Abstract
BACKGROUND:
Adolescents admitted to youth custody facilities are often in need of physical and mental health care.
OBJECTIVES:
To describe primary health care practices in Ontario’s youth custody facilities.
METHOD:
A questionnaire regarding facility characteristics and primary health care practices was distributed to the directors of all youth custody facilities in Ontario.
RESULTS:
Most (87.8%) facilities obtained medical histories after the youth arrived, and 92% used health care professionals to perform that assessment. Intake medical examinations were performed on each youth admitted to custody at 94% of all facilities; however, only 57.2% of facilities reported that these examinations were performed by a doctor within 72 h of admission. Performing suicide assessments on all youth at intake was reported by 77.6% of facilities. Continuous health education was provided by 76% of facilities. Facility type and type of management appear to be related to some areas of health services provision.
CONCLUSIONS:
Youth custody facilities in Ontario are providing primary health care services. Weaknesses are, however, evident, particularly in relation to untimely intake medical examinations, failure to provide continuous health education and failure to conduct suicide assessments on all youth at intake. Future research on barriers to health service provision in Canadian youth custody facilities is recommended.
Keywords: Custody facilities, Health care, Health practices, Youth custody
Abstract
HISTORIQUE :
Les adolescents admis dans des établissements de garde ont souvent besoin de soins physiques et mentaux.
OBJECTIFS :
Décrire les pratiques de soins de première ligne dans les établissements de garde d’adolescents de l’Ontario.
MÉTHODOLOGIE :
Les directeurs de tous les établissements de garde d’adolescents de l’Ontario ont reçu un questionnaire sur les caractéristiques de leur établissement et les pratiques de soins de première ligne qui y sont offertes.
RÉSULTATS :
La plupart des établissements (87,8 %) obtenaient les antécédents médicaux de l’adolescent après son arrivée, et 92 % faisaient appel à des professionnels de la santé pour ce faire. Dans 94 % des établissements, chaque adolescent subissait un examen médical à l’arrivée, mais seulement 57,2 % des directeurs ont déclaré que ces examens étaient effectués par un médecin dans les 72 heures suivant leur admission. Tous les adolescents devaient se soumettre à une évaluation du risque de suicide à leur arrivée dans 77,6 % des établissements. Une formation continue dans le domaine de la santé était assurée dans 76 % des établissements. Le type d’établissement et le type de gestion semblaient liés à certains aspects de la prestation de services de santé.
CONCLUSIONS :
Les établissements de garde d’adolescents de l’Ontario fournissent des soins de première ligne. Les faiblesses sont toutefois évidentes, notamment en ce qui a trait à l’examen médical effectué trop longtemps après l’admission ainsi qu’au défaut de fournir une formation continue dans le domaine de la santé et de procéder à une évaluation du risque de suicide auprès de tous les adolescents à leur admission. D’autres recherches sont recommandées sur les obstacles à la prestation de services de santé dans les établissements de garde du Canada.
Research reveals that youth admitted to custodial facilities are often in need of physical, dental and psychological health care (1–3). Several studies have found that these youth have higher rates of health problems compared with the general population of youth (4–6). Many juvenile offenders also acquire injuries and health care problems while in custody due to psychological distress, fights, use of physical restraints and self-inflicted injuries (7–9).
In Canada, young people in custody usually range from 12 to 17 years of age (10). There are two types of custody in which a youth can be placed: open custody and secure custody. Secure custody is typically intended for youth who have been found guilty of serious offences or who pose an escape risk. In secure custody facilities, youth are detained by security devices, including full-perimeter fences, electronic surveillance and locked bedroom doors at night; they may also be under constant observation by staff (10,11). Alternatively, a facility is considered to be ‘open’ when there is minimal use of security devices or perimeter security (10). Most open custody facilities have fewer restrictions on youths’ movement within the facility and allow access to activities such as escorted community outings (11). Under the Youth Criminal Justice Act, open custody facilities may consist of a community residential centre, a child care institution, a group home, and a forest or wilderness camp (10).
The living arrangements in youth custody facilities may vary depending on the type and size of the facility. Small open and secure custody facilities may have single rooms or a mixture of single and double rooms, whereas large secure custody facilities may have cells with bunk beds. All youth custody facilities in Ontario are funded by the provincial government. However, not all youth custody facilities are managed by the provincial government; there are numerous privately operated facilities (12).
