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Purpose: This study identifies the healthcare education needs of incarcerated women in a state corrections facility.
This was a naturalistic qualitative study. Focus groups included two groups of adult women incarcerated in a state corrections facility. One group consisted of women housed in maximum security, and one group consisted of women housed in medium security.
Data were analyzed using a constant comparison approach. Findings: Three guiding questions provided the foundation for the identified themes.
Themes included six healthcare education topics important to incar- cerated women and three related to health education strategies best suited for incarcerated women.
Trust, respect and empowerment are key concepts in educating incarcerated women about their personal health and health of their families.
Clinical Relevance: With over 200,000 women incarcerated in the United States today, creating policies and practices that focus on the healthcare edu- cation needs of women that are woman focused may enhance knowledge and skills and may ultimately lead to reduced recidivism.
Over 200,000 women are currently imprisoned in the United States, a number that has grown more than 800% over the past three decades (Institute on Women & Crim- inal Justice, 2009).
Because the majority of prisoners are male, prison programs often focus on issues faced by male prisoners and overlook those faced by female prisoners (Bissonnette, n.d; Stolnik, 2011). As the population of in- carcerated females continues to increase at a rate nearly twice that of males (Stolnik, 2011), health-related pro- grams, educational opportunities, and initiatives focus- ing on the specific needs of female inmates are becoming more and more essential.

Incarcerated women often have a history of sub- stance abuse; physical, sexual, and emotional trauma (Bissonnette, n.d.); and limited access to healthcare ser- vices (Palmer, 2007). The World Health Organization has identified this trend globally, as research conducted in the United Kingdom (Palmer, 2007) revealed simi- lar conclusions. Because of intense, pre-incarceration liv- ing situations, women often neglect their health while at
liberty. When they enter prison, they make great de- mands on corrections health services (Yeager, 2012). The limited research conducted on incarcerated females throughout the United States consistently identifies the intense physical and mental health needs of both the newly and long-term incarcerated woman, including care of chronic health conditions (Binswanger, Mueller, Clark, & Cropsey, 2011).

A need for a radical increase in specific health-related educational opportunities for the incarcerated female has emerged. Women entering prison are more likely to re- quire healthcare education to help them build a self-care skill set to better prepare them for release. This skill set may ultimately lead to reduced recidivism (Robertson- James & Nunez, 2012; Zaitzow, 2010). Hatton and Fisher (2011) stress the importance of using participatory meth- ods to examine and educate this high-risk population. The purpose of this qualitative study, therefore, was to understand the health education needs of female inmates in a state correctional facility.

Journal of Nursing Scholarship, 2014; 46:4, 229 234. 229 C 2014 Sigma Theta Tau International
Health Education Needs of Incarcerated Women Dinkel & Schmidt
A qualitative, naturalist design was used for this investigation. Two focus groups were conducted at a Mid- western, state correctional facility for women. The facil- ity houses three groups of women: minimum-, medium-, and maximum-security inmates. Because focus groups were conducted within the correctional facility, inmates provided unique insight into their lives within prison walls. Their responses to guiding questions were al- lowed to unfold and guided the development of emergent themes.
Recruitment and Informed Consent Procedure
Approval was obtained from the university institu- tional review board (IRB) and the state Department of Corrections (DOC) IRB. One inmate was chosen by the DOC to serve on the university IRB as required. The chair of the university IRB met with the inmate at the correc- tional facility, provided IRB training, and reviewed each section of the proposal. The inmate granted her approval of the proposal.

Two focus groups were conducted to assess the health- care educational needs of women incarcerated at this fa- cility. The Director of Nursing at the prison posted par- ticipation information in public areas. Participants were selected from inmates who indicated an interest in the project. Final selections were made by the prison Direc- tor of Nursing to represent diversity in race or ethnicity, age, and educational accomplishments. All participating inmates provided written, informed consent and were in- structed to offer no personal identification. All inmates were numerically identified based on which group they were in and how they entered the room.

Data Collection
Confidential, aggregate demographic data were ob- tained from the prison Director of Nursing. Focus groups were conducted in correctional facility classrooms with guards posted outside the door. Women were counted when entering and leaving the classrooms. Each group was conducted in English and lasted approximately 1 hr. While healthcare education is offered at this facility, to better understand the experiences of inmates, three guid- ing questions were asked of each group. They included: What are the top ten health education needs of inmates in this facility? What is the best method for educat- ing inmates on these topics?; and What would a health fair look like for you? Participants freely shared informa- tion and stimulated other participants to elaborate, con- tradict, and add to the discussion. Knowledge generation
was viewed as participatory and co-created by all mem- bers of each focus group. Groups were allowed to answer each question until no inmate had additional new infor- mation to offer. While one interviewer presented guid- ing questions to the inmates, the second interviewer kept written field notes. Participants were not known to the researchers and no prison staff were present in the class- room during the focus group discussions.

