were illustrative of power asymmetry. “I have heard certainly where nurses might say, ‘I went in to do someone’s blood sugar and they [Corrections] will say, ‘We are not doing it until we have got two officers.’ You know, ‘…. And I think like if you have already antagonised someone then you are going to have a harder time without a doubt. Yeah, you are going to have a harder time.” (Justice Health staff member, JH6) “There is some trepidation in the nurses in the [de-identified] unit. For example, if someone needs to go out to hospital, they kind of feel like ‘Hm, got to go and ask …” (Justice Health staff member, JH7) There were instances where patient management recommendations initially made on the basis of medical conditions were altered to meet the demands of Corrections. This presents potential harm to patients due to changes in medical recommendations. “I have had officers come and ask me to change my recommendation or ask other nurses to change their recommendations to suit the needs of the centre. Um, I do not do that …but I have seen nurses in the past change their recommendation.” (Justice Health staff member, JH11) Punitive practices Punitive practices can limit older incarcerated adults’ access to prison health care. Some Corrections staff saw older incarcerated adults as less deserving of care and kindness because of the crime they committed, which delayed their access to the care they needed. “I think that officers can be extremely difficult. They may be punitive to patients in this environment, so you know, I guess in ‘Why are you being so kind to this patient? Do not you know what he has done?’ … I have never seen a nurse withholding any level of care to patient, whereas you can get delayed access to patients by an officer because of their punitive idea.” (Justice Health staff member, JH5) Older incarcerated adults experienced punitive practices during their daily routine, which was a reason to avoid seeking care . “I learned very quickly you do not tell them how you feel because you get punished, you are treated like that, until you say “No it is alright I will not hurt myself I will be alright,” and then they let you out you know.” (Older incarcerated adult, P9) Punitive practices can also stem from Custody’s rigid procedures. Despite their limited relevance to ensure safety and security, these procedures delay access to critical services such as hearing aids. “There are some things that I do not like, you know. If you have got older people coming into jail, I do not understand why you have to wait to get your hearing aid done or get your dentures until you have actually gone through a court process. You might be there two years, waiting on your dentures. You know that is not about keeping someone secure. I do not think it is right.” (Justice Health staff member, JH6) 3. Personal barriers Personal barriers are related to older incarcerated adults’ capacity, choice and control over their health and perceived attitudes toward accessing prison health care. Personal barriers included perceived stigma , fear of retribution and deprived autonomy. Perceived stigma Accessing health care that involves travel to clinics outside of prison can be a daunting experience for older incarcerated adults. For example, some older incarcerated adults find travel to hospitals stigmatising and traumatic, as they are required to be handcuffed and become fully displayed to the public. “I had to walk through that whole distance in shackles and yeah, so it is an embarrassing and long procedure.” (Older incarcerated adult, P4) “…when you get to the hospital because of the way you are chained up in that sense, it is quite humiliating, which I suppose it is designed to be in a way.” (Older incarcerated adult, P2) The stigma associated with being seen handcuffed in public was significant in that some older people with no history of travel to hospitals for medical referrals were ready to refuse such travel, leading to complete avoidance of the service. “I have not gone yet to any medical centre outside the prison, but I would refuse to go. I do not want anyone to see me handcuffed.” (Older incarcerated adult, P13) Others preferred to delay travelling until their health condition deteriorated. “Travelling for me is an issue. So, for me my thoughts are unless I am really, really ill I do not particularly want to raise any flags.” (Older incarcerated adult, P7) Older incarcerated adults’ feelings during medical referrals were given less priority by Corrections, as the primary focus was on ensuring the safety and security of the public. “Our priorities [during medical referral] change a little bit because it’s less so much about the inmate and more about the public. … And the public intervening with us because they generally get curious about us. And that can agitate the inmate sometimes…” (Corrections staff member, CS2) Fear of retribution Owing to being in a disempowered position and owing to a perceived fear of further consequences for their actions, older incarcerated adults were reserved to make demands for accessing and using prison health care. Some were avoiding the situation. “If you raise concerns with the case manager and she can then ring the clinic and take it from there and for us that is just another way of putting another iron in the fire.” (Older incarcerated adult, P1) “Oh, but if you go too much [asking], they think you are going to commit suicide or something, and they will lock you up in a nuthouse you know for a while in a cell, in a dress. Therefore, many people just do not say anything just to avoid that situation.” (older incarcerated adult, P4) The reluctance to demand services was also due to fear of negative reactions from health care professionals, potentially indicating underlying issues in patient–provider relationships. “I do not want to be pushy, as I have seen it with others; the nurses become cranky on you.” (Older incarcerated adult, P10) Older incarcerated adults can also become reluctant to share information with Corrections staff in fear or potential retaliation. This can lead older incarcerated adults to avoid seeking help. “I know that again there are certain things they [older incarcerated adults] will not say around us because they are afraid that they will get into trouble.” (Corrections staff member, CS3) Deprived autonomy Older incarcerated adults had limited control and choice over their health, which compromises the quality of care they receive. While they recognised their right to participate and contribute to decisions about their health care (e.g., in relation to the use of medication), such a right was not often honoured. “If I have got a review for my medication and if a change is going to take place to me a consultation should happen. So, I mean if I have got a concern, I can raise it with doctor or nurse practitioner rather than just saying ‘well there you go’. I mean, it is like buying a car and saying well you are buying this car but I cannot let you see it. You know it makes no sense to me.” (Older incarcerated adult, P1) When older incarcerated adults were not involved in decisions about their health care, they become frustrated and left with no choice but to live with it. Others developed complications . “They changed my medication without telling me. This is not good. I am sick of it [asking]. You just go with the flow.” (Older incarcerated adult, P10) “…there’s an inmate that’s in my pod, and he nearly died because they messed up his medication, but it happens everywhere…” (Older incarcerated adult, P2) Denial of involvement in care plans also occurred during medical referrals where older incarcerated adults were not informed when to travel. “There is no sort of guidance on when you ought to leave and when you are going. It is just, ‘Do not worry about it, mate you go when you go.’ So, you get treated quite woefully.” (Older incarcerated adult, P7) “They do not tell you; they do not tell you, they just say you are required at reception…then they tell you, you’re going to the clinic, going to the hospital or whatever.” (Older incarcerated adult, P4) DISCUSSION The study identified comprehensive and interrelated barriers to access and quality of prison health services for older incarcerated adults. These barriers are indicative of the complexity involved in prison health service delivery. The findings showed that competing priorities between custody and health can compromise the healthcare received by older incarcerated adults. Studies investigating issues of access to health services for older incarcerated adults are scarce. However, Galli, Bretschneider ( 26 ) reported delays in receiving care. Despite not being specific to older incarcerated adults, an Australian study revealed that level of security was a barrier to accessing prison health services ( 18 ). Competing priorities have previously been discussed in a broader sense of a ‘philosophical problem’ between custody and health, particularly in terms of correctional nurses’ dual and challenging role of providing autonomous care and maintaining interest in corrections, where nurses’ lack of autonomy in providing care was seen as a barrier to quality of care ( 17 , 34 ). Our findings confirm that issues of access to health services for older incarcerated adults are a reflection of fundamental differences in organisational culture, purpose and focus between custody and health. Corrections and Justice Health staff indicated that a shortage of resources and personnel was a key barrier to delivering health services to older incarcerated adults. This was also evident from older incarcerated adults’ complaints of long waiting times to see a doctor. Low staffing levels and an imbalance between needs and capacity can result in delayed access to health services and cause medical encounters to be rushed ( 23 , 24 ). Older incarcerated adults’ increasing demand for specialised care is also straining resources not only because specialised healthcare personnel are in short supply but also because medical referrals for specialised care at external (to prison) clinics are costly ( 23 , 25 ). A recent submission by JHFMHN to the NSW Special Commission of Inquiry into Healthcare Funding revealed that the speciality network had constrained resources to meet the growing healthcare needs in prisons, as government budget allocations to the network were based on historical funding levels ( 35 ). This creates competing priorities and is a clear indication that the increasing number of older incarcerated adults and their complex health needs has become a significant challenge for correctional facilities. The findings also revealed that older incarcerated adults’ access to health care was delayed and that their immediate health needs were deferred to conform to prison procedures. Prison bureaucracy is seen as a challenge to the delivery of health care to incarcerated adults ( 19 , 20 , 24 ). In addition to being a barrier to accessing health services, the current findings revealed that prison bureaucracy is a reason for frustration among older incarcerated adults because of prison staffs’ focus on the process of prison routine paying little attention to the needs of the cohort. This shows the persistence of what was referred to two decades ago as institutional thoughtlessness, where older incarcerated adults’ unique needs are often overlooked as correctional facilities continue to hinge on their command and control rules ( 36 ). Power and staff relationships reflect the culture of the working environment in prison. Justice health staff reported corrections’ superiority in the decision-making process regarding patient care, impacting timely access to care. Security can override health concerns ( 19 ), and its dominance creates feelings of being devalued among nurses, further affecting their relationship with prison staff ( 34 ). Our findings showed limitations in terms of shared knowledge and mutual understanding between corrections and health, which in turn impacted the delivery of appropriate care to older incarcerated adults and triggered conflicts between health and custodial