In Ontario, 7511 youth were admitted to custody (pretrial detention) between 2010 and 2011 (13); however, only 1152 youth received a custodial sentence. A total of 647 youth were sentenced to open custody facilities (517 males and 130 females). Secure custody sentences totaled 505 youth (437 males and 68 females) (14). The majority (54.8%) of all youth who received custodial sentences to both open and secure custody facilities spent between one and six months in custody, whereas 65.3% of youth admitted to pretrial detention spent between one and 30 days in custody (14).
Despite the evidence of high rates of health issues within this population, health services within many youth custody facilities are often deficient (15,16). Several investigations into youth custody facilities within Ontario have revealed inadequate levels of care. Concerns identified by the youth include unavailability of nonprescription medications on week nights and weekends, dry air that causes nose bleeds, poor food quality and quantity, and lack of access to fresh air (17,18).
Information regarding health care practices in youth custody facilities in Canada and Ontario is limited, unlike in the United Kingdom and the United States (US), where such information is available on websites of the departments responsible for juvenile justice services. To increase information regarding this area of Canadian youth justice services, the main purpose of the present study was to describe primary health care services in Ontario’s youth custody facilities. To the best of our knowledge, no studies examining a wide range of primary health care practices in Canadian youth custody facilities have been published.
METHODS
An 81-item questionnaire was distributed via e-mail to the directors of all open and secure youth custody facilities in Ontario. There were 70 youth custody facilities in Ontario when the survey was conducted; 49 of the facilities were open custody facilities and 21 were secure custody facilities. All 70 facilities were invited to participate in the survey. The director of each facility was the intended respondent, and each director was contacted by telephone to discuss participation in the study and to obtain his or her e-mail address. A copy of the survey, the letter of information and instructions for completion and return of the survey were forwarded via e-mail to the facility director. No surveys were distributed to the youth detained in the facilities.
The questionnaire was developed from a review of the Canadian Paediatric Society, WHO and United Nations (19) recommendations for the health care of youth in custody, and from a review of reports on health care practices in youth custody in the United Kingdom and the US (20,21). The questionnaire consisted of 79 closed-ended questions and two open-ended questions; it contained 13 sections and requested information on the following domains: facility demographic information; health care oversight and guidelines; health care program; intake assessments; postintake health services provision; privacy and consent issues; staffing information; emergency care; nutrition; health education; physical activity; mental health care; and long-term care. Only items related to program oversight, intake assessment, postintake health services provision, medical staff complement, health education and mental health are reported in the present study.
The questions were designed to elicit information about the availability and provision of primary health care services, eg, “After arrival at this facility do the youth undergo a medical evaluation?” “If yes, within what time period after admission are medical evaluations generally performed?” “Is there an ongoing health education program for the youth?” “How often are health education sessions conducted?”. The questions and the response options relating to the data provided in the present study are listed in Tables 1 and 2.
TABLE 1.
Postintake health care services
| Question* | Open custody | Secure custody | All facilities |
|---|---|---|---|
