Capacity-building strategies that support correctional and justice health professionals to provide best-evidenced based healthcare for people in prison: a systematic review

Abstract

Background

The United Nations (UN) 2015 ‘Mandela Rules’ stipulates that people in prison will have access to equivalent healthcare to other community members. This expectation has challenged prisons in high-income countries to strengthen healthcare delivery to better meet the needs of the growing number of incarcerated First Nations and older, frailer people, many with complex healthcare needs. Yet little is known about correctional and justice health professionals’ (‘prison workforces’) capacity to identify and support people in prisons with complex healthcare needs.

Aim

To identify the post-Mandela Rules strategies that have increased the prison workforce’s capacity to provide evidence-based healthcare.

Methods

A systematic review. Three health and Criminal Justice databases were searched (2015-June 2024) to identify empirical data regarding the ‘individual’, ‘organizational’ and ‘community’ capacity-building strategies employed to improve the prison workforce's healthcare capabilities. Kirkpatrick's Model was used to assess the evaluation level, while Popay’s narrative synthesis was applied to the extracted data. Findings are reported according to the PRISMA Statement.

Results

Of the 20 included articles, the highest level of evidence (level III) was generated by a mixed methods study, with most (n = 17) generating low-level (Level IV) evidence. Ten studies evaluated mental health behavioral capacity-building strategies, with limited attention given to other chronic illnesses, ageing, palliative care, or cultural needs. More complex capacity-building strategies that included individual, organizational, and community-level elements generated the best outcomes. The best individual-level capacity-building outcomes were more frequent (> 5 occasions) interactive health-related education delivered in partnership with external experts. However, the commonly employed capacity-building strategies were short didactic education sessions, which were less effective.

Conclusion

If prisons are to meet the UN Mandela Rules’ aspirations, more impactful individual, organizational and community-level capacity-building strategies are urgently required. Transitioning to co-designed, interactive, culturally sensitive, evidence-based approaches is crucial if the prison workforce is to better recognize and effectively respond to the needs of more culturally diverse and older, sicker populations with complex healthcare needs.

Trial registration

Prospero CRD42023410564.

Background

The 2015 United Nations (UN) Standard Minimum Rules for the Treatment of Prisoners (‘Mandela Rules’) [1] are crucial for improving prison healthcare as they set internationally recognized standards for the humane treatment of people in prison. They emphasize that healthcare is a right and ought to be equivalent to that available in the community, including access to qualified health professionals, independent healthcare oversight, and protection from inhumane treatment or neglect [1]. They highlight the need for healthcare to be impartial, patient-centered and focused on rehabilitation rather than punishment [1]. When implemented the Mandela Rules ensure dignity and prevent the physical and mental health deterioration of people in prison, which is critical given this population's changing demographic and epidemiological profile [1].

Changing epidemiological profile of people in prison

In high-income countries, First Nations people, compared to non-First Nations people, are overrepresented in prison populations, including in Australia (2,701 vs 208 persons per 100,000) [2]; United States of America (763 vs 181 persons per 100,000)[3]; Canada (426 vs. 40 persons per 100 000, and New Zealand, where 50.9% of the prison population is Māori (528 per 100,000)[4], which is seven times higher than the general population [5].

A combination of poor social determinants of health, sedentary prison lifestyles, inadequate nutrition, and the psychological strain of incarceration, along with a higher prevalence of mental health and/or substance use disorders, contribute to earlier onset of comorbid illnesses for people in prison [6]. Due to the compounded effects of accelerated physiological ageing and its related challenges [7], people in prison are considered older at 50 or 45 years for First Nations people [8]. Increasingly, older people in prison experience disability, mobility issues, loss of independence, impaired cognition, and progressive life-limiting illnesses [9], which increase their vulnerability and need for timely healthcare, which is of considerable concern as the prison population is rapidly ageing due to historical convictions and longer sentences [10]. In Australia, between 2009 and 2018, the number of people in prison aged 45 and over rose by 79% from 5,300 to 9,600 individuals [11] and is currently 25% of the prison population [12]. The United States, 32.6% of people in prison are 46 years old and over [13], Canada has 26.1% a prison population of over 50 years [14], with UK 17% of people in prison are aged 50 years or older [15].

