Development and Validation of a Manual of Skin Care for Persons Deprived of Liberty in the São Paulo State Prison System: A Descriptive Study

Brazil has the third largest prison population in the world. Studies on the health status of prisoners have shown that skin diseases, especially infectious skin diseases, are prevalent in this population. Because some skin diseases can be prevented, strategies to inform and guide incarcerated persons may be helpful. Purpose: The purpose of this study was to develop and validate a manual of skin care for use by prisoners in the São Paulo State Prison System. Methods: To develop the manual, a Google search to ensure originality of the concept was conducted, followed by an integrative literature search of the MEDLINE and the Latin American and Caribbean Health Science Literature, and the medical records of the prison system were reviewed for content. The Delphi technique was used to validate content; the content validity index (CVI) was determined based on the ratings of an expert panel of 10 prison employees who were health professionals and have experience providing care to prisoners. Twenty (20) target-users (prisoners) also evaluated the manual. The experts responded to questionnaires (sent by email) containing 19 items related to the manual’s objective, structure and presentation, and relevance. Items were rated on a Likert-type scale where 1 = inadequate, 2 = partially inadequate, 3 = adequate, 4 = very adequate, and NA = not applicable, and participants also could provide suggestions and comments on the manual. The prisoners used a paper-and-pencil questionnaire to assess the manual that included 14 items with 3-choice answers (agree, undecided, disagree) on the utility and ability to understand the manual topics and space to write concerns and suggestions regarding the utility of the content; they also could offer their thoughts and opinions about the manual. The proportion of agreement among responses was calculated. Results: The overall CVI of the first round of evaluations was 1.0. Suggested changes were to include guidelines on the proper use of medications and modify some wording. The overall CVI of the next round was 1.0 (100% agreement). The evaluation by target users showed an agreement of 98.6%. The final version of the manual has 8 topics, 12 subtopics, and 29 illustrations; topics include skin, hair, and nail care and skin diseases. A printed version is available in the prison library and an electronic copy was sent to all prisons in the State of São Paulo to be printed as needed. Conclusion: A manual providing guidelines on skin care for prison populations was developed and validated with the intent to improve prisoner quality of life and care. Research to examine overall manual usage and the effect of the information and guidance on healthy behaviors, prevention, and management of skin diseases is warranted.

Brazil has the third largest prison population in the world after the United States and China.¹ Studies on the conditions of life and health status of prisoners have only recently been conducted. Although the right to health of persons deprived of liberty is protected by law, the exploratory study by Minayo and Ribeiro² has shown many prisoners exhibit health problems, receive inadequate treatment, and lack information on disease prevention. Infectious diseases, including skin diseases, in prisons worldwide have been described in cross-sectional, descriptive, and observational studies.^3-5

Factors such as stress, smoking, hygiene habits, age, drug use, time spent in prison, and prison overcrowding may contribute to the onset of skin diseases in the prison environment.⁵ The most commonly reported skin diseases in prisons include folliculitis, furunculosis, pediculosis, scabies,⁴ skin and subcutaneous infections, dermatitis, eczema,  papulosquamous diseases,⁵ and the presence of fungal infections, which are usually associated with hot and humid climates, overcrowding, and poor hygiene.³

Few studies on skin diseases have been conducted among the Brazilian prison population.^2,6 A qualitative and quantitative exploratory study² on the living conditions of prison populations in the State of Rio de Janeiro was conducted among a stratified sample of 1573 prisoners, who were mostly men (70.6%), had no education or incomplete primary education (58.4%), and were a mean age of 31.1 years. The study found 43.4% of prisoners had allergies, allergic or contact dermatitis, and hives; 15.9% had ulcers, eczema, and psoriasis.²

Staphylococcus aureus can cause infections ranging from minor skin and soft tissue infections to life-threatening pneumonia or toxin-mediated diseases.⁶ A cross-sectional study⁷ conducted in a resocialization center in the state of São Paulo tested 302 male prisoners for nasopharyngeal colonization with S aureus and found prevalence rates of 16.5% and 0.7% for S aureus and methicillin-resistant S aureus (MRSA), respectively, in asymptomatic individuals. Men who had sex with men, individuals receiving medication delivered by inhalers, and those with previous lung or skin diseases were more likely to be colonized with S aureus.⁷

