Unlocking Silent Suffering: Addressing the Otorhinolaryngologic Needs of Incarcerated Persons Through Carceral Health Education

Abstract

Mass incarceration in the United States presents major healthcare challenges, and otorhinolaryngology-related needs within carceral settings are underrecognized. Public health crises, as exemplified by the COVID-19 pandemic which led to over 3,000 deaths among incarcerated individuals, can intensify disparities. Both acute otorhinolaryngology conditions, such as craniomaxillofacial trauma, impending airway compromise, and life-threatening infection, as well as more chronic conditions such as cancer, sinusitis, or ear infections can lead to impaired quality of life, disability, or preventable mortality. Incarcerated individuals experience substantial healthcare disparities, which are driven by intrinsic individual and carceral facility factors such as resource scarcity, structural barriers, limited self-advocacy, and social determinants of health, as well as extrinsic factors related to societal misconceptions, inadequate education of healthcare providers on carceral healthcare, and underdeveloped care systems. To address these issues, a comprehensive approach is needed, incorporating experiential learning, bias reduction, and trust building. Early clinical exposure, enhanced public health education, and community outreach efforts are conducive to cultivating structural competence and relevant skills. Carceral health initiatives can thus raise awareness and enhance the healthcare of incarcerated individuals. Healthcare professionals can expand their roles to advocate for equitable care, prioritize rehabilitation over punishment, and support individuals upon reentry into society. Healthcare professionals in otorhinolaryngology, play a pivotal role in addressing the needs of incarcerated individuals, with nurses, physicians, and allied health stakeholders working together. Education, advocacy, and compassionate care provide the basis for a more equitable and humane carceral healthcare system that upholds the dignity and well-being of all individuals.

INTRODUCTION

The United States (U.S.) has the highest incarceration rate in the world with approximately 660 individuals incarcerated per 100,000 in the overall population (Kluckow & Zeng, 2022). This mass incarceration has profound implications for healthcare, and almost all practicing healthcare professionals will encounter and treat currently or formerly incarcerated patients. There is growing awareness of the need to better serve this population, but limited attention has focused on the otorhinolaryngology-related needs within carceral systems. Given the acuity and complexity of many otolaryngology disorders, this gap is a pressing concern.

The healthcare provided to incarcerated individuals has long been recognized to fall below the standard of care available to the general population. Many factors, intrinsic and extrinsic to the carceral system, contribute to wide disparities in access, safety, and quality of healthcare for incarcerated persons. Intrinsic factors include resource scarcity, lack of protections, structural barriers to accessing care, limited capacity of self-advocacy, power differentials, and social determinants of health. Extrinsic factors relating to the healthcare system include pervasive misconceptions, limited educational exposure to special needs of individuals in carceral settings, and lack of protocols to ensure access to high quality care.

Although the challenges and suffering faced by incarcerated persons have been a longstanding concern, public health crises, such as the coronavirus disease 2019 (COVID-19) pandemic, palpably demonstrate how structural inequities can render not only individuals but whole populations acutely susceptible to harm. Over 3,000 incarcerated and detained people in the U.S. died in the first two years of the pandemic, underscoring the urgent obligation to address the healthcare needs of this population (Widra, 2022). Individuals with complex needs relating to airway, trauma, cancer, or infection are easily overlooked. While curricula that educate learners and clinicians about disparities are vital in rousing awareness, early-career exposure to carceral settings and first-hand experience are likely the most potent catalysts for driving positive change.

The purpose of this study was to survey health professional learners at one institution regarding their self-reported perceptions of carceral healthcare both prior to and after their rotations in the clinical setting, demonstrating the education deficiencies in this area.

METHODS

Survey Design and Administration

To assess the preparedness and perceptions of health professional learners regarding their ability to care for incarcerated individuals, a survey was developed. The survey aimed to capture data on their self-reported levels of confidence and preparedness in providing healthcare to the incarcerated population. The survey also collected information on the respondents’ current level of clinical exposure, differentiating between pre-clinical (first-year) and clinical (second, third, and fourth years) students.

Survey Participants

The survey was administered to a total of 170 health professional learners at a single academic institution. The participants were selected from different stages of their training, allowing for an analysis of their preparedness based on clinical exposure.

Data Collection

The survey was distributed electronically to the participants, who were provided with clear instructions on how to complete it. Participants were assured of the confidentiality of their responses and were informed that their participation was voluntary. The survey collected both quantitative and qualitative data, allowing for a comprehensive assessment of participants’ preparedness to care for incarcerated individuals.

