Health problems among detainees in Switzerland: a study using the ICPC-2 classification

Prisoners are an underserved and vulnerable population. They frequently have had limited previous access to healthcare due to educational, social and economic disadvantage [1, 2]. Prison has been identified as a significant opportunity to address the health needs of vulnerable groups. In particular, prison health services aim to reduce inequalities by providing primary care services that are similar in range and quality to those available in the community [3]. Addiction, psychiatric problems and infectious disease are recognized as important health problems in prison, their extent varies widely from one setting to another [1]. Belgian prisoners have been shown to make substantial use of primary care services during incarceration [4]. In US jails 36.9% of inmates in 2002 reported having a current medical problem but only 42% of them said that they had seen a health care professional about it. The most frequent specific health problems were dental problems (25%), arthritis (13%), followed by hypertension (11%) and asthma (10%). Furthermore, 13% of inmates reported being injured since admission [5].

The frequency and range of health problems encountered in prisons should shape the composition and competence profile of prison health care services. Yet little is known about the primary care needs of detainees in most European countries, and no detailed description is available for Switzerland. The aim of this study was thus to provide a detailed description of the health problems of detainees in Switzerland's largest remand prison.

This study is the first to detail the wide range of health problems among detainees in a Swiss remand prison. Illicit drug use (40.2%) and mental health problems (32.6%) were frequent in this mainly migrant population, but most of these detainees (57.6%) required care for common primary care problems, such as skin (27.0%), infectious diseases (23.5%), musculoskeletal (19.2%), injury related (18.3%), digestive (15.0%) or respiratory problems (14.0%). Until recently Switzerland lacked national comparative data concerning health problems in primary care. With the advent of electronic medical records this is slowly changing. A recent publication provides data about ICPC-2 coded electronic medical records of 24 Swiss GPs concerning 29'398 doctor-patient encounters. Main reasons for encounter were musculoskeletal (21%), circulatory (19%), respiratory (9%) and endocrine, metabolic and nutritional disorders (8%) [15]. Prevalence data in our study were different for most health problems (with the exception of musculoskeletal disorders). This adds value to our findings in highlighting the extent to which primary care services in prison may differ from those provided to the general population. Our findings are consistent with findings in Britain [16] and Belgium [4], where detainees consulted 3 to 3.8 times more frequently compared to the age-and sex-adjusted general population. Main ICPC-2 code groups in the Belgium study were the same as in ours. Nearly 70% of detainees in our study had consultations with a primary care physician. The high need for primary care services in prison can be explained by the accumulation of negative social determinants of health which contributes to a high burden of disease [2, 4, 17] but also by improved access to health care services in prison as well as the prison culture. For example, self-medication is usually forbidden in prison. Prisoners therefore have few opportunities to resort to self-care and are more likely to request medical help even for simple complaints [16].

Publications concerning US jail inmates report the following most frequent medical problems: arthritis (13-20%), hypertension (11-21%), asthma (10-24%), heart problems (5.9-11%), hepatitis (2.6-10%) and diabetes (2.7-6.5%) [5, 18] Gender differences were observed with higher burden of chronic medical disorders, psychiatric disorders and drug dependence in women compared to men [18]. Our study identified higher burden of psychiatric disorders in women, an equal burden of somatic health problems in both groups and a higher burden of drug dependence in men. Cardiovascular risk factors such as hypertension (3.5%) and diabetes (1.2%) appear to be less frequent in the population involved in our study. As blood pressure was checked among all prisoners during the initial nurse evaluation, measurement bias is unlikely to explain the low proportion of hypertension in our study. In addition our findings in relation to hypertension and diabetes are well in line with population data in Switzerland, suggesting that, with the exception of tobacco cessation counseling, these detainees may have little need for cardiovascular preventive care.

Our study identified prevalence rates ≥10 times those found in the general population for tuberculosis (0.2% vs. 0.006% [19]), HCV infection (5.7% vs. 0.7-1% [20] and heroin use (12.3% vs. 0.7%[21]). Worldwide, TB-notification rates are found to be 14.9 times higher in prisoners compared to civilians, in Western Europe TB-notification rates are 8.1-times higher [22]. The high rates of infectious diseases and particularly of tuberculosis are related to risk factors which aggregate in prison: low socioeconomic status, intravenous drug use, homelessness, lack of access community based health care as well as the origin of high TB-incidence countries [22, 23]. Our findings highlight the vulnerability of detainees to TB and other infectious diseases and stress the need for effective screening and containment measures in prison [22]. The frequency of common health problems such as dyslipidemia, back pain, or epigastralgia was well in line with that observed in the general Swiss population [24‐26]. Asthma was less frequently reported than in prison settings in the US, UK or Australia [18, 23], but in accordance with general population data of Switzerland [27].

Most psychiatric disorders were observed more frequently than in the general population. However, the proportion of detainees with psychiatric disorders was low compared to available data from the literature where prevalence rates of up to 65% for personality disorder (including 47% with antisocial personality) were found [23, 28]. Several reasons may explain these findings. First, the health problems were identified by general practitioners and not by specialists. The ICPC-2 tool favors the identification of symptoms and complaints where diagnoses are not available and is particularly adapted for ambulatory settings in primary care. Second, we did not systematically use a diagnostic screening interview which explains why certain diagnoses were less prevalent in our study than usually described in the literature. This appears to be particularly true for long lasting problems such as personality disorders compared with acutely symptomatic mental disorders. Third, remand detainees differ from the local Swiss population regarding several socio-demographic characteristics, all of which are relevant for the prevalence, course and outcome of most mental disorders. More specifically, compared with the general Swiss population, detainees included in our study were younger, more often foreign born and with lower socioeconomic status. However, in order to allow for a broad comparison, ranges of prevalence mentioned in the DSM-IV [29] for specific disorders are presented in Table 3.