A case-control study⁸ with 10 cases and 18 controls was conducted to characterize the relationship between S aureus environmental contamination and clinical infection in 2 New York state maximum security prisons (men at Sing Sing Correctional Facility, Ossining, NY; women at Bedford Hills Correctional Facility, Bedford Hills, NY). Consenting study participants had a standardized set of environmental surfaces cultured, such as bed, sheets, sink handles, toilet flushes, toilet seats, and cell bars, among others. No significant associations were found between case status and gender, age, race/ethnicity, self-perceived health, shower frequency, and gym use. When present, surface contamination was more frequent among cases than among controls. None of the S aureus isolates were methicillin-resistant.⁸

An outbreak of skin infections caused by S aureus was observed in a prison in Nantes, France.⁶ Panton-Valentine, leukocidin-positive, methicillin-susceptible S aureus, which causes leukocyte destruction and tissue necrosis, was detected in 14 prisoners. Skin and soft-tissue infections tended to develop in tattooed areas of the body (n = 4) and in areas shaved daily with a mechanical razor (n = 4). The outbreak was controlled through individual and collective hygiene measures, educational interventions provided to prisoners and prison employees, and antibiotic treatment of skin and soft tissue infections.⁶

The prison population in the São Paulo State Prison System has access to health information brochures, especially on tuberculosis and sexually transmitted infections. In 2017, the State Department of Prison Administration [SAP] (Secretaria de Administração Penitenciária in Brazilian Portuguese) prepared a poster with guidelines for the prevention and control of scabies.

Although studies have reported the occurrence of skin diseases in prison units,^2-8 the development of an educational manual of skin care for prisoner use that takes into account the characteristics of the prison environment has not been described to date in the literature.

Educational materials can deliver standardized information regarding health care.⁹ Manuals can provide instructions on treatment, recovery, and self-care to patients and their families.

The purpose of this study was to develop and validate a manual of skin care for persons deprived of liberty in the São Paulo State Prison System.

Ethical considerations. This descriptive study was approved by the Research Ethics Committees of the Federal University of São Paulo (UNIFESP; certificate no. CAAE 74601417.2.0000.5505) and the State Department of Prison Administration (certificate no. CAAE 74601417.2.3001.5563), São Paulo, Brazil, and performed in accordance with the ethical standards of the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from all participants before their inclusion in the study and anonymity was ensured.

Determination of manual originality. A novelty search for similar publications to verify the originality of the main topic of the manual was conducted on Google Scholar and Google search engines as well as on the Brazilian Society of Dermatology and State Department of Prison Administration websites, with no restrictions on year of publication, using the terms handbooks, skin care, skin diseases, prisons, and prisoners for publications in English and Portuguese. No educational publication similar to the manual proposed in this study was found.

Manual development. All authors participated in manual development and conducted research accordingly. The studies were organized by topic, and content was included according to the skin diseases found in data collected from the medical records from January 2016 to January 2017 at the “Nestor Canoa” Prison in Mirandópolis, Brazil, to identify the most common skin diseases in this prison unit. Content for the manual was based on an integrative literature review covering the period 2012–2017 and limited to Portuguese and English publications performed of MEDLINE/PubMed) and the Latin American and Caribbean Health Science Literature (LILACS) databases using combinations of the terms skin care, skin diseases, and prisoners. In addition, a search was performed on Google Scholar and the Brazilian Society of Dermatology and Brazilian Health Ministry websites using the terms skin hygiene, skin diseases, and people in prison.

First, articles were screened for relevance by title and abstract. Articles on prevention and control of skin diseases in the general population or in the prison environment were included in the study; articles on drug treatments and duplicate publications were excluded. Articles that met the inclusion criteria were read in full by a researcher. The literature search yielded 311 potentially relevant publications; 279 articles were excluded from the study because they were duplicate publications, not related to skin diseases, dealt only with the treatment of skin lesions, or the title and abstract were in English but the full text was in Italian or French. Of the 32 selected articles, 3 addressed the general health condition of prisoners, 4 were related to skin diseases in prisons, and 25 publications provided information on skin diseases (eg, scabies, onychomycosis, and psoriasis) in the general population. The main author (who works in the prison system) organized the information; to determine what topics would be appropriate to include in the manual, all authors selected the hygiene measures that could be performed in a prison. Information regarding the skin diseases noted in the research and during data collection also were included.

The manual content includes information on the skin, personal care, and skin hygiene and guidelines on the prevention of skin diseases. The layout of the manual followed the Brazilian Standard NBR-6029.10 The visual layout was completed by a graphic designer experienced in text design and images were purchased from a stock image provider (Shutterstock, New York, NY).

Manual validation. The manual was validated for content by an expert panel through a questionnaire in the search for a consensus opinion among experts (Delphi technique).¹² Two (2) to 3 rounds or cycles of consultation are usually necessary to reach a consensus among the experts, but more rounds may be needed.¹² The experts were coded from E1 to E10 for easy reference.