Data Analysis

The data collected from the survey were analyzed using appropriate statistical methods. Descriptive statistics were used to summarize the self-reported perceptions of the participants, including their levels of confidence in providing healthcare to the incarcerated population. The responses were stratified based on the participants’ year of training (pre-clinical vs. clinical), enabling a comparison of preparedness levels between these groups.

Ethical Considerations

Ethical approval for the survey was exempt from the Institutional Review Board (IRB) of the academic institution where the study was conducted (HUM00174766). Informed consent was obtained from all participants, and their anonymity was ensured throughout the study to protect their privacy.

RESULTS

Carceral Health and Education

Carceral health is a blind spot in most health professions education. Few nursing, medical, pharmacy, public health, dental or social work students have significant experience caring for incarcerated individuals, and virtually none have provided care within carceral facilities. Figure 1 illustrates the self-reported perceptions of 170 health professional learners regarding their preparedness to care for the incarcerated population. No matter their level of clinical exposure, over 97% of learners felt low levels of confidence to treat this population (defined as not prepared or somewhat prepared). Notably, this survey demonstrated minimal preparation by health care curriculum. Instead, the majority of preparation came from prior experience working with this population outside of formal training. Carceral health integrates diverse fields of nursing, medicine, medical humanities, clinical ethics, bioethics, social work, and care management, affording a rich milieu for learners.

Figure 1.

Health Professional Learner Perceptions on Readiness to Care for Individuals Experiencing Incarceration.

Results of a survey from 170 respondents self-reporting their comfort level in treating incarcerated individuals. The respondents were separated into two groups depending on what year they were in their training. They were classified as either pre-clinical (first year) or clinical (second, third, and fourth years) which stratified them based on their level of clinical exposure.

DISCUSSION

A 2012 review found that only 22 U.S. academic medical programs provided some level of carceral health exposure (Gips et al., 2020). Nursing leadership has been critical in attending to the needs of the incarcerated population, but the pattern of exposure remains limited for nursing and other health professions. In addition, only 23% of U.S. medical school programs incorporate explicit criminal legal and health curricula (Conger et al., 2022; Simon & Tobey, 2019). Beyond graduate-level education, many federal and state prisons have reduced or eliminated prevention education programs aimed at addressing the needs of incarcerated populations (Dubik-Unruh, 1999). Therefore, the responsibility to advocate and protect these individuals falls upon health professionals in these settings.

Carceral health has been described as a “nurse driven system,” as nurses are the largest group of healthcare providers in the carceral system. Nurses are often the first healthcare professional to access and care for persons during incarceration (Maruca & Shelton, 2016). They perform assessments, administer medications, and provide general healthcare services. However, there are critical gaps in nurses’ knowledge of protective laws for incarcerated patients. For example, regarding incarcerated women during pregnancy, a study showed that while 82.9% of the nurses reported their incarcerated patients were shackled sometimes to all the time; only 3% could correctly identify the conditions under which shackling may be ethically permissible; and only 7.4% correctly identified whether their states had shackling laws (Goshin et al., 2019). There are deficits in training in regard to other health professions as well. Studies have shown that medical trainees appreciate an increased freedom to practice what they are learning unencumbered by patient autonomy, “annoying” family interventions, and no fear of legal or professional repercussions, demonstrating how medical training exploits the vulnerability of this population to the advantage of learners (Glenn et al., 2020).

Although nursing leadership has highlighted quality improvement opportunities from a nursing perspective, there are similar needs for other health disciplines. For example, one study of internal medicine residents in carceral health found that these learners often failed to recognize how power structures exploited the often-neglected health of incarcerated persons. The residents not only had the educational benefit afforded by advanced pathology afflicting incarcerated individuals but were noted increased freedom to develop their skills from increased compliance of incarcerated patients, fewer family interruptions, and reduced fear of legal or professional repercussions. The article’s title, “‘It’s like heaven over there’: medicine as discipline and the production of the carceral body,” reveals how educational experiences can exploit the vulnerability of this population (Glenn et al., 2020). Thus, the utmost care to safeguard dignity and autonomy of patients is needed when introducing learners of any discipline to carceral health.

Limited data specific to otorhinolaryngology-Head and Neck nursing care is available and addressing context-specific needs of patients with conditions such as airway stenosis, chronic ear disease, or head and neck cancer in carceral settings remains largely uncharted territory. The knowledge and overall central role of nurses in carceral health positions them to influence policies to develop and implement educational programs for incarcerated persons and staff (Dubik-Unruh, 1999). However, there is an obvious need for more intensive, in-service training for those involved in the care of incarcerated individuals. Integrating the quality, quantity, and level of exposure to incarcerated patients across healthcare professional specialties would ultimately streamline opportunities for education and clinical decision making in this challenging setting.