staff. Custody and health staff roles are considered distinct, offering inadequate avenues for collaboration in the delivery of health care to older incarcerated adults ( 37 ). Another cultural barrier was punitive practices. This practice was mentioned as a reason for delayed access and for preventing older incarcerated adults from seeking care. Our findings correspond with the results of a study from the UK where dismissive attitudes and a lack of empathy toward older incarcerated adults were reported ( 37 ). The reasons behind punitive practices vary. Prison staff have conflicts of interest and lack proper guidance on how to manage incarcerated adults, as they struggle with meeting their welfare needs and adhering to security requirements ( 38 ). Punitive attitudes toward incarcerated adults have also been shown to emanate from workplace culture of maintaining order and security ( 39 , 40 ). Other reasons are staff members’ stress due to the working environment, pressure from peers to act tough and undesirable attitudes toward the crimes committed by incarcerated adults ( 40 – 42 ). Personal barriers, including perceived stigma, fear of retribution and deprived autonomy, were reported. Travelling to hospitals and being viewed in public whilst handcuffed was an embarrassing experience for older incarcerated adults, and as a result, they often preferred to avoid or delay their travel. While this cumbersome experience was recognised by correctional officers, it was deprioritised given the focus on maintaining the safety and security of the public, revealing the interplay between personal and structural barriers and the significant influence of the latter on the individual experience of accessing health services in prison. This is further demonstrated by older incarcerated adults’ reluctance to demand health services in fear of potential retaliation. In a qualitative study in Switzerland, the only study in which older incarcerated adults’ access to health services was assessed, Heidari, Wangmo ( 43 ) reported similar findings in which older incarcerated adults had fears of visiting prison health services falsely, accusing them of being a ‘faker’ or punishment for refusing to take prescribed medication. Older incarcerated adults had limited autonomy over their healthcare decisions, which created frustrations with the health services they received in prison. Denial of incarcerated adults’ right to participate and contribute to decisions about their health can occur throughout the prison journey and adversely affect their health status ( 21 , 44 ). It is an indication of challenges in providing patient-centred care and meeting patient needs ( 21 , 24 , 44 ). The loss of autonomy is also a reflection of the power imbalance between the prison regime and incarcerated adults ( 21 ). Our findings indicated that structural barriers (e.g., the focus on safety and security) can compromise patients’ autonomy. Available evidence also shows that some incarcerated adults are considered misleading or illegitimate patients; thus, their access to or involvement in health services can be dishonoured ( 18 , 37 ). Implications for policy and practice The findings have important implications for policy and practice in correctional health and custodial systems. Below, we draw on some propositions that respond to the barriers identified in this study. Working through custody and health policies to address the barriers , the structural and cultural barriers identified in the study are indications of challenges in custody and health policies. Custody policies can restrict the delivery of certain health services for older incarcerated adults (e.g., access to hearing aids) ( 45 ), and this demographic’s health care needs are invisible in healthcare policies and provisions, resulting in a lack of adequate support to respond to their needs ( 36 , 46 ). Thus, improvements in access to and quality of health services for older incarcerated adults start with addressing health care needs in these policies. This includes promoting age-friendly approaches, building the necessary infrastructure and capacity and advocating for policy changes that are inclusive of the needs of the cohort. The barriers to relational coordination between custodial and health staff necessitate more work on improving shared goals and mutual respect between the two organisations with different priorities. Organisational structures such as shared accountability, shared conflict resolution, relational job design, relational leadership roles, shared meetings, and shared protocols can improve work relationships and communication ( 47 ). Efficient approaches to address the shortage of resources and the increasing cost of caring for older people in prison lack of resources and capacity triggered by the increasing number of older incarcerated adults and their complex health care needs, call for the design and implementation of efficient models of healthcare to meet growing needs. One area of intervention is training and education of custodial staff ( 27 ) on the health care needs of older incarcerated adults and the ways in which staff are able to assist in identifying and triaging these needs as part of their daily role in maintaining safety and security. Such interventions not only help address older incarcerated adults’ needs in an efficient fashion but also lessen the barriers related to custody staff’s gatekeeper role in prison health delivery. As demonstrated in different programs, involving older incarcerated adults in some care activities as peer carers can also reduce the burden on the correctional health system ( 48 ). Challenging punitive practices through shaping public opinion Instances of punitive attitudes toward older incarcerated adults are influenced by workplace culture, which in turn is shaped by public opinion. Both in Australia and internationally, public opinion is generally inclined toward punitive approaches to sentencing ( 49 , 50 ). Public misperceptions expressed as overestimations of the utility of punishment, underestimations of alternative approaches and a limited understanding of how the criminal justice system operates are common ( 51 ). As a result, there is a view that health care in prison ought to be inferior to that enjoyed by the general community ( 52 ). This is something that prison medical services need to be cognizant of while addressing the significant health needs of this group. Public education on the criminal justice system is thus key to creating a balanced public attitude towards the system ( 49 ). Policymakers, health planners and the media also need to be aware of public attitudes and provide evidence-based information on older incarcerated adults’ rights to equivalent care and demonstrate its benefits to the general public ( 51 ). Empowering older incarcerated adults to improve their access to health services Despite the challenges of promoting patient autonomy in prison, involving older incarcerated adults in planning and delivering person-centred care can significantly improve the quality of care ( 53 ). An important first step to promote their involvement is improving custody staff’s understanding of the challenges that older incarcerated adults experience when their autonomy is deprived off ( 19 ) so that staff exercise agility and sympathy when older incarcerated adults access prison health services. Promoting self-management practices can also encourage participation in care planning and help offset the increasing cost needed to care for the cohort ( 48 ). Corrections’ recognition of the cohort’s right to be treated with respect and dignity and compliance with the implementation of this right was enshrined in the United Nations’ basic principles for the treatment of prisoners ( 54 ), which Australia and other countries are signatories can also have meaningful outcomes in realising older incarcerated adults’ control and choice over their health care. LIMITATIONS This study has some limitations. The interviews with older incarcerated adults were conducted in two out of the three prisons. The interview schedule with older incarcerated adults in one Correctional Centre overlapped with a new wave of COVID-19, and restrictions did not permit the conduct of the interview at this centre. This may have affected the amount and diversity of information that could have been obtained from older adults imprisoned in this centre. However, older incarcerated adults’ experience from other centres during their referral to this centre and interviews with Corrective Services staff at the same centre addressed some of the missing information and contributed to the completeness of the data. The study was limited to three correctional centres in New South Wales. Given the variability in prison health care delivery across different jurisdictions, both within Australia and internationally, the findings may not be directly generalizable to broader settings globally. However, the unique insights from this study are still relevant to similar environments. This is due to common challenges faced by correctional facilities worldwide, such as overcrowding, limited health service resources, and the commitment to providing equivalent care on the basis of internationally agreed-upon standards and guidelines. CONCLUSIONS The multistakeholder perspectives from this study identified diverse and interrelated structural, cultural and personal barriers to access and quality of prison health services for older incarcerated adults. The barriers represented a complex interplay between the prison environment, custody and health relationships and the dual patient‒prisoner status of older incarcerated adults, where custody’s considerable influence on prison health service delivery was revealed. Addressing these barriers requires working through custody and health policies, enhancing relational coordination between actors, empowering older incarcerated adults to have choice and control over their health and implementing efficient approaches to offset the rising cost of delivering health services to the increasing number of older incarcerated adults. Declarations Ethics approval and consent to participate In adherence to the Declaration of Helsinki, the study received ethics approval from the University of New South Wales (HC 190951), Corrective Services New South Wales and Justice Health and Forensic Mental Health Network (JHFMHN) (2020 ETH/002658), and site-specific permission to conduct interviews from individual correctional centres. Written informed consent to participate in interviews was obtained from all study participants. Consent for publication Not Applicable Availability of data and materials Data used for the purpose this study are not publicly available. Our data are transcripts from individual interviews with older incarcerated adults and Corrective Services and Justice Health staff and their privacy will be compromised if data are shared publicly. However, parts of the transcripts can be shared upon reasonable request to the corresponding author. Competing interests The authors declare that they have no competing interests. Funding No outside funding was used to support this work. Authors' contributions AKH: Conception and initialization, methodology, data analysis, result interpretation, manuscript preparation and revision. AW: Conception and initialization, result interpretation, manuscript revision. NG: Methodology (data collection), result interpretation, manuscript revision. JH: Result interpretation, manuscript revision. TB: Conception and initialization, result interpretation, manuscript revision. All authors read and approved the final manuscript. Acknowledgements The authors would like to thank Corrective Services New South Wales, Justice Health and Forensic Mental Health Network, Correctional Centres and all study participants for their support and cooperation in this study. Authors' information (optional) Not Applicable References Bedard R, Metzger L, Williams B. 