| How soon are postintake medical concerns addressed (n=49) | |||
| 24 h by doctor | 17 (50.0) | 7 (50.0) | 24 (50.0) |
| 24 h by nurse | 1 (2.9) | 1 (7.1) | 2 (4.2) |
| 48 h | 3 (8.8) | 2 (14.3) | 5 (10.4) |
| 72 h | 3 (8.8) | 1 (7.1) | 4 (8.3) |
| 4 to 7 days | 2 (5.9) | 0 (0) | 2 (4.2) |
| Doctor’s availability | 8 (23.6) | 3 (21.5) | 11 (22.9) |
| Medical service providers used for postintake health care (n=49) | |||
| Contracted doctors | 19 (57.6) | 5 (41.7) | 25 (55.5) |
| Emergency room | 18 (54.5) | 11 (91.7) | 29 (64.4) |
| Walk in clinic | 20 (60.6) | 6 (50.0) | 26 (57.8) |
| Any available doctor | 17 (21.2) | 4 (33.3) | 11 (24.4) |
| Other medical office | 12 (36.4) | 2 (16.7) | 14 (31.1) |
| Health education classes (n=49) | |||
| Yes | 26 (74.3) | 11 (78.6) | 37 (75.5) |
| No | 9 (25.7) | 3 (21.4) | 12 (24.5) |
| Frequency of health education classes (n=37) | |||
| Daily | 2 (7.7) | 0 (0) | 2 (5.4) |
| 3 to 4 times per week | 2 (7.7) | 0 (0) | 2 (5.4) |
| Weekly | 10 (38.5) | 5 (45.4) | 15 (40.5) |
| Biweekly | 2 (7.7) | 2 (18.2) | 4 (10.8) |
| Monthly | 7 (26.9) | 2 (18.2) | 9 (24.4) |
| Quarterly | 3 (11.5) | 2 (18.2) | 5 (13.5) |
| Health education topics (n=37) | |||
| Dermatology | 5 (19.2) | 3 (27.2) | 8 (21.6) |
| Drug use | 23 (88.4) | 11 (100.0) | 34 (91.8) |
| Exercise and sports | 22 (84.6) | 10 (90.9) | 32 (86.4) |
| Food and nutrition | 21 (80.7) | 11 (100.0) | 32 (86.4) |
| Hygiene | 26 (100.0) | 10 (90.9) | 36 (97.2) |
| Mental health | 10 (16.5) | 8 (72.7) | 24 (64.8) |
| Parenting classes | 12 (46.1) | 5 (45.4) | 17 (45.9) |
| Prenatal classes | 26 (100.0) | 1 (9.0) | 6 (16.2) |
| Sexual health | 26 (100.0) | 11 (100.0) | 37 (100.0) |
| Other | 4 (15.3) | 3 (27.2) | 7 (18.9) |
Data presented as n (%).
Totals differ because of appropriate skips in questions or nonresponse to questions
TABLE 2.
Mental health services
| Question* | Open custody | Secure custody | All facilities |
|---|---|---|---|
| Suicide assessments at intake (n=49) | |||
| Yes | 25 (71.4) | 13 (92.9) | 38 (77.6) |
| No | 10 (28.6) | 1 (7.1) | 11 (22.4) |
| Screen for recent/past drug use at intake (n=49) | |||
| Yes | 30 (85.7) | 14 (100.0) | 44 (75.5) |
| No | 5 (14.3) | 0 (0) | 5 (24.5) |
| Access to trained counsellors (n=40) | |||
| Always | 18 (62.1) | 8 (72.7) | 26 (65.0) |
| Sometimes | 3 (10.3) | 2 (18.2) | 5 (12.5) |
| Never | 8 (27.6) | 1 (9.1) | 9 (22.5) |
Data presented as n (%).
Totals differ because of appropriate skips in questions or nonresponse to questions
The present study was approved by the Research Ethics Committee of the University of Western Ontario (London, Ontario) and Ontario’s Youth Justice Research Committee.
Data analysis
SPSS version 17.0 (IBM Corporation, USA) was used to analyze the data. Descriptive statistics were used to summarize the presence and prevalence of primary health care practices. χ2 tests were performed to determine whether there were associations among facility type or type of management and primary health care practices. Relationships among facility type, type of management and provision of health services were also examined using correlation analyses. Results are reported for the total sample, and also for open and secure custody facilities separately.
RESULTS
Facility characterictics
The total response rate was 70%; this included 71.4% (35 of 49) of open custody facilities and 66.6% (14 of 21) of secure custody facilities. The majority (77.7%) of the open custody facilities were privately run, whereas only one-half (50.0%) of the secure custody facilities were privately run. The health program was overseen by a health professional at 57.1% of secure custody facilities and 45.2% of open custody facilities. χ2 tests revealed an association between having a health professional oversee the program and whether facilities were managed by government or private agencies (χ2 [1, n=49] = 11.794; P=0.003). Correlation analyses showed that there was a strong relationship between the variables (r[47] = −0.51; P<0.001). The other characteristics of the facilities are presented in Table 3.
TABLE 3.