Otorhinolaryngology-Head and Neck Disorders and Disability

Otorhinolaryngology-Head and Neck disorders are prevalent in the incarcerated population, making it imperative for all healthcare professionals involved in otolaryngologic care to be stakeholders. A recent study found that the two most common reasons for physical examination at a hospital emergency center for incarcerated individuals were trauma and dyspnea, both areas closely linked to the specialty of otorhinolaryngology (Maestro-González et al., 2021). Violence is endemic in prison culture, as evidenced by approximately 21% of males who are incarcerated being physically assaulted every 6 months, and 40% of these assaults leading to physical injury (McFadden et al., 2021). Of these injuries, the most frequently affected body regions identified in this carceral trauma were the head and neck. The same findings occur in the incarcerated adolescent population, as trauma and surgical subspecialty care account for 86% of encounters in the emergency department (16.7% relating to otolaryngology-specific care) (Zagory et al., 2022). Therefore, timely attention to soft tissue and bony trauma, as well as wound care, are prominent concerns requiring otolaryngology-related expertise. The morbidity associated with delayed or inadequate repair of mandibular trauma, periorbital injury, or midface trauma is significant, including complications such as malocclusion, bone loss, double vision, or permanent deformity.

Airway emergencies pose a unique challenge in carceral settings. While dyspnea constitutes a frequent cause for emergency evaluation, it is unknown how often instances of compromised airways result in death before reaching the hospital. Reactive airway disease can be exacerbated by the prevalence of tobacco use and smoking among incarcerated individuals. Additionally, overcrowded living conditions, inadequate ventilation, and the stress and anxiety associated with incarceration may exacerbate underlying laryngotracheal disorders. Furthermore, injuries to the head and neck can pose a risk for airway compromise. Disorders such as angioedema can have sudden, abrupt onset. Similarly, given limited dental services, there is a risk of serious and potentially life-threatening bacterial infection that affects the floor of the mouth and extending to the neck, such as Ludwig’s Angina. Rapidly progressing cellulitis can present as difficulties in swallowing and breathing, often necessitating urgent tracheostomy.

Many other common otorhinolaryngology-head and neck diseases are chronic conditions in the incarcerated population. An evaluation of medical problems of individuals held in jails identified 227,200 individuals with impairments, including speech and hearing difficulties, with 6% of incarcerated individuals reporting difficulty hearing a normal conversation even when wearing a hearing aid (Maruschak, 2006). This issue also affects incarcerated adolescents, as two-thirds of them report having physical care needs that involve hearing or injury, among other medical problems (Sedlak & Bruce, 2010). What is perceived as age-related hearing loss might be a vestibular schwannoma or other reversible disorder in need of treatment. Similarly, what is perceived as a chronic ear infection might be coalescent mastoiditis with risk of meningitis or brain abscess. Neglected sinus infections also have the potential, if neglected, to progress to periorbital or brain involvement that can cause vision loss, venous sinus thrombosis, or brain abscess. The ability to intervene and reverse such disease processes is predicated on timely diagnosis and intervention.

Action Plan

A multi-pronged approach has the potential to significantly improve the access and quality of carceral health. Core areas include early educational exposure with continuing education, improving public health efforts and timely access to diagnostic and therapeutic interventions, and developing community outreach efforts. A detailed description of gaps and recommended actions is detailed in Table 1 (Brean et al., 2023; Hurst et al., 2019; Levy et al., 2003; McParland et al., 2023; Needham et al., 2023; So et al., 2023). These efforts can effectively raise awareness and attract passionate individuals to advocate for change. Few healthcare professionals possess the necessary knowledge to meet the needs of individuals in carceral facilities. Furthermore, these individuals are dispersed and primarily self-selected, which contributes to overall gaps in care. Structural changes to interprofessional healthcare education can ensure that learners receive a broad-based understanding. Increasing collaborative initiatives across stakeholders is crucial, drawing on the collective expertise of nurses, physicians, public health leaders, attorneys, social workers, clinical ethicists, patients, and their families.

Table 1.