Security concerns, limited resources, and the need to manage chronic complex illnesses, substance use disorders, infectious diseases and the needs of an increasingly diverse and older population in a confined and highly regulated setting challenge the provision of optimal healthcare for people in prison [9]. In most countries, the challenge of delivering prison healthcare is compounded by the relative independence of correctional and justice health services and staff. Two distinct professional groups, correctional staff and justice health professionals, make up the prison workforce. Correctional staff (e.g., prison officers and administrators) are primarily responsible for safety, security, and the overall management of the prison environment. In contrast, justice health (e.g. doctors, nurses and allied health) professionals are responsible for providing clinical care that aligns with community healthcare standards [16, 17]. These distinct roles mean that correctional staff often lack the capabilities required to notice, escalate and effectively support people in prisons living with multiple comorbidities, declining health or to identify the cultural safety needs of First Nations people [18, 19]. This is despite the Mandela Rule's [1], and the UN Declaration on the Rights of Indigenous Peoples [20, 21] requiring the highest standard of health and well-being to be afforded to people in prison.

Given the rapidly changing demographic profile of people in prison due to historical crimes and longer sentences [10], understanding what capacity-building strategies have enabled the prison workforce to support a more culturally diverse and older, sicker and prison population is of growing global importance [18, 22].

Capacity-building

Capacity-building is integral to extending care to underserved populations, such as people in prison, as it assists with:

…the development of knowledge, skills, commitment, structures, systems, and leadership to enable effective health promotion [23] page 341.

To be effective, capacity-building requires actions at three levels: “…1) the advancement of knowledge and skills among practitioners; 2) the expansion of support and infrastructure for health promotion in organizations; and 3) the development of partnerships for health in communities” [23] page 341. Yet, little is known about the capacity-building strategies required to build the prison workforce’s capacity to care for people in prison with complex and diverse healthcare needs.

Aim

To identify the strategies implemented since the introduction of the -Mandela Rules and their impact on the prison workforce’s capacity to provide evidence-based healthcare to people in prison.

Method

Design: A systematic review reported according to the PRISMA Statement [24] and registered in PROSPERO (CRD42023410564).

Search strategy

Keywords and Medical Subject Headings (MeSH) were developed with support from a university librarian (Supplementary Material 2). A systematic search of relevant justice and health-related electronic databases, including ProQuest Criminal Justice, Web of Science and CINAHL was completed in June 2024.

The reference lists of all included articles were manually searched to obtain other pertinent articles.

Eligibility criteria

Eligible studies were those published in English, in peer-reviewed journals since the adoption of The Mandela Rules in 2015 [1] and reported empirical data measuring the impact of strategies designed to build the capacity of correctional and/or justice health professionals (≥ 50% of the sample) to improve the health of adults in prison.

Study selection

Articles were downloaded into Covidence, and duplicates and non-primary articles were removed. Title and abstract screening was conducted by three reviewers (MH, CV and JLP) to eliminate ineligible studies [25]. One reviewer (MH) assessed all remaining for final inclusion, resolving disagreements through discussion with another reviewer (CV or JLP).

Risk of bias and quality

One author (MH) completed quality appraisal using the JBI Critical Appraisal Checklist for Quasi-Experimental Studies [26], confirmed by a second author (CV). Disagreements were resolved through discussion with the full authorship team.

Definitions

In this systematic review, the term"prison workforce"refers to the entire correctional workforce, including both correctional staff and justice health professionals. If a capacity-building strategy targets only one segment of the workforce, that specific group will be explicitly identified, such as"correctional staff"or"justice health professionals,"rather than both.

Data collection and analysis

A standardized table was used to capture: 1) details and results of included studies, 2) capacity-building strategies, and 3) Kirkpatrick Evaluation levels [27] (Table 1).

Table 1 Summary table

Capacity-building and evaluation

Identified capacity-building strategies were classified as targeting: 1) individual (i.e., correctional or justice health professionals), 2) infrastructure (i.e., changes to the prison environment), and/or 3) community-level actions (i.e. within or outside the prison) [23]. The evaluation of the capacity-building strategies was assessed using the Kirkpatrick Evaluation Model [27], as summarized below:

• Level 1 (Reaction) evaluates participants’ perception of training relevance, engagement, and satisfaction.