Our findings in relation to the high rates of heroin, cocaine and benzodiazepine use were well in range with those from previous studies, both in the US and in Europe [30‐33]. That 40.2% detainees used at least one illicit drug at entry highlights the need for general practitioners (GP) working in detention to be well trained in addiction medicine. Offering adequate care to detainees who suffer from drug addiction is an important priority. It is particularly important to implement harm reduction strategies, such as opioid substitution treatment which has been shown to be a powerful tool to: 1. decrease the level of injecting, 2. prevent the transmission of blood-borne viruses, 3. prevent drug-related prison violence and crime following release as well as recidivism [30, 34]. Furthermore, excessive use of alcohol (34.8%) and tobacco (61.5%) requires particular attention. Smoking rates were more than twice as high as in the general population in Switzerland where 32% of men and 23.8% of women smoked in 2007 [35]. Smoking is highly problematic in confined institutions as exposure to passive smoking is almost inevitable for everyone: inmates, prison officers and health professionals.

A challenge for the GP working in prison is continuity of care. Disease management requires good coordination with different health services before and after imprisonment. This is particularly important for medical management of infectious diseases such as hepatitis which is more prevalent in prison compared to the general population [36]. Fifty-six percent of iv drug users in Switzerland are infected with hepatitis C virus (HCV) [37]. Our study identified hepatitis C in 15.4% of those who reported using either heroin or cocaine on admission compared to 0.8% who denied use of illicit drugs. Vescio showed in a meta-analysis that HCV sero-prevalence in prison is closely related to the proportion of iv drug users in prison who are found to have a 24 times higher risk of HCV infection [38]. We identified highest sex- and age-adjusted opiate-consumption rates in Asians. These findings are concordant with international prevalence studies which confirm high rates of opiate and intravenous drug use in Asia. This region represents almost one-quarter of people who inject drugs worldwide [39]. In particular Georgia has one of the highest intravenous drug use rates worldwide (4.2% of 15-64 year olds), compared to Switzerland where 0.65% of 15-64 year olds inject drugs [40]. Georgians in our sample had high prevalence rates of HCV infection which were four times higher than the average (20.8% vs 5.7%). High rates of hepatitis C in this sample, even in the absence of a systematic screening policy, confirm the need to develop such a policy in our setting, and country of origin could serve as a rough decision-making criterion for ordering additional health screening. Imprisonment has to be considered as an opportunity to provide medical care and preventive measures to this hard-to-reach population. Furthermore, hepatitis C treatment is proven cost-effective in prison settings [41] but can only be effective if the prison health services and particularly the GP is able to achieve continuity of care.

Following systematic screening upon admission, alleged violence from the authorities was reported by 8% of detainees. Our health service has set-up a system for reporting these alleged violent events to a state ombudsman in order to favor a reduction in unethical behavior in law enforcement state services.

In the absence of systematic screening policies in our institution, the identification of problems such as STI, AIDS, hepatitis and psychiatric illnesses was based on clinical evaluation and/or patient requests for tests. This may have led to underestimations of the frequency of these health problems. Yet, our primary aim was not to provide precise prevalence data but to offer data on frequently encountered health problems in order to inform prison healthcare services development. Even if our findings provide conservative estimates of prevalence rates, they underline the high morbidity in this population in particular in relation to addiction and infectious diseases but also in relation to more common health problems seen in general practice. That all detainees underwent a health evaluation and were systematically referred to the physician when a medical problem was identified adds strength to the notion that, despite its limitations, our study provides a comprehensive picture of the health status of this population.

Another limitation was that data were extracted retrospectively by only one coder, a primary care physician who had not necessarily been involved in the care of each of the patients. Errors in coding, however, were minimized by setting strict rules for coding at the initiation of the study. Doubts were discussed and resolved in regular meetings with the research team. Finally, we studied a single facility in one country. Thus our findings may not necessarily be generaliseable to other detention centers in other countries. Yet we hypothesize that the health profile described here would be comparable in other detention centers where the sociodemographic profile corresponds to that described here. The study population was similar to that of other pre-trial prisons in Switzerland, which are also characterized by high proportions of migrants (81.4%) and males (94%) [6]. Factors contributing to the high rates of incarceration in migrants include high rates of illegal migration throughout Europe, the lower socio-economic status of this group and the fact that they are less likely to be granted a bail sentence. The high proportion of foreigners in Swiss jails underlines the need for culturally-sensitive approaches and non-stigmatizing attitudes towards this vulnerable population.

Strengths of the study include the large sample size including inmates of both genders. Information was gathered on all inmates present in the detention facility over an entire year. The use of the ICPC-2 coding system allowed us to capture the full range of health needs for which these inmates could benefit from primary care services upon admission and during their incarceration.

The wide range of health problems that were identified in this prison population highlights the need for GP working in prison to acquire skills in many domains, including general internal medicine, addiction medicine, psychiatry and language- and culturally-appropriate communication with patients. Prison health services and prison authorities should carefully assess the possibilities for strengthening self-care options in prison in order to reduce the burden of self-limited illnesses on primary care services. For many inmates, contact with the prison health service is their first ever opportunity to meet a health professional. Addressing the health needs of these prisoners through well coordinated psychiatric and primary care services offers an opportunity to reach-out to this hard-to-reach vulnerable population in the interest of their individual health and of public health.