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NSW Government; 2023. https://correctiveservices.dcj.nsw.gov.au/correctional-centres/find-a-correctional-centre.html Justice Health and Forensic Mental Health Network. About us: Justice Health and Forensic Mental Health Network; 2023. https://www.nsw.gov.au/health/justicehealth Lukmanjaya W, Butler T, Taflan P, Simpson P, Ginnivan N, Buchan I, et al. Population Characteristics in Justice Health Research Based on PubMed Abstracts From 1963 to 2023. Text Min Study. 2024;8:e60878. Merkt H, Haesen S, Meyer L, Kressig RW, Elger BS, Wangmo T. Defining an age cut-off for older offenders: a systematic review of literature. Int J Prison Health. 2020;16(2):95–116. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101. Dhaliwal K, Hirst S. Caring in Correctional Nursing: A Systematic Search and Narrative Synthesis. J Forensic Nurs. 2016;12(1):5–12. Justice Health and Forensic Mental Health Network. 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Correctional Officers' Views of Prison, Punishment, and Rehabilitation. Handbook on Prisons and Jails. Routledge; 2023. pp. 119–41. Badgett K. Correctional Officer Professional Orientations toward Prisoners, Pluralistic Ignorance, and Barriers to Resolution 2016. Oberholtzer M. Correctional officers’ perceptions of punitive force in solitary confinement. Walden University; 2023. Heidari R, Wangmo T, Galli S, Shaw DM, Elger BS. Accessibility of prison healthcare for elderly inmates, a qualitative assessment. J Forensic Leg Med. 2017;52:223–8. Brinkley-Rubinstein L. Incarceration as a catalyst for worsening health. Health justice. 2013;1(1):3. Macleod A, Nair D, Ilbahar E, Sellars M, Nolte L. Identifying barriers and facilitators to implementing advance care planning in prisons: a rapid literature review. Health justice. 2020;8(1):22. Van Hout MC, Srisuwan L, Plugge E. 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United Nations. Basic principles for the treatment of prisoners. United Nations (UN); 1990. Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterial1InterviewGuides.pdf Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 04 Nov, 2025 Reviews received at journal 15 Aug, 2025 Reviews received at journal 05 Aug, 2025 Reviewers agreed at journal 04 Aug, 2025 Reviewers agreed at journal 28 Jul, 2025 Reviews received at journal 02 Jul, 2025 Reviewers agreed at journal 02 Jul, 2025 Reviewers invited by journal 29 Jun, 2025 Editor invited by journal 05 Jun, 2025 Editor assigned by journal 23 Apr, 2025 Submission checks completed at journal 21 Apr, 2025 First submitted to journal 21 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6407981","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":479485183,"identity":"36da6a14-3bad-4819-bab7-a0af68f84f62","order_by":0,"name":"Amanuel Kidane Hagos","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYFACHjApB+UxE6/FmHQtiQ1Ea+Fv4D348UtFXfqG2+3PJBgqrBMb2M8Y4NUicYAvWVrmzOHcDXfOmEkwnElPbODJwa+F4QCPgbRk24HcDTdy2G4wth0GupCAFvkDPMa/Jdvq0g1upD+7wfgPqIX/DX4tBgd4zCQ/tjEnGNxIMLvB2ADUIkHAFsPDPGbWDGcOG868kWP+I+FYunGbxLMCvFrkjvcY3/xRUSfPdyP9scGHGmvZfv7kDXi1gCKCmQfGSQBiNvzqIYDxBzGqRsEoGAWjYOQCAC7+Rc0XptS7AAAAAElFTkSuQmCC","orcid":"","institution":"UNSW Sydney","correspondingAuthor":true,"prefix":"","firstName":"Amanuel","middleName":"Kidane","lastName":"Hagos","suffix":""},{"id":479485184,"identity":"b05d1286-cab8-4847-a669-2ed4caa1d9e4","order_by":1,"name":"Adrienne Withall","email":"","orcid":"","institution":"UNSW Sydney","correspondingAuthor":false,"prefix":"","firstName":"Adrienne","middleName":"","lastName":"Withall","suffix":""},{"id":479485185,"identity":"b4b2c7dc-9f02-4704-b74b-1e07464a28c4","order_by":2,"name":"Natasha Ginnivan","email":"","orcid":"","institution":"UNSW Sydney","correspondingAuthor":false,"prefix":"","firstName":"Natasha","middleName":"","lastName":"Ginnivan","suffix":""},{"id":479485186,"identity":"6e2ecf3c-4d20-4d6b-9ad6-5c617bf81c52","order_by":3,"name":"Ye In (Jane) Hwang","email":"","orcid":"","institution":"UNSW Sydney","correspondingAuthor":false,"prefix":"","firstName":"Ye","middleName":"In (Jane)","lastName":"Hwang","suffix":""},{"id":479485187,"identity":"4fd0d826-8b0c-4264-a849-b355aa73de66","order_by":4,"name":"Tony Butler","email":"","orcid":"","institution":"UNSW Sydney","correspondingAuthor":false,"prefix":"","firstName":"Tony","middleName":"","lastName":"Butler","suffix":""}],"badges":[],"createdAt":"2025-04-09 04:53:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6407981/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6407981/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85946193,"identity":"30eaae07-c0ad-4178-8f0a-82c5d99a1d8e","added_by":"auto","created_at":"2025-07-03 12:50:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1031399,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6407981/v1/4b9c8658-d0f3-4905-918e-5c085ae509fa.pdf"},{"id":85945800,"identity":"df2958ac-4ea5-43a9-a600-563a1809bbe0","added_by":"auto","created_at":"2025-07-03 12:42:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":188078,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial1InterviewGuides.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6407981/v1/b91cecf6f00e245984355993.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Structural, cultural and personal barriers to healthcare for older adults in prison: insights from a qualitative study in New South Wales, Australia","fulltext":[{"header":"INTRODUCTION","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eOlder incarcerated adults and their growing and complex needs\u003c/h2\u003e \u003cp\u003eThe rapid increase in the number of older incarcerated adults in recent years has become a challenge for correctional and healthcare systems in Australia and internationally (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Between 2009 and 2023, the older incarcerated adult population in Australia increased by 105% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In New South Wales (NSW), the most populous state in Australia, where this study was conducted, the proportion of this population increased by 325% between 2002 and 2021, compared with only a 47% increase among the older general population during the same period (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe older incarcerated adult population has unique and complex health, social and custodial needs (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Compared with both younger incarcerated adults and older adults in the community, they present multiple and significantly greater rates of chronic illness and disability, drug- and alcohol-related diseases, cognitive impairment, and increased levels of physical and mental health conditions (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). For example, 90% of older incarcerated adults in Northwest England prisons had a physical health disorder, and 35% of older adults entering prison in Australia in 2018 reported poor or fair physical health, whereas 22% of younger entrants reported poor or fair physical health (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Older incarcerated adults require assistance with mobility and personal hygiene and with identifying their physical and mental health needs (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Difficulties with accommodations, program activities and daily routines in prisons, which are not age-appropriate to suit their needs, have been frequently reported (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eAccess to and quality of health care for older adults in prison\u003c/h2\u003e \u003cp\u003eGiven their complex and unique needs, older incarcerated adults require proper access to high-quality prison health care. The World Health Organisation defines access to health care as:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The continuing and organised supply of care that is geographically, financially, culturally, and functionally within easy reach of the whole community. The care has to be appropriate and adequate in content and in amount to satisfy the needs of people, and it has to be provided by methods acceptable to them\u0026rdquo;\u003c/em\u003e (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOn the other hand, quality of health care signifies the ability of health services to adequetly meet individuals\u0026rsquo; and population\u0026rsquo;s desired health outcomes, characterised by key attributes of effectiveness and efficiency, patient-centredness, timeliness, safety and equity (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccess to and quality of health care for incarcerated adults in general are poor. In the United States, a cross-sectional analysis of decades of national surveys revealed that incarcerated adults lack access to health services (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Among the 40% of respondents reporting ever having a mental health condition, more than one-third had received no mental health treatment during incarceration (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Incarceration is also a known reason for worsening health status (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). For example, an Italian study reported that 60% of incarcerated adults perceived that their health status was worse after they entered prison (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Similarly, in other countries, such as the United Kingdom, Australia and Iran, incarcerated adults and prison staff face numerous obstacles to accessing and ensuring the quality of health care in prisons, including security, the prison regime, staffing, and transport issues (\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConversely, prisons can offer an opportunity for improved health status among some groups of incarcerated adults. For example, a study among 111 incarcerated adults in England indicated improvements in physical and mental health services for people who had limited access in the general community before their entry to prison (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In another study in Italy, 72.8% of participants reported moderate or high satisfaction with their health status in prison (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Health service provisions in prisons are quite variable among and within countries, and such variability contributes to the differences reported as improvements in or deterioration of health status ((\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOlder incarcerated adults consistently indicated dissatisfaction and poor access to prison health services (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Some reported concerns with the quality of treatment they received, and others rated their experience in prison as poor (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). This is despite demographic making more visits to prison health services than the younger prisoner population does (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Health care provision to older incarcerated adults is a complex phenomenon, as the group represents a dynamic cohort of varying health profiles and intersectional disadvantages related to socioeconomic status, gender and imprisonment history, requiring targeted, closely monitored, and highly specialised services (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Australia, health care provisions in prisons are largely the responsibility of state and territory governments, with a wide range of variability in the scope and quality of services across jurisdictions. In New South Wales, Corrective Services New South Wales manages most correctional centres in the state, and in 2023, the state had 42 adult correctional centres with different security levels both within and between facilities (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The Justice Health and Forensic Mental Health Network is the agency responsible for providing healthcare to people who come in contact with forensic mental health and the criminal justice system. In 2023, the agency managed more than 30,000 patients annually in custody, court, and community and inpatient settings in metropolitan, regional and rural areas of the state (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMost studies conducted on incarcerated adults in Australia and internationally have focused on describing prevalence, identifying risk factors and prevention and treatment approaches for mental illness and substance abuse (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). While there is emerging evidence on data specific to older incarcerated adults, the emphasis has been on assessing needs and investigating general challenges; thus, investigations of systemic factors that demonstrate the complex nature of health service provision to older incarcerated adults have previously been recommended (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The purpose of this study was to provide an in-depth exploration of the barriers to access and quality of healthcare for older incarcerated adults.