Participant eligibility. Eligibility criteria for the expert panel stipulated participants must be prison employees who were health professionals with a college degree and experience in providing care to prisoners, working in units located in the Western region of the state of São Paulo, and having agreed to participate in the study by providing written informed consent. Professionals who did not meet inclusion criteria and persons holding only administrative positions who did not provide direct care to the prison population, and/or persons from different administrative regions of the State of São Paulo were not included in the study.

Health professionals who met study criteria received an invitation letter via email to participate in the study; those who agreed to participate received an additional email message containing the informed consent form, an electronic copy of the manual, and a questionnaire. The experts were requested to read the manual and return the completed questionnaire within 15 days (deadline).

Validation questionnaire for professionals. Questionnaires adapted from a study by Teles et al1¹ were used in the validation process. The questionnaire given to the experts had 19 items assessing the topics Objective (4 items), Structure and Presentation (11 items), and Relevance (4 items) of the manual. Every item had 5 possible responses (1 = inadequate, 2 = partially adequate, 3 = adequate, 4 = very adequate, and NA = not applicable) and a space provided for the respondents to optionally express their personal opinion and suggestions.

The content validity index (CVI) was used to measure the proportion or percent of experts who were in agreement on certain aspects of the manual. The CVI was calculated considering the number of responses adequate or very adequate for each item and was determined using the following formula:
CVI =      Number of responses adequate and very adequate/Total number of responses for the item

The CVI for each item should be ≥0.78 for content validation of an instrument when the panel is comprised of 6 or more experts.¹³

The overall CVI was calculated using the formula below. The minimum agreement of 90% was required among experts.

Overall CVI =  Sum of all CVI values/Total number of items

The manual then was checked for spelling and grammar errors and sent for the second round of consultation.

Validation questionnaire for prisoners. The manual also was evaluated by 20 prisoners randomly selected from persons who requested health care in May 2018, met study criteria, agreed to participate in the study, and signed the written informed consent. Inclusion criteria were imprisonment under closed conditions (ie, the prisoner must stay incarcerated at penitentiary at all times; he/she is not permitted to leave the prison, except for an emergency) at the participating prison unit and agreeing to read the printed version of the manual and respond to a questionnaire. Persons who were illiterate or imprisoned under semi-open conditions were not included in the study.

Each participant received a printed copy of both the manual and questionnaire. The timeframe for reading the manual and submitting the completed questionnaire was 7 days. The participants were coded from P1 to P20 for easy reference.

The questionnaire given to the participants had 14 items divided into the topics Manual organization (4 items), Ease of reading and understanding (3 items), Presentation (3 items), and Motivation for reading the manual (4 items). Every item had 3 closed alternative responses (1 = agree, 2 = undecided, 3 = disagree), a space provided for the respondents to optionally express their concerns and suggestions, and instructions to underline the words in the manual that were difficult to understand.¹¹

The percent of target users who agreed with the characteristics of the manual was calculated considering the number of responses agree divided by the total number of responses. The minimum agreement of 75% was required among the prisoners to validate the manual.¹⁴

Of the 11 health professionals invited to participate, 10 returned the validation questionnaire within the deadline, corresponding to a response rate of 90.9% (10/11), and were included in the study. The expert panel was comprised of 3 men and 7 women (age range 31–35 years); 7 were Caucasian, all 10 had at least a bachelor’s degree (6 had at least one postgraduate qualification and 2 had a master’s degree), and all of them worked in prisons in the Western region of the State of São Paulo.

Manual content. Medical record review showed 71 prisoners presented with 82 skin-related issues(5 inmates had multiple skin-related conditions) from January 2016 to January 2017 at the participating prison unit. The most common skin diseases were superficial fungal infections (26, 31.7%), onychomycosis (14, 17.1%), furunculosis (12, 14,6%), pruritus (12, 14.6%), and nonspecific dermatitis (8, 9,8%). Acne, basal cell carcinoma, erythema, scabies, folliculitis, and xeroderma also were found in smaller proportions (n = 10), together representing 12.2%. This information was taken into consideration when developing the manual. The topics covered in the manual included “The skin,” “Why take care of the skin?” “Skin care,” “Hair and nails,” and “What to do about skin diseases?” which deals with prevention and management of acne, skin cancer, dermatitis, scabies, furunculosis, leprosy, herpes, fungal infections, pediculosis, pruritis, psoriasis, and xerosis.

