Helen Osborne:Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month and your host of Health Literacy Out Loud. In these podcasts, you get to listen in on my conversations with some really amazing people.

Today, I’m talking with David Young who is a Professor and Community Health Specialist at Montana State University. His work involves improving the health and well-being of vulnerable, at-risk, marginalized, hard-to-reach populations.

Dave’s research is focused on promoting health literacy, health insurance literacy and improved healthcare management skills for those who are incarcerated.

I met Dave when he was part of a panel presentation at a health literacy conference. We later chatted informally about the intersection of health and the US justice system. Much of this information was new and, honestly, very startling to me. I think you might be interested in hearing from Dave, too.

Welcome to Health Literacy Out Loud, Dave.

David Young:Hello there.

Helen Osborne:When you talked, I think the very first words I heard you explain were about justice-involved individuals. That was a term I had never before heard. Why don’t you explain it to all of us?

David Young:That is a new term on the market today. In fact, the federal government came out in April, I believe, of 2016 with that term to help get away from the stigma that’s associated with terms like convict, ex-con, offender, ex-offender or criminal.

Basically, it covers anybody that’s involved in our criminal justice system, and that’s quite a broad swath because it does include one out of every three adults, or about 70 million people, are trapped.

Helen Osborne:Oh my goodness.

David Young:I shouldn’t say trapped, but are involved in our criminal justice system, either in a pre-trial phase or they’re out on probation or parole, or they’re housed in secure facilities, like a jail or a prison.

Helen Osborne:Did I hear you right, one out of three adults in the United States?

David Young:Yes, that’s true, and it’s about that same number that could not pass a criminal background check because of that same reason.

Helen Osborne:Our listeners come from all over the world. The United States is reported to have the highest percentage of people who are justice-involved. Is that correct?

David Young:That is correct. The U.S. accounts for 5% of the world’s population, yet we house 25% of the prisoners of the world.

Helen Osborne:Wow. Can you explain some more terms to me? I get confused between what’s a jail and what’s a prison. Then I know there’s parole afterward, but there’s something that happened before trial.

Just walk us all through very briefly, please, that process and the different segments of it. Then we’ll get on to health and health literacy in this population.

David Young:I know it is somewhat complicated to wrap your brain around all those different areas in our criminal justice system, but what I’d like to do is maybe three compartments.

Think about a jail, which is local, where many times it’s just really a detention facility, which is another name for a jail. It’s just holding people to be sure they show up for court or jury or whatever they are supposed to be at the right time.

Then if they are convicted and sent off to prison, that’s a second location or second compartment of secure facility.

Then the third is community supervision. That third pot involves anybody that could be pre-trial waiting, or they could be on probation or parole. They could be in pre-release. They could be on an ankle bracelet. They could be on a GPS monitor.

Helen Osborne:Wow. Thank you very much for making that clear. It’s a whole big spectrum. The equivalent in healthcare is that continuum of healthcare. There’s outpatient and inpatient and everything in between.

Let’s talk about that interception between the justice-involved individuals and health or poor health. I read the paper. I see that this is a factor, but from your perspective, and you go in and you work in the prisons. Can you just explain your part of that piece of the puzzle, please?

David Young:I’ve been involved in the county system here for, I think, probably close to 15 years, mainly going in with programs to help with the re-entry phase, where they come back in. That’s another new term, too. We’re supposed to be using the term “returning citizens,” rather than “ex-offenders” or whatever, but these are returning citizens.

We release, in the United States, I think, about 636,000 individuals back into the communities. In our local jail, we have 40 different programs and I’m only involved in two of those. One is a recovery program.

Helen Osborne:Recovery from substances, substance abuse?

David Young:Exactly. We do that on Wednesday nights. It’s a two-hour program, and we try to get around to as many individuals interested in taking that class as possible.

Then we started doing a health literacy curriculum program that we built. We did do a test on that in the sense that we had a pre-survey and a post to see if we’re really gaining some health literacy skills along with some computer skills.

Helen Osborne:Wow. I most want to hear about that, for sure, because our listeners and my work and your work, that’s how we all connect, on an area of health literacy and health understanding.

Before we get there, you had spoken with me a little more informally about the issues of health that show up in that justice system. You just mentioned something about substance abuse. Can you just make a little more clear that whole array of health issues that might be cropping up in the jail/prison justice system?

David Young:Yes. As you probably recall, I mentioned that the justice-involved population is disproportionately high in a number of health conditions, especially of public health interest. Most likely, top on the list is chronic health conditions, everything from diabetes, heart disease, hypertension and the list goes on.

Also, then, infectious diseases, hepatitis, sexually transmitted diseases and so on, they are very high in those areas of disease.