\u003c/p\u003e \u003c/div\u003e"},{"header":"METHODOLOGY","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSampling and recruitment of study participants\u003c/h2\u003e \u003cp\u003eThe study involved maximum variation purposive sampling to select the prisons and study participants. This process considered several comparator factors, including typical cases (of mainstream prisons), the gender of older incarcerated adults, and diversity in the main function or purpose of correctional centres to identify and include three prisons. With the aim of gaining multistakeholder perspectives, the study involved healthcare professionals, Corrective Services staff and older incarcerated adults in individual in-depth interviews. The inclusion criteria for staff were having one or more years of experience working as a correctional officer or prison health staff, being aged 18 years and above, and being willing to provide informed consent.\u003c/p\u003e \u003cp\u003eSimilarly, for interviews with older incarcerated adults, the inclusion criteria were being aged 50 years and above (45 years and above if Indigenous), experiencing incarceration (either currently imprisoned, being released or on parole in a NSW correctional centre or parole unit), being able to conduct the interview in English, being willing and able to participate in an interview and being able to provide written informed consent. The age cut-off of 50 years (45 years if Indigenous) was used to align with the commonly used definition of older status of the cohort (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eFollowing ethics approvals (see Declaration section) and site-specific permission to conduct interviews, the research team approached Corrective Services staff with whom we had established communication during previous studies. The staff members liaised with security managers in each centre, who served as the focal points to grant access to each centre, screen and recruit interview participants (older incarcerated adults and Corrective Services staff). The security managers also provided contact details of the Nursing Unit Managers (NUMs) at each centre, who then assisted in recruiting Justice Health staff for interviews. The research team shared an invitation to participate in the study and the Participant Information Statement and Consent Forms with both the security managers and the NUMs of the three correctional centres. This occurred before the actual schedule of interviews. The data were collected from December 2020 to May 2021 via a combination of face-to-face, phone and audio‒visual links to suit the easing and tightening of COVID-19 restrictions during the study period.\u003c/p\u003e \u003cp\u003eData were collected as part of the first author\u0026rsquo;s PhD study, where three interview guides were developed to conduct interviews with older incarcerated adults and Corrective Services and Justice Health staff (Supplementary Material 1_Interview Guides). The interview guides for staff members focused on communication and relationships, tensions that arise during service provision and recommendations to improve current practices in the care and management of older incarcerated adults. Questions for older incarcerated adults included their experience and evaluation of the health service they receive in prison during entry through to pre-release (see supplementary material for interview guides).\u003c/p\u003e \u003cp\u003eThe first author (AKH) conducted the interviews, with each interview lasting for a maximum of one hour. Through purposive sampling, a total of 23 interviews were conducted with Corrective Services and Justice Health staff at three correctional centres. Similarly, AKH interviewed 14 older incarcerated adults from two of the three prisons. The study participants provided written consent before each interview, and all except six face-to-face interviews with older female incarcerated adults were audio-recorded. Permission to audio-record the six face-to-face interviews was not granted, and the interviewer took notes instead. A transcription company transcribed the audio-recorded interviews.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe study employed and systematically applied the six steps of thematic analysis approach (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). First, interview transcripts were uploaded into qualitative data analysis software (NVivo Version 12, QSR International) for coding and data management. The first author, who also conducted the interviews, read and re-read the transcripts to further immerse themselves in the data. This was followed by immersive reading into the first transcript and developing initial codes inductively. The initial list of codes was further examined, and differences in meanings were critiqued to develop a revised list of codes. At this stage, the analysis process was further checked against the audio recordings of the interviews to ensure that these represent participants\u0026rsquo; voices while progressing from semantic coding to latent or interpretive coding. The revised codes were then applied to the analysis of the rest of the transcripts and further refined and expanded to capture participants\u0026rsquo; perspectives. This iterative process continued with observing shared meanings and emerging patterns across the codes and grouping similar codes to generate themes. Once the themes were drafted, the naming and meaning of each theme and their relationships were assessed to check if they still represented the data, had a central concept and that these stood by themselves. This led to the naming and defining of the themes and the production of the report for the study.\u003c/p\u003e \u003c/div\u003e "},{"header":"FINDINGS","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eI. Characteristics of study participants\u003c/h2\u003e \u003cp\u003e Interview participants included 14 older incarcerated adults (P1\u0026ndash;P4), 10 Corrective Services staff (CS1\u0026ndash;CS10) and 13 Justice Health staff (JH1\u0026ndash;JH13). Older incarcerated adults had a median age of 61 years, with an age range of 53\u0026ndash;67 years. Most staff participants were female nurses (48%) and male correctional officers (26%). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e below describes the demographic characteristics of study participants.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics of study participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographic characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipants (n\u0026thinsp;=\u0026thinsp;37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOlder Prisoners\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (38%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCorrective Services Staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (27%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJustice Health Staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (35%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian Age of Prisoners (Range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (53\u0026ndash;67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePrisoners (n\u0026thinsp;=\u0026thinsp;14)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (57%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (43%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStaff (n\u0026thinsp;=\u0026thinsp;23)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (30%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (70%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStaff profession/role (n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (39%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNursing Unit Manager\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral Practitioner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCorrectional Officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (26%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior Correctional Officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunctional Manager\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eII. Themes\u003c/h3\u003e\n\u003cp\u003eThree organising themes (\u003cem\u003estructural, cultural and personal\u003c/em\u003e) and nine sub-themes of barriers to prison healthcare emerged from the analysis of the data. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e below provides a summary of the organising themes and sub-themes.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of the themes and sub-themes of barriers to prison healthcare for older incarcerated adults.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrganising themes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-themes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eStructural\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCompeting priorities of custody and health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDiffering policies and working procedures between custody and health.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResources and capacity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWorkforce and monetary resources that are incommensurate with older incarcerated adults\u0026rsquo; growing health care needs.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrison bureaucracy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStringent prison procedures and rules that delay access or compromise quality of care.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eCultural\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRelational coordination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLimitations to shared knowledge and mutual understanding between custody and health during provision of health care to older incarcerated adults.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePower relationships\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePower asymmetry between custody and health in making decisions about healthcare provision.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePunitive practices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMeasures targeted at limiting access to healthcare merely due crimes committed.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ePersonal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerceived stigma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUndesired feelings due to negative attitudes others hold towards incarcerated adults.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFear of retribution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnxiety over potential retaliation for actions committed while accessing health service in prison.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeprived autonomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIncarcerated adults\u0026rsquo; limited control and choice over their health care.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e1. Structural barriers\u003c/h3\u003e\n\u003cp\u003eStructural barriers refer to (inter)organisational and systemic challenges in prison that limit access to and quality of prison healthcare for older incarcerated adults. The study identified three structural barriers: \u003cem\u003ecompeting priorities of custody and health\u003c/em\u003e, \u003cem\u003eresources and capacity\u003c/em\u003e, and \u003cem\u003eprison bureaucracy.