• Level 2 (Learning) measures participants’ knowledge, confidence, skills, attitude, and commitment acquired.

• Level 3 (Behavior) appraises participants'application of the learned concepts to their practice.

• Level 4 (Results) assesses the achievement of targeted outcomes post-training [49].

Narrative synthesis

A narrative synthesis was used to summarize and explain the study findings [50]. Preliminary synthesis identified patterns in the effects’ direction, size and relationships between facilitators and barriers to successful capacity-building strategies. Differences between studies were examined to understand the intervention's impact on capacity-building. Validity assessment and critical appraisal ensured robustness of synthesis, providing insights into evidence-based approaches beneficial for building the prison workforce capacity to manage complex health needs [50].

Results

Of the 20 included studies (Fig. 1), most originated from the United States of America (USA) (n = 12) or Canada (n = 3)). Despite the high risk of bias (Supplementary Material 3), no studies were excluded as each offered valuable insights into capacity-building strategies for improving prison healthcare.

Fig. 1

PRISMA flow diagram

Evidence levels

Most studies (n = 17) generated lower-level IV evidence, except for a mixed-methods feasibility and acceptability study evaluating the implementation of Problem-Solving Training to reduce self-harm in prisons (Level III evidence)[44].

Capacity-building primary, secondary and tertiary healthcare focus

Two studies sought to build the prison workforce’s (e.g. Justice Health and Correctional staffs) capacity to reduce the impact of Hepatitis A and infections through routine screening and vaccination [31, 38]. While most capacity-building strategies focused on the correctional staffs’ role in reducing the impact of mental health events [30, 37, 40, 47, 48], a smaller number of strategies focused on the secondary prevention of opioid misuse disorder, hepatitis and suicide [32, 33, 38]. Antimicrobial stewardship was the only secondary prevention capacity-building strategy solely involving justice health clinicians [46]. Most interprofessional tertiary-level prevention capacity-building strategies sought to reduce the impact of various complex comorbidities, including mental health [34, 39, 41, 42, 44] or substance misuse disorders [29, 41, 43, 45]. Two studies focused on improving care for older people in prison [22, 36].

Level of evaluation

The evaluation of the capacity-building strategies varied widely, as summarized below (Table 2).

Table 2 Summary of the capacity-building strategies by engagement occasions, capacity-building levels and strategies and evaluation levels

Kirkpatrick evaluation level 1

Two studies involving justice health clinicians assessing the training format, relevance and engagement [41, 43] reported that workload constraints impeded their participation [41, 43]. Leading Pearce, Mathany [43] to recommend that correctional staff be included in all health-related interventions so they can be more successfully implemented.

Kirkpatrick level 2

Five of the six studies that measured knowledge and skill acquisition [22, 30, 33, 36, 39, 42] reported a higher level of knowledge attainment, which was attributed to tailoring the content to the unique operational and learning environments [30, 33, 36, 39, 42]. While short courses delivered by external content experts who understood the prison context increased correctional staff trauma-informed mental health knowledge (p = 0.046)[42].

Kirkpatrick level 3

Five studies evaluated skill application in the work environment [29, 32, 34, 47, 48]. A 17-month experiential training for psychology graduates (n = 7) enhanced prison-related skills, but frequent transfers hindered post-treatment outcome assessment [29]. Similarly, a trauma-informed workshop improved correctional staff's perception of the quality of life (QoL) for people in prison ($\overline{x}$ 3.45 vs. 2.69); however this strategy did not result in people in prisons reporting a better QoL [34].

Three studies evaluating strategies to enhance the mental health capabilities of corrections staff found that more intensive engagement yielded the best outcomes [32, 47, 48]. A six-day (48-h) experiential workshop delivered by psychiatric nurses improved correctional staff (n = 83) mental health knowledge (p = < 0.01), reduced stigmatization (p = < 0.5) and enhanced their interactions with people with mental illness (p = < 0.05) [47]. Similarly, a five-day (40-h) experiential workshop for correctional (n = 100) and law enforcement (n = 179) staff increased their mental health knowledge (p = < 0.001), self-efficacy (p = < 0.001), perceptions of verbal de-escalation (p = < 0.001), sustaining improvements 30-days post-training [48]. Qualitative prison workforce feedback on the mandatory biannual suicide prevention training provided in 22 USA prisons indicated that it enhanced their behavior and improved their ability to respond to people in prison’s suicide risk [32].