Challenges in Carceral Health and Actions for Nurses and Partnering Professionals

Carceral Health Area	Specific Barriers to Optimal Care	Actions to Address Gap
Awareness, Access, and Communication
Awareness and Education	Incarcerated individuals often lack the necessary awareness and education about otorhinolaryngology-head and neck health and overall health to self-advocate.	Develop educational materials and workshops on otorhinolaryngology-head and neck health for incarcerated populations.
		Collaborate with carceral facilities to implement health education programs.
		Advocate for mandatory health education in carceral settings.
Access to Information	Incarcerated individuals and those providing their care may have limited access to necessary knowledge and information.	Create easy-to-understand pamphlets and resources on common otorhinolaryngology-head and neck problems.
		Facilitate access to health information through libraries or digital resources.
		Promote peer-led education initiatives among incarcerated persons.
Access to Specialized Care	In many carceral facilities, access to specialized care for otorhinolaryngology-head and neck issues is limited. Prisons and jails seldom have full-time otorhinolaryngology-head and neck specialists on staff, and arranging consultations with external specialists can take time and resources.	Train carceral facility staff to recognize and address common otorhinolaryngology-head and neck issues.
		Establish partnerships with local healthcare providers for specialized care.
		Advocate for improved access to interprofessional specialists in otorhinolaryngology-head and neck.
		Implement routine screening to identify patients with or at high-risk for otorhinolaryngology-head and neck disorders.
Access to Technology	Correctional facilities often have limitations in the technological services available to individuals. These can be barriers to care as treatments to various otorhinolaryngologic disorders involve assistive devices. Additionally, as access to such specialists are limited, it can be difficult to have otorhinolaryngologic-specific care on site.	Set up telemedicine facilities within correctional facilities to allow remote consultations with specialists.
		Ensure that incarcerated patients have access to necessary hearing aids and communication devices.
		Schedule regular maintenance and adjustments for assistive devices alongside training sessions to ensure patients can effectively use their devices.
Communication Barriers	The limited communication allowed from inside carceral facilities to family and friends outside is well-known. However, there are also communication barriers within the facility in those with disabilities in hearing and speaking. Literacy may also be a concern for many individuals in this population.	Ensure availability of sign language interpreters for patients with hearing impairments.
		Offer speech therapy programs to improve communication skills for patients with speech disorders.
		Provide written communication aids for patients who have difficulty speaking.
Safety, Security, Crowding, and Mental Health
Security Concerns	Security concerns within carceral facilities can create challenges for providing healthcare. Nurses and other team members may need to work in environments with heightened security measures, which can impede care delivery and access to equipment or resources.	Establish clear protocols to maintain safety and security during patient transfers, medical care, and follow-up.
		Ensure staff training on security procedures and protocols.
High Patient Volume	Carceral health professionals often face high patient caseloads due to the large number of incarcerated individuals in their care. High work burden can make it challenging to provide comprehensive and timely care, especially for individuals with chronic or complex conditions.	Implement triage systems to prioritize and escalate care based on both acuity and severity.
		Advocate for adequate nursing staffing levels and nursing authority in decisions.
Mental Health Considerations	Incarcerated individuals may have co-occurring mental health issues that affect management of physical health problems.	Deliver mental health training to nurses to provide holistic patient care.
	Compassionate, high-quality healthcare is predicated on a healthy workforce, and attending to team needs is paramount. Carceral health can induce challenges of moral injury or post-traumatic stress.	Provide nurses and all other carceral health team members access to mental health resources.
High-Risk Behavior	The incarcerated population tends to have higher rates of high-risk lifestyle behaviors including tobacco use, alcohol use, and multiple sexual partners.	Develop easily accessible routine screening and counseling regarding cessation and risk mitigation strategies.
Diagnostic, Therapeutic, and Staffing Considerations
Diagnostic Equipment	Some carceral facilities may lack advanced diagnostic equipment for otolaryngology-head and neck issues, leading to delayed or inaccurate diagnosis.	Develop partnerships with external facilities for diagnostics.
Therapeutic Options	The availability of treatment options, including surgeries or specialized procedures, may be limited within the carceral system. Some treatments may not be feasible in the prison or jails.	Advocate for access to necessary treatments or procedures and create therapeutic alliances.
		Provide social work resources and explore alternative, less invasive treatment options.
		Address inadequate medication management with medication adherence programs, educational workshops, and regular medication reviews.
Staffing	Staffing shortages and high turnover rates can degrade the continuity and quality of care provided to incarcerated individuals. It may also limit the availability of experienced nursing staff.	Promote retention strategies for nursing staff.
		Offer ongoing training and professional development.
Coordination with External Facilities	When an incarcerated individual requires care beyond the capabilities of the carceral facility, coordinating transfers to external healthcare facilities can be challenging and time-consuming.	Streamline the transfer process to expedite external care and institute protocols to escalate urgent conditions.
Care Transition, Health Inequity, and Legal/Ethical Considerations
Continuity of Care and Transitions	Significant challenges exist in assuring continuity of care for individuals transitioning out of incarceration.	Develop transitional care plans for released incarcerated individuals with otorhinolaryngology-head and neck related conditions.
		Collaborate with community health organizations to ensure post-release care.
		Advocate for policies supporting healthcare continuity post-incarceration.
Health Inequity	Disparities in healthcare access and quality within the carceral system can lead to inequitable care for incarcerated individuals with otorhinolaryngology-head and neck disorders. These issues can lead to reduced quality of life, permanent disability, or even loss of life.	Monitor and address healthcare disparities within the system.
		Advocate for the development of policies addressing otorhinolaryngology-head and neck care standards in carceral facilities.
		Work with legislative bodies to ensure funding for otorhinolaryngology-head and neck services in carceral facilities.
		Form coalitions with other healthcare professionals to lobby for policy changes.
Legal and Ethical Considerations	Nurses working in carceral settings must navigate complex legal and ethical considerations related to patient rights, confidentiality, and the duty to provide care within the constraints of the carceral environment.	Ensure nurses and all stakeholders are educated on legal and ethical responsibilities.