\u003c/em\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCompeting priorities of custody and health\u003c/h2\u003e \u003cp\u003eCompeting priorities are differing policies and working procedures between custody and health encountered during the provision of health care to older incarcerated adults. Corrections and health staff recognised these differences as real and evident.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Our roles are just so different \u0026hellip; it is like chalk and cheese.\u0026rdquo; (Corrections staff member, CS4)\u003c/em\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There are sometimes a few setbacks but obviously everybody has got their own policies and procedures and sometimes the Justice Health procedures clash with the Correctional Officers\u0026rsquo; Policy and Procedures.\u0026rdquo; (Justice Health staff member, JH2)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eCorrections prioritised preventing risk and ensuring safety and security to self and others, whereas Justice Health staff members were concerned with treating patients to save lives and adhering to treatment protocols to reduce harm or complications. Such competing priorities were reasons for \u003cem\u003edelaying access\u003c/em\u003e and increasing the \u003cem\u003erisk of harm\u003c/em\u003e, such as medication error.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;When something bad happens, nurses have this sort of innate instinct to go over and help, whereas our innate instinct is to make sure we are protected first. So that is the time that there is a real sort of clash because they are like, \u0026lsquo;Well, come on, hurry up!\u0026rsquo; \u0026lsquo;No, let me put my gear on.\u0026rsquo; \u0026lsquo;\u0026rsquo; (Corrections staff member, CS7)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;So that is where our policies sort of clash. Like ours would be \u0026lsquo;Let us all just have a methadone so we can focus on the methadone\u0026rsquo; because that is our policy, you know? Whereas the correctional officers were like, \u0026lsquo;Well no because we cannot cross these guys with these guys so we have to get them individually out.\u0026rsquo; Then, you had to do like a methadone as well as a supervised pill back to methadone to a supervised pill to insulin to methadone. So there was a higher risk there of a medication error because you are actually swapping from one part to another.\u0026rdquo; (Justice Health staff member, JH2)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSafety and security considerations took precedence over health care provisions, where the priorities of Corrections were either \u003cem\u003elimiting access\u003c/em\u003e or causing services to be \u003cem\u003erushed\u003c/em\u003e because of time constraints in providing health care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So, obviously, one of the barriers is having access, you know. Sometimes you can plan to do a clinic and then only see one person for various reasons. There might be a lockdown; there might be a union meeting on the side of Corrective Services.\u0026rdquo; (Justice Health staff member, JH7)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It is routine as well because we start at 7 o\u0026rsquo;clock and we have half an hour, only half an hour, to pack all the medications for the morning. So, it is really a time factor as well.\u0026rdquo; (Justice Health staff member, JH3).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMore attention was given to health care, primarily during a health emergency or when a patient\u0026rsquo;s condition deteriorated, further confirming the \u003cem\u003edelay in access\u003c/em\u003e for non-emergency cases and the priority given to safety and security.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The only real time you get to see somebody in a short period of time is if there is an emergency of some description.\u0026rdquo; (Older incarcerated adult, P7)\u003c/em\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think you have to be on your death bed there to get any help. If you want to see a doctor you have got to be something major wrong with you.\u0026rdquo; (Older incarcerated adult, P4)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eResources and capacity\u003c/h2\u003e \u003cp\u003eCorrections\u0026rsquo; and Justice Health\u0026rsquo;s resources and capacity were insufficient to meet the health assessment needs of prison entrants and the increasing demand for secondary care and treatment of chronic conditions. Shortage of doctors and nurses and the high cost of escorting older incarcerated adults to referral hospitals were significant barriers to delivering the required health services. These barriers \u003cem\u003elimit the\u003c/em\u003e reach \u003cem\u003eand scope\u003c/em\u003e of some services (e.g., supervised medication and aged care assessment).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;you have to remember they are very understaffed at reception centres; they get a lot of new receptions. They do not have a lot of time to be spending doing a lot of age health assessments there and also because, you know, when you are assessing an older person, it just takes longer.\u0026rdquo; (Justice Health staff member, JH7)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Increased costs to the centre because we have to pay staff to go out to the hospital\u0026hellip;sometimes we have to shut down a wing or an area to get the staff to take somebody to the hospital.\u0026rdquo; (Corrections staff member, CS10)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There is so many more that can probably be put on supervised medication\u0026hellip;there is not the staff really available to be giving everyone supervised medications.\u0026rdquo; (Justice Health staff member, JH3)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe constraints on resources and capacity were also evident from the prison clinics\u0026rsquo; \u003cem\u003elong waiting list\u003c/em\u003e and \u003cem\u003epatients\u0026rsquo; extended time\u003c/em\u003e to see a doctor.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;often by the time we actually called up to see the GP, we cannot remember why we are there, that is how long it is.\u0026rdquo; (Older incarcerated adult, P14)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Our GP list, for example, is extremely extensive, and so in order for patients to be seen, they have to wait.\u0026rdquo; (Justice Health staff member, JH10)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePrison bureaucracy\u003c/h2\u003e \u003cp\u003eCorrectional facilities\u0026rsquo; stringent processes to ensure safety and security means that older incarcerated adults\u0026rsquo; access to health care could be \u003cem\u003edelayed\u003c/em\u003e. This was particularly evident during entry to prison, where validating patients\u0026rsquo; pre-imprisonment medical history and diagnosis was required before commencing treatment. The process involved establishing contact with patients\u0026rsquo; medical centre in the community, releasing information from a community general practitioner (GP), and reviewing and approving the information by prison GPs.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;For someone who waits for too long it means if they are on medications that are not approved by our pharmacy and then they have to see the doctor and then\u0026hellip;.And then even the doctor reviews the medication we send to pharmacy, the pharmacy might say \u0026ldquo;Not approved\u0026rdquo;, so that goes back and then the doctor will try to find the alternative\u0026hellip;\u0026rdquo; (Justice Health staff member, JH4)\u003c/em\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Release of information [from community GP] is done by the nurse and then we fax it off. It goes to the community doctor and then we wait for them to send the information back.\u0026rdquo; (Justice Health staff member, JH3)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eFor older incarcerated adults, the bureaucracy involved in ascertaining patients\u0026rsquo; details often resulted in considerable \u003cem\u003edelays\u003c/em\u003e in starting the medication they used to take before they came to prison.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I waited for two months to get the medication I was taking before coming into prison... They had to get authorisation from my family doctor\u0026hellip; My brain was about to explode when I was not able to get the medication\u0026rdquo; (Older incarcerated adult, P13)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The problem is timing \u0026ndash; one month to get a medication is long. I also know an inmate who has been waiting for two weeks for psych medication\u0026hellip;.\u0026rdquo; (Older incarcerated adult, P12)\u003c/em\u003e \u003c/p\u003e \u003cp\u003ePrison bureaucracy also occurred beyond the initial entry period and persisted during routine health care services in prison. Older incarcerated adults reported several instances where their immediate need for a service was deferred to set procedures that they must follow before they can access care.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I have seen it where an incarcerated adult has cut his finger and he was walked out and all he wants was a Band-Aid. Stood there and you can see through the window a stack of Band-Aids on the trolley and \u0026lsquo;No, not going to see you. Just fill out a request form for a Band-Aid. Hold the finger with a bit of tissue.\u0026rdquo; (Older incarcerated adult, P5)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Just to get Nurofen or Panadol, you cannot just go up. You have to go through a whole rigmarole. By the time you get your Panadol the headache is over.\u0026rdquo; (Older incarcerated adult, P2)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e2. Cultural barriers\u003c/h2\u003e \u003cp\u003eCultural barriers arise from (inter)organisational values, norms and attitudes that are explicitly or inexplicitly exercised during routine healthcare provision to older incarcerated adults. These barriers include \u003cem\u003erelational coordination\u003c/em\u003e, \u003cem\u003epower relationships\u003c/em\u003e, and \u003cem\u003epunitive practices\u003c/em\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eRelational coordination\u003c/h2\u003e \u003cp\u003eThis sub-theme describes limitations to shared knowledge and mutual understanding between custody and health during the provision of healthcare to older incarcerated adults. These limitations increased the \u003cem\u003erisk of harm or safety\u003c/em\u003e concerns to patients and were a reason for conflicts between Corrections and Justice Health staff.\u003c/p\u003e \u003cp\u003eFor example, Corrections staff\u0026rsquo;s inadequate understanding of the process of care involved in managing a patient presented a challenge to providing the appropriate level of care to older incarcerated adults.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;So if they [Corrections staff] phone up or they ask us \u0026lsquo;She complains of a headache and you just give her a Panadol.\u0026rsquo; No, it requires assessment. They do not understand what is involved.\u0026rdquo; (Justice Health staff member, JH12)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;So sometimes they [Corrections staff] do not understand you know why we do that extra mile for that patient where you know, \u0026lsquo;Just give them a Band-Aid and let them go back\u0026rsquo; kind of thing.\u0026rdquo; (Justice Health staff member, JH2)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eCorrections staff\u0026rsquo;s limited understanding of the medical conditions of patients also resulted in conflicts between Corrections and Justice Health staff while potentially posing a \u003cem\u003erisk of harm/discomfort\u003c/em\u003e to patients when staff use force.