Kirkpatrick level 4 (level 4)

Seven studies assessing the impact of capacity-building strategies reported variable results [31, 37, 38, 40, 44,45,46]. People in prison’s depression improved (p = 0.06) after correctional staff completed a 3.5-h Cognitive Behavioral Therapy (CBT) workshop [37]. This improvement was attributed to adapting the learning content and materials (e.g., removal of illustrations and inclusion of permitted activities) to increase correctional staff's initial buy-in [37].

A combination of didactic lectures, peer education, and a cultural mediator inter-cultural approach delivered mixed success in increasing participation in a Hepatitis B virus screening and vaccination program across 15 Italian prisons [38]. This variance in success was attributed to different prison populations and resourcing [38]. While a 40-h Crisis Intervention Training (CIT) program combining didactic and experiential role-play successfully increased correctional staff mental health referrals and improved compliance, however it did not significantly reduce their use of force [40]. A short one-hour voluntary case-based didactic problem-solving training session for the prison workforce led to an 18% decrease in self-harm incidents involving people in prison three months post-training [44].

Few studies (n = 3) reached their desired training and support outcomes [31, 45, 46]. There was a 97.5% improvement in Hepatitis A and B vaccine status screenings, leading to an 8.7% increase in vaccination rates [31]. Though modest compared to the overall population, this outcome was adversely impacted by post-pandemic vaccine hesitancy [31]. A collaborative capacity-building strategy involving French psychiatrists and pharmacists over 15 years resulted in a 30% reduction in benzodiazepine-related issues for people in prison [45]. The implementation of multidisciplinary antimicrobial stewardship programs, closed formularies and clinical practice guidelines across 122 USA prisons effectively reduced antibiotic prescribing and increased the appropriate use of antimicrobials [46].

Capacity-building strategy levels

Singular and multi-level capacity-building strategies (i.e., individual, organizational, and/or community) and their intensity varied across the studies (Table 2). While resource constraints and institutional barriers influenced the frequency of capacity-building strategies, consistent or repeated strategies tended to lead to improved outcomes [22, 31, 32, 34, 38, 42,43,44].

Individual-level strategies

All studies implemented individual-level capacity-building strategies, and for half (n = 10), this was the only capacity-building strategy employed [30]. While the prison workforce preference is for experiential learning, 65% of the studies utilized a less effective didactic education format [22, 29, 30, 33, 40, 42,43,44, 47, 48].

Overall, the use of experiential learning capacity-building strategies delivered better outcomes. A fortnightly Opioid Use Disorder (OUD) Extension for Community Healthcare Outcomes (ECHO) delivered via videoconferencing improved justice health clinicians knowledge (p = 0.013) over five months [33]. Experiential learning augmented with weekly supervision sessions, a journal club, and leadership development improved prison psychologists'CBT knowledge and skills, acceptance and commitment therapy, and motivational interviewing [29]. In another study, experiential learning increased correctional officers’ mental health knowledge (p ≤ 0.02) [47]. A recent evaluation of co-designed ‘Enhancing Care of the Aging and Dying in Prisons’ learning modules demonstrated an improvement in affective and cognitive outcomes (p ≤ 0.0001) across seven correction sites [36]. Results suggest experiential learning co-designed with the prison workforce has the most significant impact on capacity building in prisons [29, 33, 36].

Organizational level strategies

More complex capacity-building strategies that combined individual and organizational level strategies also generated better outcomes [32, 37, 38, 41, 46]. Managerial support was vital in successfully implementing online webinars for justice health nurses working in a rural prison [41]. Managers who actively organized and promoted educational opportunities significantly enhanced the feasibility of participation [41]. Significant investment in ongoing professional development and sustained learning can improve healthcare quality in correctional settings [41]. Similarly, Long, LaPlant and McCormick [46] found frequent engagement and education regarding antimicrobial stewardship across 122 prisons led to significant improvements. Given the complexity of the prison environment, continuous real-time problem-solving and education were crucial for Justice Health clinicians maintaining best practice antibiotic stewardship behaviour [46].