Building trust is a necessary prerequisite for improving carceral health. Fear and mistrust of the healthcare system are common among incarcerated individuals. This is exemplified as 49% of individuals report trusting healthcare providers to make medically correct judgements while only 9% trust medical professionals in a prison setting to make medically correct judgements (Widra, 2022). The roots of such suspicion are multifaceted but can likely be traced in part to a legacy of mistreatment, with limited access to care and inconsistent quality of treatment. The stark contrast in trust inside and outside of the prison may also reflect the different treatment individuals feel they receive within these facilities. Students observing the administration of healthcare in prisons have reported health professional stereotyping of patients and negative impressions overall of the care provided compared to non-carceral facilities (Hashmi et al., 2021). Implicit bias training and other strategies to ensure equitable care may reduce these negative impressions.

Lastly, despite the prevalence of incarceration in the U.S, life inside carceral facilities remains opaque to the general population, with perceptions shaped by depictions in television dramas, cinema, or sensationalized media. Public understanding of the incarcerated population is seldom grounded in evidence-based reporting. Healthcare professionals must expand their efforts to confront the pressing issue of mass incarceration and strive to improve social justice. The carceral population in the U.S. continues to grow at an alarming rate, and incarcerated individuals often face significant health disparities. Nurses, as advocates for holistic patient care, are uniquely positioned to address the healthcare needs of this vulnerable population. Beyond providing clinical care, stakeholders can advocate for policies and practices that prioritize rehabilitation over punishment, emphasize mental health and addiction treatment, and work to reduce recidivism. Collaborations with community organizations can also support formerly incarcerated individuals in accessing healthcare and social services upon reentry. By engaging in dialogue, education, and activism, health professionals can play a vital role in advocating for more equitable care that values the well-being and dignity of all individuals.

Limitations

This study’s findings are subject to limitations, including its single-institution focus, reliance on self-reported data, a relatively small sample size, cross-sectional design, subjective nature of pre-paredness, and non-response bias. These factors should be considered when interpreting and generalizing the study’s results. Nevertheless, this study serves to raise awareness, providing a starting point for future research and interventions in carceral healthcare. It emphasizes interprofessional education, offers practical recommendations for action, humanizes the incarcerated population, and calls for social justice. It promotes evidence-based reporting and contributes to informed discussions on mass incarceration, making it a valuable catalyst for positive change in healthcare education and practice.

CONCLUSION

The intersection of mass incarceration and healthcare presents a critical challenge and opportunity for otorhinolaryngology-head and neck healthcare professionals. The U.S.’ exceptionally high incarceration rate is a public health crisis, and the disparities in healthcare access and quality within the carceral system require innovation in interprofessional education. This should include early educational exposure, continuing education, and a concerted effort to improve public health education. Building trust among the incarcerated population and addressing implicit biases among healthcare professionals are essential steps towards improving the quality of care. Furthermore, understanding how perceptions of incarceration are often skewed by media portrayals underscores the need for informed, evidence-based reporting and public discourse. Healthcare professionals must extend their roles to advocate for social justice within the system and serve as catalysts for positive change. Broad stakeholder engagement and a commitment to humanizing the incarcerated population are paramount for achieving more equitable and compassionate healthcare.