The final version of the manual has 31 pages, 8 topics, 12 subtopics, and 29 illustrations. The cover image of the manual is shown in Figure 1 and the Table of Contents is seen in Figure 2. The first 3 chapters (“Presentation,” “The Skin,” and “Why Take Care of the Skin”) address the importance of daily skin care in the prison environment and skin structure. Additional chapters provide guidelines about “Skin care,” “Hair care,” and “Nail care” as a guide to the basic care that should be performed daily. The chapter “What to Do About Skin Diseases?” has 12 subsections: “Acne,” “Skin cancer,” “Dermatitis,” “Scabies,” “Furunculosis,” “Leprosy,” “Herpes,” “Fungal infections,” “Pediculosis,” “Pruritus,” “Psoriasis,” and “Xerosis.” These subsections are intended to briefly describe the most common skin diseases that occur in the prison environment to enhance their identification by the prisoners, provide instructions on self-care if a skin disease is detected, and indicate situations in which it is necessary to request an appointment to see a doctor or nurse. The last chapter, “Other guidelines,” presents general information related to the prevention and treatment of skin diseases. An example of the layout of the manual is shown in Figure 3.

Professional validation. Two (2) rounds of expert consultation were performed using the  questionnaire. In the first round of consultation, the experts rated all items as adequate or very adequate, resulting in an overall CVI of 1.0 (ie, 100% consensus among experts). Some experts provided suggestions and comments:
E1: “The manual could encourage adherence to appropriate drug treatments.”
E2: “Excellent content, great helpful information, and very good to be used in health education interventions in prisons.”
E3: “The guidelines are straightforward and objective and correspond to the logical sequence of the routine found in the prison environment. The material is of great relevance and quality and will significantly contribute to the prison population.”
E4: “This manual provides clear, accurate, and objective information for the target audience, most of whom lack basic education.”
E10: “I congratulate the authors for the excellent work in the creation of a manual specific for the prison environment, containing information on prevention and treatment of skin diseases, to be used in health education interventions. This is a very important initiative, considering that little material on health care management for the prison population is available and understanding that interventions for prisoners differ from those performed in the primary care due to factors characteristic of the prison environment. This manual delivers clear, concise information on a topic highly relevant to the everyday life of persons deprived of liberty.”

To perform the second round of evaluation, the revised manual was sent to the same 10 professionals who participated in the first round. Guidelines on the proper use of medications (when prescribed), such as adherence to treatment and administration schedules and compliance with the correct dose and dose frequency, were included in the chapter “Other guidelines,” as suggested by E1.

Nine experts returned the completed questionnaire within the 10-day deadline for a response rate of 90% (9/10), with the following comments:
E1: “The creation of a manual of skin care for the prison population is essential for their education and to reduce the incidence of skin diseases in prison units.”
E2: “Excellent manual. I congratulate the authors.”
E4: “I continue to believe that this manual is consistent with the purpose of providing information and guiding the target audience.”

In the second round of consultation, the experts rated all items adequate or very adequate, maintaining the overall CVI of 1.0 (ie, 100% consensus among experts). Therefore, the manual was considered validated for content.

Prisoner feedback. All invited prisoners agreed to participate in the study (response rate of 100%) and responded to the questionnaire within the required period. The 20 prisoners who evaluated the manual were men with a mean age of 37.7 (range 21–54) years, 11 Caucasian (11, 55%), with a low education level (8 with some or complete primary education [40%], 10 with some or complete secondary education [50%], and 2 with incomplete college education [10%]). Mean time served in prison was 9.0 years (range 8 months to 22 years).

Three (3) participants (P) made the following comments:
P1: “I think the cover could be a little more colorful to call attention and stimulate the curiosity and willingness to open the manual. If possible, the cover should also contain some illustrations related to the topic.”
P6: “In my opinion, we should receive a lecture on health care in the prison blocks. I have been well treated here in the prison infirmary and the nurses treated me very well. Especially the bruise on my leg that, by the way, is healing very well. I just have to thank the care provided in the nursing unit. Thank you!!!”
P7: “I think that this work is very important, especially in prisons, where there is a lack of information mainly in the health area. Lack of health information leads to illness in humans, especially in the prison where mental temptations are constant. I hope that this project will reach as many people as possible. Thank you and good luck!”

P3 underlined the word filth, which was replaced by dirt; P5 underlined the words involvement (which was removed from the sentence) and melanoma (which was maintained in the text). Only the questionnaire item, The cover catches your attention, had 80% agreement. The cover was not changed because its design followed the guidelines of the Coordination of Health Services of the São Paulo State Prison System. All other items achieved 100% agreement for an overall agreement of 98.6%. The manual then was considered validated for use in the prison population of the São Paulo State Prison System.