The introduction of a three-level suicide rating scale, which categorized individuals based on their suicide risk (Level 1 for verbal threats, Level 2 for suicidal gestures, and Level 3 for serious suicide attempts) was a successful infrastructure strategy [32]. This risk stratification system helped increase the prison workforces suicide risk factors knowledge, more effectively identify and monitor individuals at risk, leading to a reduction in completed suicides[32]. Organizational capacity-building strategies (e.g., clinical champions, a national closed formulary, clinical practice guidelines and antimicrobial stewardship) led to a significant reduction in antibiotic prescription rates across four USA prisons [46]. Monthly benzodiazepine prescription review meetings involving psychiatrists and pharmacists lead to lower benzodiazepine doses for people in prison, particularly those taking high doses [45]. The introduction of Hepatitis B screening and vaccination programs across fifteen prisons resulted in most (91.3%) of the prison population being screened and 67% of at-risk individuals receiving their first Hepatitis B vaccination [38]. Using cultural mediators and peer educators to support individuals from multi-ethnic backgrounds and a preparedness to adapt the program based on early feedback was central to this program's success [38]. Structured opportunities for reflection and learning, supported by management and strategies tailored to the unique prison context, collectively improved the prison workforce’s engagement and care provision [32, 37, 38, 41, 46].

Individual, organizational infrastructure and community strategies

Results indicate frequent, multi-level capacity-building strategies across individual, organizational, and community levels produce better and more sustainable outcomes in correctional settings. High-intensity engagement across the three capacity-building levels improved mental health treatment in a rural correctional facility by focusing on the consistent development of trainee psychologist skills, long-term infrastructure development, and strong prison, university and federal judiciary partnerships to ensure adaptability and long-term sustainability [29]. Integrating the role of correctional health within broader community health supported by integrated electronic medical records improved continuity of care and health outcomes [31]. Evidence from a pharmacotherapy program involving psychiatrists and pharmacists, utilizing multilevel capacity-building strategies, effectively reduced benzodiazepine use among people in prison over 15-years [45].

Ongoing education (i.e., advancing knowledge and skills through monthly meetings), infrastructure development (i.e., systematic prescription review and the creation of guidelines), and fostering partnerships (i.e., teamwork between healthcare professionals). The consistent application of these approaches over time led to significant reductions in high-dose benzodiazepine prescriptions and improved medication management within the prison system [45]. A variety of strategies were used to increase correctional staff's capacity to manage the mental health needs of people in prison, including theoretical learning over a four-day workshop, a psychoeducational approach through problem-based learning with simulations and role-play, two days of observational experience with structured personal exposure, and peer supervision sessions equating to 12 occasions of engagement [47]. Davidson [48] also employed a number of strategies to engage learners, focusing on active learning strategies, including role-playing exercises, to reinforce skill development; refresher training to strengthen the skills and knowledge gained from initial training; and mentorship through newly trained officers being paired with veterans for brief periods of field training, allowing them to apply their new skills in real-world scenarios under the guidance of experienced personnel. Training a diverse group of professionals with a high frequency of engagement (n = 5) across both law enforcement and corrections systems developed a more informed and capable infrastructure for managing mental health crises, empowering multiple sectors of the community to address mental health concerns [40] effectively.

A more recent study led by McNeeley and Donley [40] addressed capacity-building strategies at all three levels, leading to improved capacity for mental health care provision. At the individual level, CIT enhanced correctional officers'knowledge and skills in mental health crisis management and de-escalation techniques. At the organizational level, the implementation of CIT expanded the support and infrastructure for mental health interventions within the correctional system, helping to institutionalize these practices. Finally, at the community level, the CIT model fostered partnerships with external mental health services, ensuring that people in prison had access to necessary mental health resources through referrals exemplified by the proportion of employees with CIT training were positively related to a mental health referral (p = 0.002). These strategies combined to build capacity in managing mental health crises in correctional facilities [40].