Characteristics of youth custody facilities
| Characteristic* | Open custody | Secure custody | All facilities |
|---|---|---|---|
| Type of management (n=49) | |||
| Government | 8 (22.9) | 7 (50.0) | 15 (30.6) |
| Private | 27 (77.1) | 7 (50.0) | 34 (69.4) |
| Population type (n=49) | |||
| All male | 22 (62.9) | 6 (42.9) | 28 (57.1) |
| All female | 6 (17.1) | 2 (14.3) | 8 (16.3) |
| Male and female | 7 (20.0) | 6 (42.9) | 13 (26.5) |
| Capacity, number of youth (n=41) | |||
| 6–10 | 23 (79.3) | 1 (8.3) | 24 (58.6) |
| 11–19 | 5 (17.2) | 4 (33.3) | 9 (22.0) |
| 20–29 | 1 (3.5) | 2 (16.7) | 3 (7.3) |
| 30–39 | 0 (0) | 2 (16.7) | 2 (4.8) |
| >40 | 0 (0) | 3 (25.0) | 3 (7.3) |
| Average stay (n=31) | |||
| <7 days | 1 (4.7) | 0 (0) | 1 (3.2) |
| 7–14 days | 4 (19.0) | 2 (20.0) | 6 (19.3) |
| 15–30 days | 7 (33.3) | 3 (30.0) | 10 (32.2) |
| 31–60 days | 5 (23.8) | 3 (30.0) | 8 (25.9) |
| 61–90 days | 3 (14.2) | 0 (0) | 3 (9.7) |
| 91–120 days | 1 (4.7) | 1 (10.0) | 2 (6.4) |
| <12 months | 0 (0) | 1 (10.0) | 1 (3.2) |
| Health professional oversees program | |||
| Yes | 14 (45.2) | 8 (57.1) | 22 (44.8) |
| Committee meets to review program | |||
| Yes | 6 (17.2) | 4 (28.5) | 10 (20.4) |
| Onsite medical facility (n=46) | |||
| Yes | 8 (23.5) | 9 (75.0) | 17 (36.9) |
Data presented as n (%).
Totals differ because of appropriate skips in questions or nonresponse to questions
Intake health care practices
Of the total sample (n=49) 87.8% obtain medical histories after the youth arrive, and 92% use health care professionals to perform that assessment. Ninety-four per cent of all facilities perform an intake medical examination on each youth admitted to custody; however, only 57.2% of all facilities were able to meet the Ministry of Children and Youth Services (MCYS) requirement that these examinations be performed by a doctor within 72 h of admission. A higher proportion of secure custody facilities (85.7%) were able to meet the 72 h requirement, whereas only 45.7% of open facilities were able to do so. Correlation analyses revealed that there was a strong relationship between facility type and the time in which evaluations are performed (r[47] = −0.40; P=0.004). No other significant relationships were found among facility type, type of management and primary health care practices.
Many of the facilities that were unable to have medical examinations performed within the recommended time period reported that this was often due to doctor shortages. Facilities located in rural areas noted that doctor shortages were severe. Two of the 14 secure custody facilities and two of the 35 open custody facilities reported having doctors on staff, while nine of 14 secure custody facilities and nine of 35 open custody facilities reported having nurses on staff. All facilities were asked about the provision of various types of medical tests and examinations during intake evaluations, including dental and vision examinations, and tests for sexually transmitted infections (STIs). The majority of examinations were conducted either as necessary or at the request of youth at both open and secure custody facilities. Only 24.4% of all facilities noted that youth experiencing withdrawal symptoms are always seen in medically supervised settings. Full data regarding primary health care practices are presented in Table 4.
TABLE 4.