Prisoners learned about the manual through an expository presentation in the participating prison unit, and it was made available in the unit’s library. Distribution of the manual is governed by cost, which would be prohibitive. An electronic copy of the Manual of Skin Care for Persons Deprived of Liberty in the São Paulo State Prison System was emailed to all prisons in the State of São Paulo to be printed as needed.

Brazil has the third largest prison population in the world, and the State of São Paulo has the highest rate of imprisonment in the country.¹ Prison overcrowding is one of the factors that affect health policies in the prison system. Studies have indicated the need for implementation of adequate health policies in the prison environment because, in addition to overcrowding, factors such as inadequate infrastructure, stress, tobacco use, and poor personal hygiene increase the incidence of health problems, including skin diseases.^5,15

Studies regarding manual development have shown printed materials such as educational manuals are useful for health promotion and may provide information and guidance on healthy behaviors and prevention and treatment of diseases, answer questions about health-related problems in daily life, and improve self-care.^9,16-18

Skin diseases were detected among the prison population in the participating prison unit as described by other authors.^2,5,15 The information in the manual is intended to guide prisoners in daily self-care, indicating situations when it is necessary to request an appointment with a doctor or nurse. The topics of the manual first dealt with daily skin care, followed by the most common skin diseases occurring in the participating prison unit and those identified through the literature review. Additionally, skin diseases that were verbally reported but not found in the medical records also were considered; this “missing” information may be attributed to transfers of patients to a different prison unit, patients attending a clinic outside the prison, or reports of the Coordination of Health Services of the São Paulo State Prison System about diseases (eg, leprosy) that occur more frequently in other prison units.

The most common skin diseases found in medical records from the participating prison unit were fungal infections, onychomycosis, furunculosis, pruritus, and dermatitis, similar to the findings of Wolff et al,⁴ who reported the occurrence of fungal infections, furunculosis, folliculitis, pediculosis, scabies, pruritus, xerosis, acne, and eczema in Swiss prisons. The major skin-related diseases in a Canadian prison unit that were observed by Gavigan et al⁵ included acne, psoriasis, and superficial fungal infections. Minayo and Ribeiro² described the presence of ulcers, eczema, psoriasis, allergies, dermatitis, and urticaria in prisons in the State of Rio de Janeiro (Brazil). Although several studies show the occurrence of skin diseases in different prison systems, no educational material seems to have been produced by these authors.

In this study, the Delphi technique was used to validate the manual of skin care for persons deprived of liberty. This technique seeks a consensus opinion among experts through the use of questionnaires.^11,17-21 The overall CVI for the first round of consultation was 1.0, corresponding to 100% consensus among experts. However, the Delphi technique requires at least 2 rounds of consultation, so the manual was revised according to comments made by the experts in the first round of consultation, checked for spelling and grammar, and returned to the experts for a second round, providing them the opportunity to follow the review process and present new comments or suggestions.²⁰ The overall CVI of 1.0 was maintained, and the agreement among the target users (prisoners) was 98.6%.

Similar results have been reported in several studies using the Delphi technique for content validation of educational materials.^11,17,19 An educational manual for users of a health service had an overall CVI of 0.94 and an agreement among the target audience of 81.8%.¹¹ A similar study with an expert panel of 5 health professionals validated an educational manual for women who had recently given birth and achieved an overall CVI of 0.97.17 The development of a manual for the prevention and treatment of skin tears showed an overall CVI of 0.95.¹⁹

The experts and participants made several comments on the importance of the manual for the State Department of Prison Administration, considering the lack of educational materials for the prison population. One expert commented that the manual should encourage adherence to treatments and compliance with prescribed medication, and other experts indicated it could be used in health education in prisons. In the first and second rounds of consultation, 5 and 3 experts made comments, respectively, about the importance of the manual for the prison population and on the manual itself.

The comments made by the experts and target users reflected the need for health information in the prison environment and indicated that the manual developed in this study may help fill this gap. The experts considered that the manual provides clear, accurate, objective, and concise information and may be used as an educational tool for prisoners.

The manual attempts to show the importance of daily self-care in preventing skin diseases, provides the necessary information for skin care in the prison environment, and shows how to recognize changes in the skin that require an appointment with a health professional, thus contributing to a reduction in patient care time and a more appropriate distribution of medical products, such as medications, to the prison population.

The Manual of Skin Care for Persons Deprived of Liberty in the São Paulo State Prison System was approved by the Coordination of Health Services of the São Paulo State Prison System for distribution to all prisons in the State of São Paulo.