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;They [Corrections staff] think that the patient was trying to go to be violent, to be aggressive towards other people. But it is just a medical condition. And the officer in one case would be just going in and try to use force to stop the patient, and her patient had no idea. So, you know, it caused conflicts between the health staff and officer.\u0026rdquo; (Justice Health staff member, JH8).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eReciprocally, Justice Health staff\u0026rsquo;s inadequate attention to safety and security procedures posed a \u003cem\u003esafety\u003c/em\u003e concern among Corrections staff and led to conflicts between the two coworkers.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;A lot of the nurses often forget. So they will make mistakes like leave a needle on the bed and it is up for us. That is why we go in. \u0026lsquo;No, you cannot leave the needle there.\u0026rsquo; \u0026lsquo;But why?\u0026rsquo; \u0026lsquo;No, you cannot leave a needle right next to an inmate because he can grab it and stab you with it.\u0026rsquo; So it is little things like that. People do not realise unless you are working in the industry.\u0026rdquo; (Corrections staff member, CS7).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eJustice Health staff might also not fully understand the behaviour of some incarcerated adults and thus could undermine the level of \u003cem\u003esafety\u003c/em\u003e and security required to keep everyone safe.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think a lot of them [nurses] come in a little bit blind and do not realise the sort of people that we are dealing with day to day\u0026rdquo; (Corrections staff member, CS3)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;They [Justice health staff] sometimes cannot see the sense in handcuffs and things like that, but we rarely get any big dramas.\u0026rdquo; (Corrections staff member, CS9)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003ePower relationships\u003c/h2\u003e \u003cp\u003eCorrections, as the host of Justice Health\u0026rsquo;s operations and holding the authority of managing correctional centres, had the upper hand in influencing patient care decisions, impacting \u003cem\u003etimely access\u003c/em\u003e to care and creating unease among Justice Health staff.\u003c/p\u003e \u003cp\u003eJustice Health staff members\u0026rsquo; reflections on their interactions with Corrections staff during the routine care of older incarcerated adults were illustrative of power asymmetry.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I have heard certainly where nurses might say, \u0026lsquo;I went in to do someone\u0026rsquo;s blood sugar and they [Corrections] will say, \u0026lsquo;We are not doing it until we have got two officers.\u0026rsquo; You know, \u0026lsquo;\u0026hellip;. And I think like if you have already antagonised someone then you are going to have a harder time without a doubt. Yeah, you are going to have a harder time.\u0026rdquo; (Justice Health staff member, JH6)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;There is some trepidation in the nurses in the [de-identified] unit. For example, if someone needs to go out to hospital, they kind of feel like \u0026lsquo;Hm, got to go and ask \u0026hellip;\u0026rdquo; (Justice Health staff member, JH7)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThere were instances where patient management recommendations initially made on the basis of medical conditions were altered to meet the demands of Corrections. This presents potential \u003cem\u003eharm\u003c/em\u003e to patients due to changes in medical recommendations.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I have had officers come and ask me to change my recommendation or ask other nurses to change their recommendations to suit the needs of the centre. Um, I do not do that \u0026hellip;but I have seen nurses in the past change their recommendation.\u0026rdquo; (Justice Health staff member, JH11)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003ePunitive practices\u003c/h2\u003e \u003cp\u003ePunitive practices can limit older incarcerated adults\u0026rsquo; access to prison health care. Some Corrections staff saw older incarcerated adults as less deserving of care and kindness because of the crime they committed, which \u003cem\u003edelayed their access\u003c/em\u003e to the care they needed.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think that officers can be extremely difficult. They may be punitive to patients in this environment, so you know, I guess in \u0026lsquo;Why are you being so kind to this patient? Do not you know what he has done?\u0026rsquo; \u0026hellip; I have never seen a nurse withholding any level of care to patient, whereas you can get delayed access to patients by an officer because of their punitive idea.\u0026rdquo; (Justice Health staff member, JH5)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOlder incarcerated adults experienced punitive practices during their daily routine, which was a reason to \u003cem\u003eavoid seeking care\u003c/em\u003e.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I learned very quickly you do not tell them how you feel because you get punished, you are treated like that, until you say \u0026ldquo;No it is alright I will not hurt myself I will be alright,\u0026rdquo; and then they let you out you know.\u0026rdquo; (Older incarcerated adult, P9)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePunitive practices can also stem from Custody\u0026rsquo;s rigid procedures. Despite their limited relevance to ensure safety and security, these procedures \u003cem\u003edelay access\u003c/em\u003e to critical services such as hearing aids.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;There are some things that I do not like, you know. If you have got older people coming into jail, I do not understand why you have to wait to get your hearing aid done or get your dentures until you have actually gone through a court process. You might be there two years, waiting on your dentures. You know that is not about keeping someone secure. I do not think it is right.\u0026rdquo; (Justice Health staff member, JH6)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3. Personal barriers\u003c/h2\u003e \u003cp\u003e Personal barriers are related to older incarcerated adults\u0026rsquo; capacity, choice and control over their health and perceived attitudes toward accessing prison health care. Personal barriers included \u003cem\u003eperceived stigma\u003c/em\u003e, \u003cem\u003efear of retribution\u003c/em\u003e and \u003cem\u003edeprived autonomy.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003ePerceived stigma\u003c/h2\u003e \u003cp\u003eAccessing health care that involves travel to clinics outside of prison can be a daunting experience for older incarcerated adults. For example, some older incarcerated adults find travel to hospitals stigmatising and traumatic, as they are required to be handcuffed and become fully displayed to the public.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I had to walk through that whole distance in shackles and yeah, so it is an embarrassing and long procedure.\u0026rdquo; (Older incarcerated adult, P4)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;when you get to the hospital because of the way you are chained up in that sense, it is quite humiliating, which I suppose it is designed to be in a way.\u0026rdquo; (Older incarcerated adult, P2)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe stigma associated with being seen handcuffed in public was significant in that some older people with no history of travel to hospitals for medical referrals were ready to refuse such travel, leading to complete \u003cem\u003eavoidance\u003c/em\u003e of the service.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I have not gone yet to any medical centre outside the prison, but I would refuse to go. I do not want anyone to see me handcuffed.\u0026rdquo; (Older incarcerated adult, P13)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOthers preferred to \u003cem\u003edelay travelling\u003c/em\u003e until their health condition deteriorated.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Travelling for me is an issue. So, for me my thoughts are unless I am really, really ill I do not particularly want to raise any flags.\u0026rdquo; (Older incarcerated adult, P7)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eOlder incarcerated adults\u0026rsquo; feelings during medical referrals were given less priority by Corrections, as the primary focus was on ensuring the safety and security of the public.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Our priorities [during medical referral] change a little bit because it\u0026rsquo;s less so much about the inmate and more about the public. \u0026hellip; And the public intervening with us because they generally get curious about us. And that can agitate the inmate sometimes\u0026hellip;\u0026rdquo; (Corrections staff member, CS2)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eFear of retribution\u003c/h2\u003e \u003cp\u003e Owing to being in a disempowered position and owing to a perceived fear of further consequences for their actions, older incarcerated adults were reserved to make demands for accessing and using prison health care. Some were \u003cem\u003eavoiding\u003c/em\u003e the situation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If you raise concerns with the case manager and she can then ring the clinic and take it from there and for us that is just another way of putting another iron in the fire.\u0026rdquo; (Older incarcerated adult, P1)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Oh, but if you go too much [asking], they think you are going to commit suicide or something, and they will lock you up in a nuthouse you know for a while in a cell, in a dress. Therefore, many people just do not say anything just to avoid that situation.\u0026rdquo; (older incarcerated adult, P4)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe reluctance to demand services was also due to fear of negative reactions from health care professionals, potentially indicating underlying issues in patient\u0026ndash;provider relationships.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I do not want to be pushy, as I have seen it with others; the nurses become cranky on you.\u0026rdquo; (Older incarcerated adult, P10)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eOlder incarcerated adults can also become reluctant to share information with Corrections staff in fear or potential retaliation. This can lead older incarcerated adults to \u003cem\u003eavoid seeking help.\u003c/em\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I know that again there are certain things they [older incarcerated adults] will not say around us because they are afraid that they will get into trouble.\u0026rdquo; (Corrections staff member, CS3)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eDeprived autonomy\u003c/h2\u003e \u003cp\u003eOlder incarcerated adults had limited \u003cem\u003econtrol and choice\u003c/em\u003e over their health, which compromises the quality of care they receive. While they recognised their right to participate and contribute to decisions about their health care (e.g., in relation to the use of medication), such a right was not often honoured.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;If I have got a review for my medication and if a change is going to take place to me a consultation should happen. So, I mean if I have got a concern, I can raise it with doctor or nurse practitioner rather than just saying \u0026lsquo;well there you go\u0026rsquo;. I mean, it is like buying a car and saying well you are buying this car but I cannot let you see it. You know it makes no sense to me.