Intake health care practices
| Question* | Open custody | Secure custody | All facilities |
|---|---|---|---|
| Medical history at intake (n=49) | |||
| Yes | 30 (85.7) | 13 (92.9) | 43 (87.8) |
| Not routine | 5 (14.3) | 1 (7.1) | 6 (12.2) |
| Who takes medical history (n=43) | |||
| Medical professional | 27 (79.0) | 13 (100.0) | 40 (93.0) |
| Trained other | 1 (3.3) | 0 (0) | 1 (3.3) |
| Untrained other | 2 (6.7) | 0 (0) | 2 (6.7) |
| Intake medical examination (n=49)† | |||
| Yes | 31 (88.5) | 14 (100.0) | 45 (91.8) |
| No | 4 (11.5) | 0 (0) | 4 (8.9) |
| Who performs intake examination (n=49) | |||
| Medical professional | 31 (100.0) | 14 (100.0) | 45 (100.0) |
| Time medical examinations are performed | |||
| 24 h | 0 (0) | 0 (0) | 0 (0) |
| 48 h | 1 (2.9) | 3 (21.4) | 4 (8.2) |
| 72 h | 15 (42.9) | 9 (64.3) | 24 (49.0) |
| 72 h or next available appointment | 2 (5.7) | 0 (0) | 2 (4.1) |
| 4 to 7 days | 10 (28.6) | 1 (7.1) | 11 (22.4) |
| After 7 days | 6 (17.1) | 1 (7.1) | 11 (22.4) |
| Other | 1 (2.9) | 0 (0) | 1 (2.0) |
| Testing for sexually transmitted infections | |||
| Always | 0 (0) | 6 (42.9) | 6 (12.2) |
| Youth request | 19 (54.3) | 3 (21.4) | 22 (44.9) |
| As needed | 12 (34.3) | 5 (35.7) | 5 (34.7) |
| Sexually active | 3 (8.8) | 0 (0) | 3 (6.1) |
| Never | 1 (2.8) | 0 (0) | 1 (2.0) |
| Medically supervised withdrawal (n=49) | |||
| Always | 9 (25.7) | 3 (21.4) | 12 (24.4) |
| Frequently | 3 (8.6) | 1 (7.1) | 4 (8.2) |
| Sometimes | 15 (42.9) | 8 (57.2) | 23 (46.9) |
| Never | 8 (22.8) | 2 (14.4) | 10 (20.4) |
Data presented as n (%).
Totals differ because of appropriate skips in questions or nonresponse to questions;
Two facilities indicated that intake medical examinations are performed before arrival at their facility
Postintake health services
At 50% of both open and secure custody facilities, postintake medical concerns were addressed within 24 h. All facilities reported using various medical services providers to provide postintake health care. The issue of doctor shortages was again highlighted; one open custody facility located in a rural area noted that they usually used the emergency room because they were often wait-listed at community centres. Thirty-seven of the 49 (76%) facilities that participated in the survey reported providing ongoing health education programming. Sex education and hygiene practices were the most prevalent health education topics. Additional data regarding postintake health services are presented in Table 1.
Mental health services
Only four facilities reported that all youth who enter their facility undergo psychological assessments. Some secure custody facilities, however, noted that they provide psychological screenings. One open custody facility reported that they experienced extreme difficulty accessing a psychologist when reports are required and that it was extremely difficult to find a child and youth psychologist in their area. Another open custody facility reported that accessing mental health services in their region was extremely difficult due to lack of availability and that wait times for assessments could be three months or longer, depending on the nature of the assessment. Four secure custody facilities reported having psychologists on staff and seven reported having social workers on staff. None of the open custody facilities had psychologists on staff and eight had social workers on staff. A substantial proportion (65.3%) of all facilities reported that youth always have access to trained counsellors. Screening each youth for recent and previous substance use was reported by 90% of all facilities. Conducting suicide assessments on all youth at intake was reported by 77.6% of all facilities. It is noted that, in Ontario, various tools such as the Risk/Needs Assessment Youth Assessment and Screening Instrument, which include questions regarding substance abuse and mental health, are used to assist in creating plans of care for youth as well as presentencing reports for the court. The questions about suicide screening in the present survey, however, related specifically to intake screening. Full data regarding mental health services are provided in Table 2.
DISCUSSION
The main purpose of the present study was to describe primary health care services in Ontario’s youth custody facilities. The results reveal that most open and secure custody facilities are providing basic primary health care services. Weaknesses in service provision are, however, evident, and include untimely intake medical examinations and failure to provide health education, suicide assessments and STI testing to all youth.
The Ontario Medical Association estimates that there is a shortage of more than 2000 physicians in the province (22) and many facilities reported that they were unable to meet the 72 h intake assessment requirement due to doctor shortages. To assist facilities located in areas that are challenged by the physician shortage, the MCYS should consider reviewing this requirement to enable experienced nurses or nurse practitioners to conduct intake medical examinations on the condition that youth are seen by a doctor at a later date. This is already the practice in the MCYS direct-operated facilities, in which youth are seen by a nurse within 24 h of admission (personal communication, MCYS) and also at some privately operated facilities that have nurses on staff but are unable to have youth seen by a doctor within 72 h. In some cases, this may require providing additional funding for a part-time nurse, especially in rural or remote areas. Inspections at British youth custody facilities have found that, at facilities at which there are adequate numbers of full-time or part-time health care professionals, the physical and mental health needs of youth are fully addressed at arrival and throughout their stay in the facility (23,24).
