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BackgroundResearch exploring the drivers of health outcomes of women who are in prison in low- and middle-income settings is largely absent. This study aimed to identify and examine the interaction between structural, organisational and relational factors influencing Zambian women prisoners' health and healthcare access.MethodsWe conducted in-depth interviews of 23 female prisoners across four prisons, as well as 21 prison officers and health care workers. The prisoners were selected in a multi-stage sampling design with a purposive selection of prisons followed by a random sampling of cells and of female inmates within cells. Largely inductive thematic analysis was guided by the concepts of dynamic interaction and emergent behaviour, drawn from the theory of complex adaptive systems.ResultsWe identified compounding and generally negative effects on health and access to healthcare from three factors: i) systemic health resource shortfalls, ii) an implicit prioritization of male prisoners' health needs, and iii) chronic and unchecked patterns of both officer- and inmate-led victimisation. Specifically, women's access to health services was shaped by the interactions between lack of in-house clinics, privileged male prisoner access to limited transport options, and weak responsiveness by female officers to prisoner requests for healthcare. Further intensifying these interactions were prisoners' differential wealth and access to family support, and appointments of senior 'special stage' prisoners which enabled chronic victimisation of less wealthy or less powerful individuals.ConclusionsThis systems-oriented analysis revealed how Zambian women's prisoners' health and access to healthcare is influenced by weak resourcing for prisoner health, administrative biases, and a prevailing organisational and inmate culture. Findings highlight the urgent need for investment in structural improvements in health service availability but also interventions to reform the organisational culture which shapes officers' understanding and responsiveness to women prisoners' health needs.

BackgroundPrison populations in sub-Saharan Africa (SSA) experience a high burden of disease and poor access to health care. Although it is generally understood that environmental conditions are dire and contribute to disease spread, evidence of how environmental conditions interact with facility-level social and institutional factors is lacking. This study aimed to unpack the nature of interactions and their influence on health and healthcare access in the Zambian prison setting.MethodsWe conducted in-depth interviews of a clustered random sample of 79 male prisoners across four prisons, as well as 32 prison officers, policy makers and health care workers. Largely inductive thematic analysis was guided by the concepts of dynamic interaction and emergent behaviour, drawn from the theory of complex adaptive systems.ResultsA majority of inmates, as well as facility-based officers reported anxiety linked to overcrowding, sanitation, infectious disease transmission, nutrition and coercion. Due in part to differential wealth of inmates and their support networks on entering prison, and in part to the accumulation of authority and material wealth within prison, we found enormous inequity in the standard of living among prisoners at each site. In the context of such inequities, failure of the Zambian prison system to provide basic necessities (including adequate and appropriate forms of nutrition, or access to quality health care) contributed to high rates of inmate-led and officer-led coercion with direct implications for health and access to healthcare.ConclusionsThis systems-oriented analysis provides a more comprehensive picture of the way resource shortages and human interactions within Zambian prisons interact and affect inmate and officer health. While not a panacea, our findings highlight some strategic entry-points for important upstream and downstream reforms including urgent improvement in the availability of human resources for health; strengthening of facility-based health services systems and more comprehensive pre-service health education for prison officers.