\u0026rdquo; (Older incarcerated adult, P1)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhen older incarcerated adults were not involved in decisions about their health care, they become frustrated and left with no choice but to live with it. Others developed \u003cem\u003ecomplications\u003c/em\u003e.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;They changed my medication without telling me. This is not good. I am sick of it [asking]. You just go with the flow.\u0026rdquo; (Older incarcerated adult, P10)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;there\u0026rsquo;s an inmate that\u0026rsquo;s in my pod, and he nearly died because they messed up his medication, but it happens everywhere\u0026hellip;\u0026rdquo; (Older incarcerated adult, P2)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eDenial of involvement in care plans also occurred during medical referrals where older incarcerated adults were not informed when to travel.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;There is no sort of guidance on when you ought to leave and when you are going. It is just, \u0026lsquo;Do not worry about it, mate you go when you go.\u0026rsquo; So, you get treated quite woefully.\u0026rdquo; (Older incarcerated adult, P7)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;They do not tell you; they do not tell you, they just say you are required at reception\u0026hellip;then they tell you, you\u0026rsquo;re going to the clinic, going to the hospital or whatever.\u0026rdquo; (Older incarcerated adult, P4)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe study identified comprehensive and interrelated barriers to access and quality of prison health services for older incarcerated adults. These barriers are indicative of the complexity involved in prison health service delivery.\u003c/p\u003e \u003cp\u003eThe findings showed that competing priorities between custody and health can compromise the healthcare received by older incarcerated adults. Studies investigating issues of access to health services for older incarcerated adults are scarce. However, Galli, Bretschneider (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) reported delays in receiving care. Despite not being specific to older incarcerated adults, an Australian study revealed that level of security was a barrier to accessing prison health services (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Competing priorities have previously been discussed in a broader sense of a \u0026lsquo;philosophical problem\u0026rsquo; between custody and health, particularly in terms of correctional nurses\u0026rsquo; dual and challenging role of providing autonomous care and maintaining interest in corrections, where nurses\u0026rsquo; lack of autonomy in providing care was seen as a barrier to quality of care (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Our findings confirm that issues of access to health services for older incarcerated adults are a reflection of fundamental differences in organisational culture, purpose and focus between custody and health.\u003c/p\u003e \u003cp\u003eCorrections and Justice Health staff indicated that a shortage of resources and personnel was a key barrier to delivering health services to older incarcerated adults. This was also evident from older incarcerated adults\u0026rsquo; complaints of long waiting times to see a doctor. Low staffing levels and an imbalance between needs and capacity can result in delayed access to health services and cause medical encounters to be rushed (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Older incarcerated adults\u0026rsquo; increasing demand for specialised care is also straining resources not only because specialised healthcare personnel are in short supply but also because medical referrals for specialised care at external (to prison) clinics are costly (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). A recent submission by JHFMHN to the NSW Special Commission of Inquiry into Healthcare Funding revealed that the speciality network had constrained resources to meet the growing healthcare needs in prisons, as government budget allocations to the network were based on historical funding levels (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). This creates competing priorities and is a clear indication that the increasing number of older incarcerated adults and their complex health needs has become a significant challenge for correctional facilities.\u003c/p\u003e \u003cp\u003eThe findings also revealed that older incarcerated adults\u0026rsquo; access to health care was delayed and that their immediate health needs were deferred to conform to prison procedures. Prison bureaucracy is seen as a challenge to the delivery of health care to incarcerated adults (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). In addition to being a barrier to accessing health services, the current findings revealed that prison bureaucracy is a reason for frustration among older incarcerated adults because of prison staffs\u0026rsquo; focus on the process of prison routine paying little attention to the needs of the cohort. This shows the persistence of what was referred to two decades ago as institutional thoughtlessness, where older incarcerated adults\u0026rsquo; unique needs are often overlooked as correctional facilities continue to hinge on their command and control rules (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePower and staff relationships reflect the culture of the working environment in prison. Justice health staff reported corrections\u0026rsquo; superiority in the decision-making process regarding patient care, impacting timely access to care. Security can override health concerns (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), and its dominance creates feelings of being devalued among nurses, further affecting their relationship with prison staff (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Our findings showed limitations in terms of shared knowledge and mutual understanding between corrections and health, which in turn impacted the delivery of appropriate care to older incarcerated adults and triggered conflicts between health and custodial staff. Custody and health staff roles are considered distinct, offering inadequate avenues for collaboration in the delivery of health care to older incarcerated adults (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnother cultural barrier was punitive practices. This practice was mentioned as a reason for delayed access and for preventing older incarcerated adults from seeking care. Our findings correspond with the results of a study from the UK where dismissive attitudes and a lack of empathy toward older incarcerated adults were reported (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). The reasons behind punitive practices vary. Prison staff have conflicts of interest and lack proper guidance on how to manage incarcerated adults, as they struggle with meeting their welfare needs and adhering to security requirements (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Punitive attitudes toward incarcerated adults have also been shown to emanate from workplace culture of maintaining order and security (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Other reasons are staff members\u0026rsquo; stress due to the working environment, pressure from peers to act tough and undesirable attitudes toward the crimes committed by incarcerated adults (\u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePersonal barriers, including perceived stigma, fear of retribution and deprived autonomy, were reported. Travelling to hospitals and being viewed in public whilst handcuffed was an embarrassing experience for older incarcerated adults, and as a result, they often preferred to avoid or delay their travel. While this cumbersome experience was recognised by correctional officers, it was deprioritised given the focus on maintaining the safety and security of the public, revealing the interplay between personal and structural barriers and the significant influence of the latter on the individual experience of accessing health services in prison. This is further demonstrated by older incarcerated adults\u0026rsquo; reluctance to demand health services in fear of potential retaliation. In a qualitative study in Switzerland, the only study in which older incarcerated adults\u0026rsquo; access to health services was assessed, Heidari, Wangmo (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) reported similar findings in which older incarcerated adults had fears of visiting prison health services falsely, accusing them of being a \u0026lsquo;faker\u0026rsquo; or punishment for refusing to take prescribed medication.\u003c/p\u003e \u003cp\u003eOlder incarcerated adults had limited autonomy over their healthcare decisions, which created frustrations with the health services they received in prison. Denial of incarcerated adults\u0026rsquo; right to participate and contribute to decisions about their health can occur throughout the prison journey and adversely affect their health status (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). It is an indication of challenges in providing patient-centred care and meeting patient needs (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). The loss of autonomy is also a reflection of the power imbalance between the prison regime and incarcerated adults (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Our findings indicated that structural barriers (e.g., the focus on safety and security) can compromise patients\u0026rsquo; autonomy. Available evidence also shows that some incarcerated adults are considered misleading or illegitimate patients; thus, their access to or involvement in health services can be dishonoured (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eImplications for policy and practice\u003c/h2\u003e \u003cp\u003eThe findings have important implications for policy and practice in correctional health and custodial systems. Below, we draw on some propositions that respond to the barriers identified in this study.\u003c/p\u003e \u003cp\u003e \u003cem\u003eWorking through custody and health policies to address the barriers\u003c/em\u003e, the structural and cultural barriers identified in the study are indications of challenges in custody and health policies. Custody policies can restrict the delivery of certain health services for older incarcerated adults (e.g., access to hearing aids) (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), and this demographic\u0026rsquo;s health care needs are invisible in healthcare policies and provisions, resulting in a lack of adequate support to respond to their needs (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Thus, improvements in access to and quality of health services for older incarcerated adults start with addressing health care needs in these policies. This includes promoting age-friendly approaches, building the necessary infrastructure and capacity and advocating for policy changes that are inclusive of the needs of the cohort. The barriers to relational coordination between custodial and health staff necessitate more work on improving shared goals and mutual respect between the two organisations with different priorities. Organisational structures such as shared accountability, shared conflict resolution, relational job design, relational leadership roles, shared meetings, and shared protocols can improve work relationships and communication (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEfficient approaches to address the shortage of resources and the increasing cost of caring for older people in prison\u003c/strong\u003e \u003cp\u003elack of resources and capacity triggered by the increasing number of older incarcerated adults and their complex health care needs, call for the design and implementation of efficient models of healthcare to meet growing needs. One area of intervention is training and education of custodial staff (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) on the health care needs of older incarcerated