The development of protocols requiring that each youth that enters custody be tested for STIs has received much attention in the literature (25,26). In the present study, most STI testing was conducted either as needed or at the request of youth. Given that there are high rates of STIs within this population (27,28) and that most of the STIs among incarcerated youth are asymptomatic (25,26), universal testing with the permission of sexually active youth may be more appropriate. Studies implementing universal screening protocols at admission have been successful; in one study, 11.5% of the cohort tested positive for chlamydia and 4.2% for gonorrhea (25).
Almost one-quarter of all facilities (n=12) reported not having continuous health education classes, and 11 of those 12 facilities reported having average custody stays of 30 days or longer. This population of youth has been found to engage in various risky health behaviours such as misuse of drugs and unsafe sex practices (5,29,30). They also have poor school attendance records (31,32) and may have missed several health education classes. In addition, they often have limited contact with the health care system due to adverse social and economic conditions and family dysfunction (6,33). Custody presents an opportunity to provide health education programming to a population of youth that is typically difficult to reach. Studies investigating sexual health education in youth custody facilities in the US have found improved health knowledge and a reduction in risky sex behaviours six to nine months after youth were released from custody (34,35).
Only 77.5% of facilities reported providing suicide assessments to all youth at intake. This figure was lower than expected, especially because the MCYS reported that there are protocols in place for suicide screening at all facilities at intake and throughout the period of a youth’s detainment. In addition, research shows that up to 65% of youth in custody have mental health disorders and that incarceration can result in psychological distress (3,5). Ensuring that each youth is assessed for suicidal ideation at intake is, therefore, critical. Studies have found that intake screening in youth custody reduces incidence of suicides and suicide attempts (36,37).
A few facilities expressed difficulty in accessing mental health services. Recent reviews into children’s mental health services in Ontario revealed several weaknesses (38) and, until the gaps in care and access are resolved, youth custody facilities will need to create stronger links with community services. In areas where community services are limited or are not available, the MCYS will need to consider providing funding for facilities to employ mental health professionals.
Another key issue in the findings from the present study was the difference in resources among the facilities. χ2 tests and correlation analyses show that facility type and type of management appear to be associated with the availability of health care staff and services. More secure custody facilities were more frequently able to meet the 72 h doctor-performed medical examination requirement. The fact that all youth who enter MCYS direct operated facilities are seen by a nurse within 24 h of admission also highlights differences in resource allocation and access within the system. A 2005 review of the open custody system reported that there are historical contract funding inequities within the system, which result in inability to recruit and maintain staff (39). Future research investigating funding and resource differences in open and secure custody facilities as well as differences between private and government-managed facilities is needed to find a way to equitably allocate funds and resources according to facility size, location and needs to allow all facilities to have the staff and resources needed to provide timely, quality services to the youth in their care.
Limitations to the interpretation of these findings should be noted. The original intent was to distribute the surveys via regular post; the MCYS, however, requested electronic distribution. It is possible that this method threatened anonymity and may have led to socially desirable responses. During the data collection period, an investigation by the Provincial Advocate for Children and Youth in Ontario into a newly opened secure custody facility occurred. It is possible that the highly publicized concerns about services and conditions within a youth custody facility may have impacted participation rates and responses. The present research project was descriptive, and the results, therefore, cannot be used to infer any direct link between the services provided and outcomes for youth who have been in custody. Finally, the results and recommendations of the present study are not generalizable to the rest of Canada. There are currently no national data regarding health care practices in youth custody; therefore, it is not clear whether a similar study conducted across Canada would produce similar results. Further research is needed to determine whether issues, such as doctor shortages and funding inequities, also exist in the youth justice system in other provinces.
Continued advocacy for the adoption of recommended best practices for youth in custody must remain a priority, especially because there is currently no research that reveals improved health in youth discharged from custody facilities (40,41). Future research investigating barriers to health service provision in Canadian youth custody facilities is recommended. A national needs assessment for youth in custody to determine the most prevalent health care needs and the actual care received would also be beneficial.
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