Data Analysis

Two research team members are doctorally prepared, with one having expertise in qualitative analysis. The third research team member has expertise in correctional health care. All three were involved in data analysis.

Prior to thematic analysis, the research team members reviewed and discussed inmate comments. Data were an- alyzed using a constant comparison approach to identify emerging patterns using a concept map approach. Field notes were reviewed and initial themes were identified for each guiding question. Repeating ideas were com- pared and contrasted across the interview groups to en- sure that each category adequately conveyed the perspec- tive of the participants. The process continued until the research team felt satisfied that all pertinent data were discussed and categorized. The summarized data were written in narrative description and reviewed for clarity and accuracy. While data were reviewed to reflect an- swers to guiding questions, researchers identified an ad- ditional theme that emerged from focus group observa- tions. All are discussed below.
The sample was a purposive sample. Focus Group One consisted of eight women housed in the maximum- security building and ranged in age from 25 to 51 years. Focus Group Two consisted of eight women housed in medium security. Their ages ranged from 22 to 48 years. Six Black women, six White women, and four Latina women participated in the groups. Projected release dates ranged from less than 1 year to 19 years.
Health Topics Important to Incarcerated Women
When asked about the top health education needs of incarcerated women in this facility, inmates identi- fied a variety of topics. While all overlapped, six specific themes emerged. They included the importance of nutri- tion and exercise to prevent and treat obesity, womens health concerns, communicable disease transmission and
230 Journal of Nursing Scholarship, 2014; 46:4, 229 234. C 2014 Sigma Theta Tau International
Dinkel & Schmidt Health Education Needs of Incarcerated Women
prevention, dental hygiene, pathophysiology and com- plications of chronic disease, and mental health condi- tions. Group One specifically identified hygiene as an additional important topic, while Group Two identified information on terminal disease as a health education need.
It is well understood that healthful nutrition and reg- ular exercise promote health and prevent obesity. In- carcerated women share this understanding, but with two particular considerations: limited choices in nutrition and exercise needs of those living in small spaces. While all inmates receive nutritionally balanced meals, several women in both groups expressed concern about the dif- fering nutritional needs of women as compared to men, and the changing nutritional needs of women across the lifespan. Inmate G17 stated that meals for all prisons in the state are the same for both men and women and is concerned that her needs as a woman might be differ- ent from her male counterparts. She also stated, Some- one who is in their 20 30s may need something different than someone in their 50 60s or older. Women in both groups requested an assessment of their individual nu- tritional needs based on age, height, weight and health conditions.
Conversation about nutrition naturally led to discus- sion about exercise. Women in both groups talked about how hard it is to exercise daily while living in an 8-foot by 14-foot space often shared with other inmates. Many participate in the prison sponsored running club. How- ever, women from both groups expressed concern about how foot health and a lack of access to high quality ex- ercise shoes impair their ability to exercise. Inmate G14 requested information on foot health, specifically injury prevention and treatment, as part of an overall exercise program. If your foot is messed up then the rest of you is messed up (Inmate G27).

Womens health was the second theme and encom- passed a broad range of topics, including age-specific screenings, menstruation and menopause, physiologic changes related to aging, and signs, symptoms, and treatment of chronic diseases more commonly seen in women. Overall, women wanted to know what they could expect as they aged and how they could stay healthy. Inmate G25 stated succinctly, We just want to know the normal signs of aging and what to ex- pect as we get older. I want to see what Im lead- ing up to as I get older (Inmate G18). Younger women in both groups wanted health educators to teach prison staff and other inmates about menstrual health and hy- giene. Women bleed and we have different cleanliness needs [than men] (Inmate G17). Lastly, women from both groups expressed a need for education on healthy sexual relationships. We need information on how to
have healthy relationships. Some of us may make differ- ent choices on the outside (Inmate G23).
Communicable disease was the third theme identified by inmates. Two primary topics emerged: skin infections and sexually transmitted infections (STIs). Because of close quarters and shared bathrooms, women in both groups were concerned about disease transmission and infection control. Inmate G23 is knowledgeable about measures to decrease the spread of disease and stated, Youre never gonna live with me because I am uned- ucated. Im gonna bleach you every 5 seconds! All pro- fessed to their own cleanliness but wanted other inmates to be educated on measures to prevent the transmission of disease. They dont get that they can get stuff
. . . drinking after each other
. . . sharing make-up
. . . (In- mate G15).

ns, Na- tional Institute of Corrections, and Substance Abuse and Mental Health Services Administration have made great efforts to operationalize gender-informed practices with female inmates (Bissonnette, n.d.). Continuing to provide quality, safe health care and proactively providing health- care education that is meaningful to women may im- prove the health of incarcerated woman and ultimately reduce the recidivism rate of women released from prison (Bissonnette, n.d.).
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