A limitation of this study was that the questionnaire for the prisoners had closed-ended questions with space for suggestions and comments (limited to half a blank page), which may have led to a high agreement rate and few suggestions for improvement of the manual content. This may be related to the low education level of the participants; according to a validation study,²¹ individuals with higher education usually provide more suggestions for content improvement in validation processes. Studies using interviews with open-ended questions, where responses are recorded and transcribed later, may encourage participants to express their opinion and provide suggestions.²² Thus, future studies on the prison population may benefit from the use of interviews for data collection.

Another limitation of the study is related to the lack of a broad distribution of the manual of skin care among prisoners in the São Paulo State Prison System due to material costs. As an alternative, the manual was made available via email to all prison units in the State of São Paulo so it can be printed when deemed necessary. The prisoners at “Nestor Canoa” Prison have access to the printed version of the manual, and the health workers from state of Sao Paulo have access to the digital format of the manual and they can print it to deliver to the prisoners in their units.

The low level of education among prisoners in Brazil also may be considered a limitation because many are illiterate or have incomplete primary education, making it difficult for these individuals to read or properly understand the guidelines provided in the manual.^2,15 As an alternative, health workers could provide educational activities with the prisoners with a low level of education using resources such as classes and lectures; however, it was not the purpose of this paper to evaluate the proper use of the manual.

Prospective studies with a large number of prisoners and involving multiple prison units are necessary to evaluate the effects of the manual of skin care on preventing skin diseases in the prison environment.

A manual of skin care was developed and validated by health professionals and content validated (CVI = 1.0)  for use by prisoners in the São Paulo State Prison System, taking into account the characteristics of the prison environment. The manual was well-received by the  health care professionals and the prison population that evaluated it. This is the first educational manual of skin diseases developed based on a literature review and validated for content by an expert panel and reviewed by a prison population in the State of São Paulo. The manual provides information and guidance on healthy behaviors and prevention of skin diseases, answers to questions about health-related problems in daily life, and may improve self-care and prevent skin diseases. This may reduce patient care time and lead to a more appropriate distribution of medical products to the prison population, which could serve as topics for future study. Prospective studies are needed to evaluate the effect of this manual on skin disease in this population.

Commentary: Providing Infection and Skin Care Education in Prisons  

Marie Brown-Etris, RN, CWON, CCHP     

In response to the article on inmate care in a Brazilian prison, Wound Management & Prevention requested the perspective of Marie Brown-Etris, RN, CWON, CCHP, a certified correctional health care provider for the Philadelphia (Pennsylvania) prison system. The author extends sincere appreciation to Elizabeth Dolan-Bird, MHA, BSHA, RN, CCHP, Regional Health Educator; and Sharon Bunting-Talarowski, BSN, RN, CCHP, Regional Infection Control Coordinator, for providing information for this commentary.
 

Infection control and education are taken seriously in jails and prisons, where hundreds to thousands of people can live in one very large building in close proximity and share community showers. In the Philadelphia Prison System, the Regional Infection Control Coordinator and Regional Health Educator oversee infection control and education for approximately 5000 inmates at any given time, as well as the 240 nurses plus other professional health care providers, administrative staff, ancillary health care staff, and hundreds of correctional officers. Their responsibilities include dealing with communicable diseases, vaccinations, and interfacing with city representatives and the city health department. Our facility not only provides these services, but it is also accredited by the National Commission on Correctional Health Care (NCCHC) for Health Services in Jails.
Because educating inmates was the focus of the article on the Brazilian prison population, I will focus my commentary on how education, both for staff and inmates, is handled where I work.

Educating Staff and Inmates
There is a contractual and collaborative relationship between the City of Philadelphia and Corizon Health, the company providing the health care services. Correctional officers (COs) are city employees, and health care providers are employees or contractors to Corizon.

COs. The COs are our first responders. If an inmate experiences bleeding from a cut incurred while working in the kitchen or from an altercation, these officers have been trained extensively on response, both from a security and health care perspective. This includes initial first aid, personal protective equipment, blood spill containment, blood-borne pathogens, and making the decision to alert the medical response team or bring the injured inmate to the medical area. All COs are CPR-certified and are mandated to attend annual training that includes education regarding various issues such as disease processes, initial response for seizures and chest pain, and infectious diseases such as human immunodeficiency virus (HIV), shingles, flu, colds, and hepatitis. Hepatitis A is a concern due to a recent outbreak in Philadelphia. Our Infection Control Coordinator is currently overseeing vaccination of COs, health care providers, and high-risk inmates. COs also are mandated to attend a biannual NCCHC Officer Training (ie, health-related training in order to promote recognition of serious medical health problems requiring immediate care). This includes topics such as blood-borne pathogen exposure, handwashing techniques, and understanding the Health Insurance Portability and Accountability Act.