Objective To improve the Zambia Prisons Service's implementation of tuberculosis screening and human immunodeficiency virus (HIV) testing. Methods For both tuberculosis and HIV, we implemented mass screening of inmates and community-based screening of those residing in encampments adjacent to prisons. We also established routine systems--with inmates as peer educators--for the screening of newly entered or symptomatic inmates. We improved infection control measures, increased diagnostic capacity and promoted awareness of tuberculosis in Zambia's prisons. Findings In a period of 9 months, we screened 7638 individuals and diagnosed 409 new patients with tuberculosis. We tested 4879 individuals for HIV and diagnosed 564 cases of infection. An additional 625 individuals had previously been found to be HIV-positive. Including those already on tuberculosis treatment at the time of screening, the prevalence of tuberculosis recorded in the prisons and adjacent encampments--6.4% (6428/100000)--is 18 times the national prevalence estimate of 0.35%. Overall, 22.9% of the inmates and 13.8% of the encampment residents were HIV-positive. Conclusion Both tuberculosis and HIV infection are common within Zambian prisons. We enhanced tuberculosis screening and improved the detection of tuberculosis and HIV in this setting. Our observations should be useful in the development of prison- based programmes for tuberculosis and HIV elsewhere. [TEXT NOT REPRODUCIBLE IN ASCII] [TEXT NOT REPRODUCIBLE IN ASCII] Objectif Ameliorer la mise en ceuvredes depistages de la tuberculose et du virus de limmunodeficience humaine (VIH) de l'Administration penitentiaire de la Zambie. Methodes Nous avons mis en oeuvre les depistages de masse a Ia fois pour la tuberculose et le VIH chez les detenus et le depistage communautaire des personnes residant dans les campements adjacents aux prisons. Nous avons egalement etabli des systemes de routine en utilisant les detenus pour eduquer leurs pairs--pour le depistage des nouveaux detenus ou des detenus symptomatiques. Nous avons ameliore les mesures de controle des infections, augmente la capacite diagnostique et promu la sensibilisation a la tuberculose dans les prisons de Zambie. Resultats Pendant une periode de 9 mois, nous avons teste 7638 personnes et diagnostique 409 nouveaux patients atteints de tuberculose. Nous avons teste 4879 personnes pour le VIH et diagnostique 564 cas d'infection. En outre, 625 personnes avaient deja ete prealablement depistees comme etant seropositives pour le VIH. En tenant compte des personnes deja traitees contre la tuberculose au moment du depistage, la prevalence de la tuberculose rapportee dans les prisons et les campements adjacents--6,4% (6428/100 000)--est 18 fois superieure a 1'estimation de la prevalence nationale de 0,35%. Dans l'ensemble, 22,9% des detenus et 13,8% des individus residant dans les campements etaient seropositifs pour le VIH. Conclusion Les infections par la tuberculose et leVIH etaient courantes dans les prisons zambiennes. Nous avons ameliore le depistage de la tuberculose et la detection de la tuberculose et du VIH dans ces conditions. Nos observations devraient etre utiles pour developper les programmes penitentiaires de lutte contre la tuberculose et le VIH ailleurs dans le monde. [TEXT NOT REPRODUCIBLE IN ASCII] Objetivo Mejorar la aplicacion dei servido de prisiones de Zambia de deteccion de la tuberculosis y Ias pruebas del virus de la inmunodeficiencia humana (VIH). Metodos Para la tuberculosis y el VIH, se llevo a cabo una deteccion masiva de reclusos y la deteccion comunitaria de aquellos que residian en campamentos adyacentes a Ias prisiones.Tambien se establecieron sistemas rutinarios para la deteccion de los reclusos reden ingresados o sintomaticos en los que los reclusos actuaban como educadores de sus companeros. Se mejoraron Ias medidas de control de la infeccion, se aumento la capacidad diagnostica y se promovio el conocimiento de la tuberculosis en Ias prisiones de Zambia. Resultados En un periodo de 9 meses, se examino a 7638 personas y se diagnostico tuberculosis a 409 pacientes nuevos. Se realizaron pruebas del VIH a 4879 personas y se diagnosticaron 564 casos de infeccion. Previamente se habia hallado que otras 625 personas era VIH positivas. Teniendo en cuenta aquellas personas que ya estaban en tratamiento para la tuberculosis en el momento de la deteccion, la prevalencia de la tuberculosis en Ias prisiones y los campamentos adyacentes, a saber, 6,4 % (6428/100 000), es 18 veces la estimacion de la prevalencia nacional de 0,35 %. En total, el 22,9 % de los reclusos y el 13,8 % de los residentes del campamento eran VIH-positivos. Conclusion Tanto la tuberculosis como la infeccion por VIH son comunes en las prisiones de Zambia. Se consiguio mejorar la deteccion de la tuberculosis y del VIH en este contexto, y esperamos que nuestras observaciones sean utiles para el desarrollo de programas de prision de la tuberculosis y el VIH en otros contextos., Introduction The United Nations has stated that prisoners are entitled to receive health care of a similar standard to that received by non-prisoners. (1) However, substandard health care and a [...]

Health and health service access in Zambian prisons are in a state of ‘chronic emergency’. This study aimed to identify major structural barriers to strengthening the prison health systems. A case-based analysis drew on key informant interviews (n = 7), memos generated during workshops (n = 4) document review and investigator experience. Structural determinants were defined as national or macro-level contextual and material factors directly or indirectly influencing prison health services. The analysis revealed that despite an favourable legal framework, four major and intersecting structural factors undermined the Zambian prison health system. Lack of healthfinancingwas a central and underlying challenge. Weak healthgovernancedue to an undermanned prisons health directorate impeded planning, inter-sectoral coordination, and recruitment and retention ofhuman resources for health. Outdated prisoninfrastructuresimultaneously contributed to high rates of preventable disease related to overcrowding and lack of basic hygiene. These findings flag the need for policy and administrative reform to establish strong mechanisms for domestic prison health financing and enable proactive prison health governance, planning and coordination. [ABSTRACT FROM PUBLISHER]