Facilitators and barriers

The key facilitators critical to the success of implementation and sustainability of capacity-building strategies in correctional settings were interdisciplinary collaboration, program flexibility, practical training methods, and the creation of supportive organizational environments (see Table 3). Conversely, the barriers highlight the challenges that hinder progress, including resource limitations, logistical constraints, and pervasive stigma and resistance to change within correctional institutions. An example of this resistance to change is seen in the recent Lai, Fiona Mair [37] study, where correctional staff declined monthly supervision. Time and resource constraints made it difficult for most correctional staff to translate their new knowledge into practice [44]. This highlights the challenges of translating potentially effective strategies in resource-constrained prison environments where participation is voluntary [44] and the need for multiple strategies across the three organizational levels (individual/organization and community) to achieve better outcomes [40].

Table 3 Facilitators and barriers table

Discussion

This systematic review highlights the growing complexity of prison healthcare needs and the lack of well-designed capacity-building strategies that have effectively improved healthcare outcomes since the introduction of the UN Mandela Rules. This gap underscores the need for comprehensive, evidence-based approaches to address healthcare disparities, particularly for First Nations people and older people in prison [51].

Building the prison workforce's healthcare capabilities

While the most successful strategies include action at all three capacity-building levels [23], this was rarely adopted. Since 2015, most capacity-building efforts in prison healthcare have focused on low-frequency individual-level strategies that rely on less effective and less preferred didactic educational approaches [22, 31, 32, 34, 38, 42,43,44]. While few interactive strategies were employed, those that did deliver better healthcare outcomes for people in prison [29, 30, 39, 40, 45, 47, 48]. Few of the individual-level strategies utilized adult learning principles [52] or experience as a basis for learning [53].

Individual-level capacity-building strategies in correctional settings ought to be grounded in adult-learning principles that respect autonomy, recognize prior knowledge, are experiential-based [43, 47, 48] and simulate forensic patients'care needs [54] using problem-focused learning that can be promptly applied [55]. To be more effective, they should also consider adopting coaching, mentoring, technical assistance, in-depth consultations, virtual or in-person training sessions, online learning options, guidance materials, or skill-based courses. [56].

While building individuals’ capabilities is necessary, most organizations that rely solely on training for job performance achieve a success rate of less than 15%. [28]. Organizational support is critical to designing sustainable, systemic, and multilevel training that improves outcomes, as demonstrated in other multi-disciplinary workforces, such as early childhood education [57], residential aged care [58, 59], and disability care [60] sectors. Processes that reinforce, monitor, encourage, and reward performance in combination with individual capacity-building strategies can expect 85% application of training, knowledge and skills to the role [28]. Infrastructure adjustment, resource allocation, active leadership involvement, and commitment to sustainability effectively built capacity in one study [31]. Investing in organizational change that creates a positive learning culture can lead to better health outcomes by enhancing teamwork and communication, fostering continuous learning, and improving training program engagement [58]. Adopting a flexible model that supports continuous quality improvements to sustain best practice [59] could be readily replicated within correctional settings.

Establishing effective community partnerships is essential because many determinants of health are outside the realm of the initial (i.e. prison) health service [17]. The power of a cohesive community-level capacity-building healthcare partnership that provides ongoing supervision and support to correctional staff can lead to more appropriate in-reach healthcare referrals for people in prison [48, 61] and a positive reduction in the use of force and associated injury [48]. Combined with continual peer and supervisor support, a collaborative in-reach model is most likely to influence positive sustained transference of learned knowledge, skills and attitudes [62]. Although implementing these strategies can be challenging, integrating clinical decision support systems into existing healthcare infrastructure can have positive long-term impacts [62]. However, the lack of documented long-term follow-up introduces uncertainty regarding the sustainability of these strategies [31].

Changing population needs

A clear gap emerging from this systematic review is the need to develop capacity-building strategies that enable the prison workforce to meet better the needs of First Nations people, older people in prison, and the growing number of people living with multiple co-morbidities. Research indicates a need to build the required competencies necessary for working with people in prison who belong to cultural, ethnic or religious minorities. [63]. This systematic review found that very few capacity-building strategies included the cultural, ethnic or religious needs of people in prison. Due to the high numbers of First Nations people incarcerated globally [6, 64, 65] that are aging [10], a cultural lens needs to be applied to all future capacity-building strategies.