Then compounding this picture is the mental illness and substance use disorder. That co-occurring mental illness and substance use disorder is very high because individuals with mental health conditions do tend to self-medicate with what they can find.

The last time I looked at that, close to half the population was co-occurring, co-morbidity. Between 65% and 85% of the people we lock up have a substance use disorder.

Helen Osborne:Wow. I’m running out of words, other than “wow.” This is just astounding.

I’ve been reading in my local news and hearing that there are also issues of aging. People who might have been in jail or prison for quite a while are now getting older and facing all those things that happen as we get older. And probably the trauma of whatever people’s lives were before they got into all this trouble, the trauma there.

At both ends of it, we have a whole other array: the situational, the life, and developmental issues that are going on.

David Young:Exactly. Our correctional facilities were never built to be hospitals or assisted-living facilities or mental health asylums, but yet they’re in that role right now.

Actually, some of the prisons have instituted a hospice program for those who are dying. It involves people in the community coming in, but also training other inmates to become caregivers in a hospice setting within the prison.

Helen Osborne:It’s almost a microcosm of what’s going on in the world. A lot of people have chronic diseases. A bunch of people have substance abuse or environmental issues there, and it’s just all coming together within a confined space, but at a higher percentage, it sounds like.

David Young:It is.

Helen Osborne:You’ve laid this out for us. I’m overwhelmed. You’re doing great work, I know, from our conversations. Start sharing that with our listeners, please. What’s going on in a good way and what are issues that still need more work about this intersection of justice-involved individuals and health?

David Young:I probably should back up and just say what we were able to do was to test out a curriculum, actually, two curricula. One was health literacy and one was health insurance literacy.

As you probably know from some of the earlier reports, those who are incarcerated do have low literacy in general and also have numeric literacy problems. That is, again, compounded when you start to apply for health insurance or get onto Medicaid.

We were trying to connect several dots because about 80% to 90% of people who are arrested don’t have health insurance, and they are high-cost entities because they go to the emergency room.

Our thrust was to improve their health literacy, their self-care management, but also get them onto health insurance. How do you apply? What are some of the terms? What’s a co-pay? What’s a premium, and so on?

Those two curricula we were able to test in our local jail and have publications on those two.

Helen Osborne:On your Health Literacy Out Loudpage, we will identify those articles and have links to them, or at least to the abstracts. Is that okay?

David Young:That’s great. You probably can get links to the full articles.

Helen Osborne:That’s even better.

David Young:Those have helped us get another grant, which we are now testing. As I mentioned to you before, we are putting those two curricula onto a secure tablet. We’re testing that out in several facilities.

Helen Osborne:Like an iPad kind of a tablet?

David Young:Yes. We’ll see how that is received by the individuals who are incarcerated so we can spend some more time getting them educated.

There are two things that impact the future of that process. One is whether or not the individual is in a state where there’s Medicaid expansion.

Helen Osborne:For people outside the U.S., this is just some quirks that we have in here for our funding programs and how healthcare gets paid for and benefits.

David Young:Again, the majority of individuals, in our experience, that are arrested do not have health insurance. But if you ask them if they’ve been to an emergency room in the last year, that also is very high. They’re a high-frequency user of emergency medical services.

Helen Osborne:You’ve talked a lot about all the underpinnings we all need to know, and I’m humbled hearing all about this. Tell us a story. I’m particularly interested in health literacy.

You’ve got your curriculum. You have people with a lot of chronic diseases, plus many other health factors. Tell us a story about what you’re teaching. What are people learning? Make it vivid.

David Young:We’re making use of a system. As you probably know, individuals in a secure facility, a jail or prison, usually don’t have access to the internet. We had to really be innovative and build what we called an internet-in-a-box system, or a closed system, that would allow them to search on a desktop computer like they were on the National Library of Medicine and looking up a disease that they had and they wanted to look at treatments. “What are the issues that I need to address?”

In addition, we had a hard copy of a document that was produced here at our College of Nursing. It’s called My Health Companion, and it’s about 10 pages. It allows the individual to go through that and also list their current medications and other aspects of their health. That was very popular.

Helen Osborne:Can I just ask a question from a position of naiveté at this point? You’re helping people with that self-care management part. It sounds like, to learn more about their condition, their medication and probably their advocacy and payment abilities there.

How much are people responsible for that while they’re incarcerated, or do they gain responsibility as they’re transitioning back to the community?

David Young:I think it’s more the latter. They are gaining as we work with them and as they go back into the community, because we have what is called “the list.”

It’s kind of like when you leave the hospital, you meet with a discharge planner who goes over a list. “You need to go to the pharmacy tomorrow and pick up this, and you have to see your doctor two weeks from today.”