adults and the ways in which staff are able to assist in identifying and triaging these needs as part of their daily role in maintaining safety and security. Such interventions not only help address older incarcerated adults\u0026rsquo; needs in an efficient fashion but also lessen the barriers related to custody staff\u0026rsquo;s gatekeeper role in prison health delivery. As demonstrated in different programs, involving older incarcerated adults in some care activities as peer carers can also reduce the burden on the correctional health system (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eChallenging punitive practices through shaping public opinion\u003c/strong\u003e \u003cp\u003eInstances of punitive attitudes toward older incarcerated adults are influenced by workplace culture, which in turn is shaped by public opinion. Both in Australia and internationally, public opinion is generally inclined toward punitive approaches to sentencing (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). Public misperceptions expressed as overestimations of the utility of punishment, underestimations of alternative approaches and a limited understanding of how the criminal justice system operates are common (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). As a result, there is a view that health care in prison ought to be inferior to that enjoyed by the general community (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). This is something that prison medical services need to be cognizant of while addressing the significant health needs of this group. Public education on the criminal justice system is thus key to creating a balanced public attitude towards the system (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Policymakers, health planners and the media also need to be aware of public attitudes and provide evidence-based information on older incarcerated adults\u0026rsquo; rights to equivalent care and demonstrate its benefits to the general public (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEmpowering older incarcerated adults to improve their access to health services\u003c/strong\u003e \u003cp\u003eDespite the challenges of promoting patient autonomy in prison, involving older incarcerated adults in planning and delivering person-centred care can significantly improve the quality of care (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). An important first step to promote their involvement is improving custody staff\u0026rsquo;s understanding of the challenges that older incarcerated adults experience when their autonomy is deprived off (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) so that staff exercise agility and sympathy when older incarcerated adults access prison health services. Promoting self-management practices can also encourage participation in care planning and help offset the increasing cost needed to care for the cohort (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Corrections\u0026rsquo; recognition of the cohort\u0026rsquo;s right to be treated with respect and dignity and compliance with the implementation of this right was enshrined in the United Nations\u0026rsquo; basic principles for the treatment of prisoners (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e), which Australia and other countries are signatories can also have meaningful outcomes in realising older incarcerated adults\u0026rsquo; control and choice over their health care.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eLIMITATIONS\u003c/h2\u003e \u003cp\u003eThis study has some limitations. The interviews with older incarcerated adults were conducted in two out of the three prisons. The interview schedule with older incarcerated adults in one Correctional Centre overlapped with a new wave of COVID-19, and restrictions did not permit the conduct of the interview at this centre. This may have affected the amount and diversity of information that could have been obtained from older adults imprisoned in this centre. However, older incarcerated adults\u0026rsquo; experience from other centres during their referral to this centre and interviews with Corrective Services staff at the same centre addressed some of the missing information and contributed to the completeness of the data.\u003c/p\u003e \u003cp\u003eThe study was limited to three correctional centres in New South Wales. Given the variability in prison health care delivery across different jurisdictions, both within Australia and internationally, the findings may not be directly generalizable to broader settings globally. However, the unique insights from this study are still relevant to similar environments. This is due to common challenges faced by correctional facilities worldwide, such as overcrowding, limited health service resources, and the commitment to providing equivalent care on the basis of internationally agreed-upon standards and guidelines.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThe multistakeholder perspectives from this study identified diverse and interrelated structural, cultural and personal barriers to access and quality of prison health services for older incarcerated adults. The barriers represented a complex interplay between the prison environment, custody and health relationships and the dual patient‒prisoner status of older incarcerated adults, where custody\u0026rsquo;s considerable influence on prison health service delivery was revealed.\u003c/p\u003e \u003cp\u003eAddressing these barriers requires working through custody and health policies, enhancing relational coordination between actors, empowering older incarcerated adults to have choice and control over their health and implementing efficient approaches to offset the rising cost of delivering health services to the increasing number of older incarcerated adults.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn adherence to the Declaration of Helsinki, the study received ethics approval from the University of New South Wales (HC 190951), Corrective Services New South Wales and Justice Health and Forensic Mental Health Network (JHFMHN) (2020 ETH/002658), and site-specific permission to conduct interviews from individual correctional centres. Written informed consent to participate in interviews was obtained from all study participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData used for the purpose this study are not publicly available. Our data are transcripts from individual interviews with older incarcerated adults and Corrective Services and Justice Health staff and their privacy will be compromised if data are shared publicly. However, parts of the transcripts can be shared upon reasonable request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo outside funding was used to support this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAKH: Conception and initialization, methodology, data analysis, result interpretation, manuscript preparation and revision.\u003c/p\u003e\n\u003cp\u003eAW: Conception and initialization, result interpretation, manuscript revision.\u003c/p\u003e\n\u003cp\u003eNG: Methodology (data collection), result interpretation, manuscript revision.\u003c/p\u003e\n\u003cp\u003eJH: Result interpretation, manuscript revision.\u003c/p\u003e\n\u003cp\u003eTB: Conception and initialization, result interpretation, manuscript revision.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Corrective Services New South Wales, Justice Health and Forensic Mental Health Network, Correctional Centres and all study participants for their support and cooperation in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information (optional)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBedard R, Metzger L, Williams B. 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Prison health: international standards and national practices in Europe. HEUNI Helsinki; 1992.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChan I. Health optimization of older people in prison. Healthc Manage Forum. 2024;38(1):35\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUnited Nations. Basic principles for the treatment of prisoners. United Nations (UN); 1990.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Prison, incarceration, older adult, access, quality, health care, barriers","lastPublishedDoi":"10.21203/rs.3.rs-6407981/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6407981/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe increasing number of older incarcerated adults and their complex health needs require concerted efforts to overcome barriers to providing proper access to high-quality healthcare. Studies investigating the complex nature of such barriers have been limited despite their identification being an important first step in addressing this challenge. The purpose of this study was to provide an in-depth exploration of the barriers to healthcare for older adults in prison.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted interviews with 23 prison staff and 14 older incarcerated adults in 3 prisons in NSW, Australia. Thematic analysis was used to analyse the data.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study identified three main themes\u0026mdash;structural, cultural, and personal\u0026mdash;along with nine sub-themes of barriers: \u003cem\u003ecompeting priorities of custody and health\u003c/em\u003e, \u003cem\u003eresources and capacity\u003c/em\u003e, \u003cem\u003eprison bureaucracy\u003c/em\u003e, \u003cem\u003erelational coordination\u003c/em\u003e, \u003cem\u003epower relationships\u003c/em\u003e, \u003cem\u003epunitive practices\u003c/em\u003e, \u003cem\u003eperceived stigma\u003c/em\u003e, \u003cem\u003efear of retribution\u003c/em\u003e, and \u003cem\u003edeprived autonomy\u003c/em\u003e. These barriers impact service timeliness, choice and control, care seeking, risk of harm/discomfort, and the reach and scope of healthcare for older incarcerated adults.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe findings revealed a diverse and interrelated set of barriers indicating the considerable influence of custody on the delivery of prison healthcare to older incarcerated adults. Addressing these barriers requires working through custody and health policies, enhancing relational coordination, empowering older incarcerated adults and implementing efficient approaches to offset the rising cost of delivering health services to the cohort.\u003c/p\u003e","manuscriptTitle":"Structural, cultural and personal barriers to healthcare for older adults in prison: insights from a qualitative study in New South Wales, Australia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-03 12:42:04","doi":"10.21203/rs.3.rs-6407981/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-04T05:45:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-15T05:32:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-05T14:37:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"306549999074948423210060893120678698444","date":"2025-08-04T14:17:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"264916888475686749966469687026655896677","date":"2025-07-28T10:44:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-02T08:21:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"220236001311612714017564088381944587098","date":"2025-07-02T07:40:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-30T01:44:30+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-05T11:46:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-23T08:29:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-21T12:25:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-04-21T12:24:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6541aa01-c5bb-4b5b-8292-c8dd7bcb7ce0","owner":[],"postedDate":"July 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-23T06:08:14+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-03 12:42:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6407981","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6407981","identity":"rs-6407981","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}