Enabling earlier identification of the declining health in older people, including those with aged, chronic and palliative care needs would help facilitate better healthcare management and outcomes for this population [66]. Increasingly, correctional staff will be called upon to identify the declining health of older people in prison, including cognitive decline, much earlier in their illness trajectory and to promptly refer those with unmet needs to their justice health colleagues [22, 48, 67,68,69]. The prison environment can mask the onset of cognitive decline with disruptive or aggressive behavior often misinterpreted as being related to the person's comorbid mental health, intellectual disability, or drug use [70]. The inability of correctional staff to differentiate between these states often results in people being reprimanded for intentional rule-breaking rather than their behavior being linked to undiagnosed dementia [70]. As the prison population continues to age and the incidence of dementia increases, the need for dementia training in prisons will increase [70]. This changing profile requires a well-prepared correctional workforce with the capacity to identify people in prison’s changing healthcare needs and clearly defined pathways that allow for timely referral to justice health.

Research implications

Most prison healthcare capacity-building has focused on mental health, crisis intervention, managing blood-borne pathogens, and opioid misuse training [71]. Human rights, tolerance and rehabilitation, along with understanding the religious, cultural, and ethnic needs of people in prison, are rarely the focus of correctional staff training [71]. Few capacity-building strategies have focused on preparing the correctional workforce for the changing needs of a more culturally diverse, aging prison population living with multi-morbidity who are increasingly likely to have future palliative care needs.

Further research is required to determine the most effective capacity-building strategies for correctional and justice health professionals to address the complex healthcare needs of people in prison. More extensive and well-designed comparative studies between countries, criminal justice systems, and correctional settings may aid in developing capacity-building strategies applicable to a broader range of settings. Given the complex nature of capacity-building, there is a need to move beyond immediate and simple evaluations to longstanding measurements. Applying the Donabedian approach to structure, process, and outcomes measurement [72] will enable a better assessment of the impact of future health-related capacity-building strategies in correctional settings.

The adoption of co-designed principles that incorporate the lived experience and acknowledge the nuanced prison environment [73] would greatly assist with the development of more tailored capacity-building strategies. Engagement with a representative spread of stakeholders and the prison workforce in co-design work [74] will increase the likelihood of successful implementation and more effective translation into policy and practice [75].

Cultural perspectives were a notable gap in this systematic review, with only one study incorporating cultural needs [38]. Yet, it is identified as an influential factor [42]. Transitioning from didactic to co-designed interactive, culturally intelligent, evidence-based approaches is most likely to build the prison workforce’s capacity to recognize and respond to First Nation peoples evolving healthcare and cultural needs. Given the decay of knowledge post-training [48, 69] training at regular intervals may be required [22]. Future research needs to determine the most effective interval for incorporating First Nation cultural needs.

Strengths and limitations

This systematic review's major strength is its systematic methodology. The screening for inclusion, completed independently by two reviewers, ensures that the included studies are relevant and few are likely to have been missed. The systematic approach to data extraction, analysis, and synthesis of information confers confidence in study outcomes.

A limitation of this systematic review is the inclusion of studies generating low levels of evidence with a high risk of bias and wide variance in study designs, small sample sizes, minimal long-term follow-up data, and non-existent data beyond service utilization. The samples are also at risk of bias due to non-responsiveness, and missing data from incomplete responses may have skewed the results. The distal relationship between building the prison workforce's capacity to provide trauma-informed care and only targeting one aspect of QoL may have impacted these results [34]. As most of the studies were undertaken in the USA and UK, this precludes broader generalization.

Conclusion

Broad capacity-building approaches are required to build the prison workforce's competence to recognize and respond to people in prisons’ complex and increasingly deteriorating healthcare needs. Co-designing these strategies with the prison workforce is pivotal to improved engagement, retained skill development and outcomes. Ensuring any health capacity-building initiative is undertaken in partnership with Justice Health and supported through formalized partnerships with other relevant health providers is also key to sustaining practice improvement. Partnership work (corrections, health staff, cultural consultants) focused on providing supervision, observational service orientation, and ongoing training at organizational and community levels shows promising impact.