COs also are required to attend an annual 3-hour training class given by our Regional Health Educator on various skin issues and interventions, including abscess, rashes, scabies and lice, and handwashing technique. This training utilizes a variety of instructional tools, including handouts, manuals, and visual projections. The educator also oversees the “monthly roll call,” a 3-minute session that provides a DVD on such topics as hepatitis and blood-borne pathogens that all COs must attend.

Nursing staff. Health care personnel of all levels are provided a variety of learning opportunities. I give a vivid PowerPoint presentation on wound interventions and healing to our nursing and medical staff. In addition, Corizon Philadelphia Region presents an annual Nursing Competency Skills Fair, which is mandatory for all 240 nurses. Every nurse must attend one session, each designed to be interactive, educational, and fun. Each station focuses on a different skill set, including trauma, respiratory, and cardiac concerns, to name a few. For example, a variety of dressings or interventions will be displayed at the wound care station, and the nurses will play a match game to connect the intervention to the appropriate wound. The nurses are required to complete competency sheets for each station.

Inmates. When an individual is arrested and incarcerated, the intake process includes testing for tuberculosis, HIV, and sexually transmitted diseases (STDs). If any of these are identified, protocols for intervention will be followed by various medical personal. The intake process also includes nurse identification and treatment of various types of wounds (eg, abscesses and boils). Intravenous (IV) drug abuse has increased the development of abscesses in the community; we are noting these on intake.

Our Infection Control Coordinator maintains skin/soft tissue surveillance spreadsheets to track prevalence, incidence, and other pertinent medical information. Newly incarcerated individuals are quarantined for a period of time and then released into the prison population when cleared or appropriate. Our Infection Control Coordinator has developed educational fact sheets  pertaining to Staphylococcus infections and methicillin-resistant S aureus (MRSA) for distribution to inmates. These sheets include information regarding what is MRSA, do’s and don’ts of MRSA, how to help prevent becoming infected with MRSA, and who to notify if you should develop a rash, fever, or chills. The Infection Control Coordinator also has developed a video that is shown inhouse on a closed circuit loop in which she discusses such things as Staph infections, why it is important to take antibiotics as prescribed when ordered, and proper handwashing techniques. Personal hygiene signs are displayed in housing areas with instruction on how to avoid an infection (eg, do not share personal items such as deodorant, razors, or tooth brushes).

Educational posters on such topics as smoking cessation and proper handwashing technique are displayed throughout our housing and medical areas; patient literature on such topics as HIV and STD prevention and treatment also are available.  

Our computer system provides access to patient education materials that are specific to various disease processes. These publications can be printed and reviewed with the patient, who can keep them for future reference. I also utilize literature and educational materials from our industry manufacturers. I have educational booklets on venous ulcer disease and compression, diabetic foot ulcers and offloading, and pressure ulcers. I sit with my patients and educate them utilizing these booklets and then give them to the inmates to keep and read, just as I would outside of the prison. For ostomy patients, I educate just as I would out in the community utilizing educational booklets from ostomy manufacturers; these materials also are available to the nursing staff for distribution to patients. I also incorporate materials from the United Ostomy Association of America (eg, their Phoenix magazine) and the Philadelphia Ostomy Association’s newsletter, so inmates have a local resource when released from custody. If the possibility exists that they will be out of custody before I would next see them, I make sure to provide a list of the ostomy equipment they are using and a medical equipment company resource. All ostomy patients enjoy my instruction on the anatomy and physiology of the gastrointestinal tract utilizing the 5 foot poster of the GI system that hangs in my exam room.  

    
Inmate workers. The Philadelphia Prison System includes workers in a multitude of areas including the kitchen, housekeeping, laundry, and our medical areas. These employees go through an educational process with involvement from our Infection Control Coordinator specific to their work area. Medical area workers are trained on how to handle red bags and medical waste for biohazard pick up, kitchen workers are educated on safe food preparation and handling practice, and laundry workers are instructed to add a specific amount of bleach to every laundry load to help kill bacteria. Instructional signs also hang by our washing machines.  

