V. Diane Woods, Dr.P.H ., M.S.N., R.N. Assistant Research Psychologist

1. 136th APHA Annual MeetingSan Diego, CASession 5196.0Invisible Bars: Barriers to Women’s Health During and After Incarceration V. Diane Woods, Dr.P.H., M.S.N., R.N. Assistant Research Psychologist University of California Riverside, California President & CEO, African American Health Institute of San Bernardino Kim Carter Founder & Executive Director, Time for Change Foundation October 29, 2008 @ 12:30pm

2. Project Funded in Part by: Time for Change Foundation California Endowment County of San Bernardino SBC Department of Public Health Presentation Sponsored by:African American Health Institute of San Bernardino County

3. Purpose of Presentation • To identify five barriers women face in accessing health resources during and after incarceration • To understand the complexity of women accessing healthcare services while detained in prison and upon release • To identify three policy change recommendations for State Correctional Systems that have the potential to improve health outcomes of women

4. WOMEN IN PRISON From 1973 to 2007, women in prisons increased by 645% --- almost twice rate of men Source: The Sentencing Project, Institute on Women and Criminal Justice (Mauer 2007)

5. The November Coalition

6. Who are these women in prison? Women … • 85% convicted of drug or drug-related offenses • 90% fragmented in their family histories • 70% from families with other members in the Criminal Justice (CJ) System • 80% survivors of physical and/or sexual abuse • overrepresented by women of color • 70% poor, undereducated, unskilled, single mothers

7. Whose Mother, Daughter or Sister?

8. CASE STUDY: City of San Bernardinolargest populated area= approx 200,000 • Source: San Bernardino County Quick Facts, U.S. Census Bureau, 2007 available at http://quickfacts.census.gov

9. U.S. Federal Court Seizes State Prison Healthcare • In 2005, the California prison healthcare system seized by the federal government • One inmate/per week dying from medical neglect • Judge cites preventable deaths of inmates - depravity of system

10. U.S. Federal CourtSeizes State Prison Healthcare 2008 Status Report: • Fired incompetent unlicensed doctors • Demand $8 billion dollars from State Treasury • Increased salaries for qualified medical staff • Little done to improve delivery systems

11. Research Questions • What are the barriers women face while incarcerated? • What are the barriers women face after incarceration? • What are healthcare needs of women during incarceration? • What are the risks to the public’s health?

12. Methods • Mixed-Methods Approach (Qualitative & Quantitative) • Current & Formerly Incarcerated Women • Location: San Bernardino County, CA • Study conducted in 2005

13. Quantitative Data • Literature Review of Best Practices • GIS Mapping to Identify Resources (housing, healthcare, dental, etc.) • Survey Development for Population Sampling • Target: formerly incarcerated women (convenience sample) • Key informants, n=5 • Survey pilot testing, n=8

14. Survey Design • Paper survey: • 6 pages • 43 questions • dichotomous (i.e., yes/no) and multiple choice responses • Face-to-Face Self-administration

15. Quantitative Data Sampling • Multi-faceted sampling sites, n=17 • California Institution for Women (CIW) • New House • Cedar House • Gibson House • Vista Recovery Center • California Rehabilitation Center (CRC) • State of California Parole Department • 12-step Anonymous Meetings, n=10

16. Data Collection • Total Survey Sample, N=152 • Survey Sampling Selection Criteria: 1. Could be on parole or probation 2. Experienced recidivism 3. 18 years old and older 4. Resident of San Bernardino County • Interviews: March - April 2005

17. DataAnalysis • SPSS Version 11.5 • Database: 95 variables and 152 respondents • Data mining • Descriptive analysis conducted

18. Post Incarceration RESULTS • Lack of Employment • Lack of Health Insurance • Mental Health Disorders • Prevalence of Drug & Sexual Abuse

19. Lack of Employment

20. Lack of Health Insurance

21. Mental Health Disorders % of Respondents

22. Substance Abuse Do you have a history of drug abuse?

23. Sexual Abuse Have you had any counseling for that abuse? Report of Sexual & Physical Abuse

24. SUMMARY of RESULTS • Incarcerated women don’t have access to competent healthcare services in prison • Previously incarcerated women do not have access to preventative healthcare • Public Health – defined as ensuring conditions exist in which people can live healthy is locked out of the prison system • Having a Felony conviction….equates into disenfranchisement of many health and social services.

25. Substance Abuse Mental Health Physical Health Trauma Similar findings by Covington, Bloom & Owens, 2006 (NIH – Gender- Responsive Strategies ) Four Critical Interrelated Issues

26. Discussion • Greater Public Health Risks • More women entering community unhealthy • More women suffering from mental health issues left untreated • Reduced chances of successful reintegration into society.

27. In Prison Did not Receive treatment for substance abuse Re-Traumatized by guards and environment Not given appropriate counseling and mental health services Suffering from multiple health conditions After Prison Gap in services available for substance abuse treatment Lack of appropriate programs available Unstable living arrangements Ineligible for most government funded support services RESULTS

28. What are the Barriers to Accessing Healthcare Services In Prison • The institution charges a $5.00 co-pay • There are not enough slots for all the women who need substance abuse treatment • Inmates are dying from preventable illnesses on average one per week which heightens fear amongst inmates • Healthcare system ineffectively dealing with • Those diagnosed with mental illness are mandated to take medications but do have mental health treatment to include counseling, information on side-effects of medications and managing their stressors

29. What are the Barriers to Accessing Healthcare Services After Prison • Lack of Health Insurance – many responded that the County –(MIA) Medical Indigent Adult insurance should be called (MIA) Missing In Action because the 3 to 4 month waiting periods for services and between referrals • No access to preventative care • Emergency Room dependency • Non-existent dental services for the indigent • Drug felony status excludes many from accessing food status and other welfare services • Loss sense of entitlement amongst this group

30. Dept. of Corrections Remove the $5.00 co-pay for the indigent Inmates should be classified into appropriate rehabilitative services All inmates should receive an annual pap smear and those above 40 should include a mammogram State of California Create a continuum of health care services coordinated for former prisoners Modify the 2006 TANF welfare reform which prohibits drug offenders from receiving food stamps, welfare and public housing Policy Recommendation

31. Public Health Risk Factors Women re-entering the community without having received healthcare during incarceration are more likely to: • Carry STD’s that have been undetected • Be released without their psychotropic medications in hand • Suffer from Post Incarceration Syndrome • Return to abusing drugs and alcohol • Re-Enter Society as Homeless

32. Recognition Received as a result of being inspired by Public Health • 2004 - NAACP – Community Pioneer Award for Social Justice • 2005 - KCET/Washington Mutual – Unsung Hero Award • 2005 – County of San Bernardino – Herstory Award • 2005 – Soroptimist International – “Woman Making a Difference Award” • 2006 – League of Women Voters – Citizens Achievement Award • 2006 – Bank of America – • Local Hero Award • 2007 – Black Culture Foundation – Black Rose Award • 2008- Loma Linda University Children’s Hospital Foundation’s – Hometown Hero Award

33. Free Copy of the report titled: “Invisible Bars- Barriers to Women’s Health and Well-Being During and After Incarceration” • Available on line at www.Timeforchange.us Carter, Ojukwu & Miller, 2006