We have a discharge planning now for our local jail. We would highly recommend that. People who have fairly complicated chronic health conditions, let them know that the community health center down the block here, “There’s no charge, and if you need transportation, and you need to see the pharmacy about getting your meds,” and so on.

Helen Osborne:You’re really helping them figure out what it is they need to do. They may not have been responsible for this for months, if not years. Is that correct?

David Young:Exactly.

Helen Osborne:When you’re in the hospital, you’re discharged, and probably it was just a few days ago. That’s a big difference. How is your health literacy program being received?

David Young:It was received very well. We’re in the process of a transition in the sense that when we had the program, we were doing Monday/Wednesday/Friday of lectures and PowerPoint. Then on Tuesdays and Thursdays, the individuals in our class would be allowed to go into the computer lab and do some self-teaching or self-learning and reviewing.

Now they’re pretty much on their own because we’re not in there with the Monday/Wednesday/Friday. Our feel is that it’s going very well.

Helen Osborne:Good.

David Young:We’re hopeful that this secure tablet technology will be something that we can implement in the very near future.

Helen Osborne:I’m so glad that you’re doing what you’re doing. I know you’re doing this in your state and local region. Are things like this happening nationwide or worldwide?

David Young:That’s a great question. I can’t speak to worldwide, but nationwide, I know that tablet technology is being implemented in a number of jails and prisons, and they’re finding that it’s well accepted by the inmates. It actually has a calming influence because there are programs and there are educational possibilities for them.

I think a recent survey showed that almost three out of four inmates would like to be doing something educationally. As you probably know, only about 40% of them have finished high school, compared to 85% as our US average. There is a hunger for educational attainment.

Helen Osborne:People are using it and clicking on it or scrolling through it.

David Young:Yes.

Helen Osborne:Whatever I might be doing too, they’re doing it and having access to these tablets.

I’m glad you’re moving forward. I know you’re a researcher and an educator as well as an advocate. Our listeners always want to be making a difference and making things better. Maybe they’re feeling as overwhelmed as I am by all this. What do you recommend that we might do to help even in a more modest way?

David Young:I think if you look at the distribution of our county jail system that almost is in every one of the 3,000-some counties and townships, people could become involved by just checking in with their local county detention center and ask what kinds of educational programs are available.

Even talk to the correctional health nurse or whoever is doing the correctional health and ask, “Is there a health literacy program here? Would there be interest in having one for the inmates that would be interested in looking at health literacy?”

Helen Osborne:You met with success when you asked that question, but you’re more familiar with the system. Do you think that’s something that would be accepted more often than not?

David Young:Again, a great question. It depends on the personalities of the people running the facility. If a lot of them are overbooked or overworked, they’re not interested in a new program.

We’ve been blessed here because the sheriff is usually the one in charge of the local facility. If the sheriff is interested, his philosophy is that people leave here better than they came in. I know we’re the top jail in our state because we have 40 programs and 160 volunteers that go in with all these different programs.

Helen Osborne:For listeners, maybe get to know some of the players. Be aware, just like you’re teaching all of us, of what the issues are. Maybe we can be finding a way to make a difference in there.

As you said, more than 600,000 people are going back to the community, so these will be our neighbors tomorrow if they’re not living next to us today.

David Young:Exactly. If you look at the total population across the country as pushing nine million that are rotating in our criminal justice system, 97% are going to be back living with us.

A lot of people think, “We locked them up and threw away the key,” but 95% to 97% of individuals currently locked up will be in our communities.

Helen Osborne:As community members, as people who care about health, as people who just want to be doing the right thing and making all this a bit more understandable, maybe it’s time to get involved.

Thank you so much, Dave, for doing what you do and sharing with us on this podcast. I really look forward to reading your articles and learning more. This has been a really important podcast. Thank you, Dave.

David Young:Thank you, Helen, for having me on this podcast. I really enjoyed it and I hope our references will get some activity.

Helen Osborne:I hope so, too. Thanks.

As we just heard from David Young, it’s important to consider that intersection between those individuals who are justice-involved and health literacy. That’s a factor, too. Considering the audience, their needs and where they are in the world and in life, is very hard to do.

For help clearly communicating your health message, please visit my Health Literacy Consulting website at www.HealthLiteracy.com. While you are there, sign up for the free monthly e-newsletter, What’s New in Health Literacy Consulting.

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Did you like this podcast? Did you learn something new? I sure hope so. If you did, tell your friends and tell your colleagues. Together, let’s tell the whole world why health literacy matters.

Until next time, I’m Helen Osborne.

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