Inmate buddy training program. This select program trains inmates how to buddy with others who may require physical assistance with such care areas as eating, transfer from bed to wheelchair or gerichair, or wheelchair transport to a clinic appointment in the medical area. This training is provided by both Corizon health care team members and members of the Philadelphia Department of Prisons. I have wound patients who are transported via wheelchair to my clinic by a buddy, who also helps transfer the inmate onto the exam table. Our Regional Health Educator provides classes for Infirmary workers covering topics such as caring for inmates with dementia, aspiration precautions, handling soiled linens, personal protection, safe transfers, and proper cleaning of the environment. These infirmary buddies are an extension of our medical team. My instructions to these men include the importance of and how to check for proper inflation of air mattresses and seat cushions, proper positioning and repositioning in a chair, the use of wedges and pillows for positioning, the importance of utilizing pillows for heel suspension, and how to properly apply heel protectors when transferring the patient back to bed. I also provide instruction on various wound types, wound healing, and dressings. I have encouraged a few of these men to explore opportunities in health care and related fields when released from custody. Inmate participation in the buddy program provides for reduced sentencing.

General wound care instructions and precautions.
Showering with dressings. I tell my patients MRSA grows on wet and dry surfaces and lives for about 30 days so that they take their wound care seriously. Although showers are cleaned regularly, many people from all walks of life are using them. I instruct my patients to take their showers with wound dressings in place, and/or cover them with a plastic bag if available; the nurse will change their dressing in the medical area at scheduled wound care times. If an inmate is unable to get out when wound care is “called,” (eg, because they are being housed in protective custody or punitive segregation (“the hole”), I add a transparent film dressing to protect the dressing from getting wet to allow them to shower when given the opportunity.

Self dressing change. Some inmates can competently perform their own dressing changes because they have had their diabetic foot ulcers or venous leg ulcers before incarceration and were changing their own dressings at home. Depending on the status of the wound and treatment ordered, an inmate may be provided products and do his own dressing change in his housing area. Once a wound is improving, I will cut pieces of hydrocolloid or foam dressing and tape, place them in a clear zip bag, and write the inmate’s name, prison photo number, and “KOP” (keep on person) on the bag. This identifies that the inmate is permitted to possess these supplies so they won’t be confiscated by the correctional officers as contraband. However, these supplies are subject to confiscation during a cell block shake down.

Supplies. Our facility has a formulary for our wound supplies that is established within Corizon Health corporate. Administrators of the individual housing areas and buildings place orders. In Philadelphia, we have a full range of wound dressings available to meet our patients’ needs; special nonformulary items can be obtained upon special request.    

Understanding Our Roles
My job is to care for patients and collaborate closely with other health care providers so we can heal our patients’ wounds, prevent pressure ulcers from occurring, get patients ambulating, and see they are provided leg prothesis or diabetic shoes. I collaborate closely with our physical therapy (PT) team; I once requested that a man who was paraplegic secondary to a gun shot wound be referred to PT. He was wheelchair bound when initially incarcerated from the community; when I met him, he had a stage 4 pressure ulcer. Because of his category of spinal cord injury, our PT and PT aides were able to work with him and within about 6 weeks he came into my wound clinic using a walker.

Our nurse liaison monitors the status of our hospitalized patients. She travels to the various hospitals and acute rehab facilities in the city to ascertain patient status and speaks with discharge planners, nurses, physicians, and the patient. She reports their status back to our Regional Medical Director, our Infirmary Chief Medical Officer, and charge nurse so our Infirmary staff can plan for incoming patients’ needs, such as antibiotics for their peripherally inserted central catheter lines, dialysis, or physical therapy (all provided in-house), pressure redistribution support surfaces, and negative pressure wound therapy.

I commend the Brazilian corrections health care team for developing a skin care manual for incarcerated individuals in their country. I can envision its use expanding into other countries. Skin care may sound so simple, but in the correctional environment it can be a challenge.

Ms. Borges is a graduate student, Professional Master’s Program in Science, Technology and Management Applied to Tissue Regeneration, Federal University of São Paulo (UNIFESP); and a registered nurse, State Department of Prison Administration; Dr. Blanes is an adviser and Vice-coordinator, Graduate Program in Science, Technology and Management Applied to Tissue Regeneration, UNIFESP; Dr. Sobral is a plastic surgeon, Hospital of Face Defects, Brazilian Red Cross; and Dr. Ferreira is a Full Professor and Head, Division of Plastic Surgery, Department of Surgery, UNIFESP, São Paulo, Brazil. Please address correspondence to: Daniela Tinti Moreira Borges, RN, MS, Division of Plastic Surgery, UNIFESP, Rua Botucatu 740, 2o. andar; CEP 04023-062 São Paulo, SP, Brazil; email: danitinti2010@gmail.com.