This study examined inmates’ HCS utilizations and associated factors in Northwestern Ethiopia. The study is the first of its kind to examine inmates’ HCS utilization in Ethiopia, at least to the knowledge of the present researchers. The study's findings will also be important because it illustrates the significant impact that inmates' knowledge of service accessibility plays in their use of HCS. This is because it is anticipated that the findings will spark scholarly discussion among experts HCS research.
In this study we first aimed to assess the knowledge inmates have about health care services available. While they are less aware of psychiatric services' availability, inmates are well-informed about the availability of medical care services as well as guidance and counseling services. The low knowledge of psychiatric services among inmates could be attributed to the fact that the services are given in nearby hospitals. Likewise, the high knowledge of inmates on the medical care services and guidance and counseling services could be attributed to the facts that the services are given inside the prisons. The prison proclamation advocate for the provision of healthcare services as well as the delivery of health education activities by prison administrators (17). The fact that there are inmates who didn’t know the availability of the healthcare services reflects the problems in the health education activities in the prisons in Northwestern Ethiopia.
These findings implied that it is improper to believe that inmates will know the presence of the services as long as the services are available. Similar findings are reported in a study in Nigeria. In the study all the inmates reported that they have knowledge of rehabilitation services available in the prison but none of them stated health care services (25).
Second, we examined inmates’ participation levels in the three health care services and similar trends to their knowledge of the services are found. The medical health care utilization is said to be high. The medical service utilization in our sample is high compared to the reported 41.8% of health care utilization in a community based study in Dessie city, Amhara region (23). Likewise, a study in East Gojam, Amhara region, reported a rate of 41.5% HCS utilization (24) while another study in Achefer, Northwest Ethiopia, reported a rate of 39.9% (26) which implies that the rates of medical care utilization in our study is high. On the other hand, higher medical care utilization comparable to our study is reported among inmates in Switzerland (13) where 82% the inmates utilized health care services from GPs and 90% of them utilized health care services from nurses. The high medical care utilization rate in our study could be attributed to high rates of illnesses reported from other studies, e.g. high rates of TB among inmates (19).
With regard to guidance and counseling service use, it is found that more than half of the inmates utilize the service. Given the high number of inmates who are knowledgeable about the service availability (87.4%) the service utilization cannot be regarded as high. On the other hand, the guidance and counseling service utilization could also be considered as high when compared with the service utilization in other settings. For example, in a country where only 2% of university students in Amhara region are using guidance and counseling services (27) the participation rate found in our study is high. Coupled with this, the utilization rate could also be regarded as high when compared with findings from other studies. For instance, in a study in the USA it was revealed that 31% of the inmates voluntarily participated in the counseling service while 22% of them participated in mandated counseling services (28).
The psychiatry service utilization is low but it was expected. This is because the services are given in the nearby hospitals to individuals with severe illnesses; psychiatric services in Ethiopia are characterized low doctor-patient ratio, one psychiatrist serving 6 million individuals (29); and many Ethiopians prefer informal help for mental illness treatment (30).
Higher rates of psychiatric service utilization were reported from other studies. The study in Switzerland reported that 43% of the inmates participate in psychiatric services (13), a rate which is higher than the rate found in our study. Another study in Norway examined inmates’ participation in mental health consultation and reported a rate of 25%, which is still higher than what is found in our study. However, the study also found that it is only 3% of the inmates who received treatment for psychotic disorders (14). The difference could be attributed to the fact that psychiatric service to inmates in Ethiopia are delivered in the nearly hospitals while in both Switzerland and Norway the services are given inside the prisons. Coupled with this, the variations on what constitute psychiatric services could also be a factor for differences in findings. In our study we have assessed the psychiatric services inmates received in the nearby hospitals through referrals from counselors in the prisons. The study in Switzerland assessed psychiatric services rendered inside the prison only (13). On the other hand, the study in Norway assessed the services inmates received from psychologists, psychiatric nurses and psychiatrists in the prisons as well as the emergency psychiatric services the inmates received from private psychologists/psychiatrists and a deviant sexuality treatment clinic (14).
When we critically look into the overall mental health care utilizations (the guidance and counseling service utilization and psychiatry service utilization combined), there are low service utilization in the present study. This finding is similar with a research finding that depicted that there are low mental health care service utilizations in Ethiopia because of stigma and discrimination associated with mental illnesses (31).
In the present study factors associated with health care service utilization were also examined. Knowledge of service availability was consistently found to be associated with inmates’ health care service utilization. Inmates who have the knowledge of medical care services, guidance and counseling services and psychiatric services utilize the services more than the inmates who didn’t have the knowledge. In the global literature low health literacy is associated with high HCS utilization (32, 33). Given the strong association between health literacy and health knowledge (34), one could argue that health knowledge and HCS utilization will have negative associations. Our findings are against this argument indicating that knowledge and utilization have positive associations. This implied that the role of knowledge on HCS utilization still needs further investigations.
Of the other variables included in the present study, education, marital status, convict status and length of stay were associated with the different health care service utilizations.
In the present study inmates who are convicted were more likely to use medical services than inmates who were in accused status. Contrary to this finding, in the two studies in Switzerland inmates with pretrial detentions were found to use more nursing and GP health care services (12, 13). However, the study in Norway that examined inmates’ participation in medical and mental health services found a similar result with our study where sentenced inmates were found to use more services than inmates in pretrial detention (6). The possible explanation for our finding is that inmates who are only accused might think of their release soon thereby delay their medical care use in the prison. Given the poor quality medical care in the prisons in Ethiopia (22) inmates who are accused might delay their service use while the only option for convicted inmates is using the prison medical services.
Inmates’ educational status was associated with medical service use. Specifically inmates who attended primary and secondary education were more likely to participate in medical services than inmates with no schooling. Contrary to this finding, in the study in Norway education was not found to be associated with inmates’ participation in medical and mental health services (6). The small number of inmates with no schooling and with higher education status in our study could explain the variation in the findings. In the community based study in Achefer inmates with primary and above primary schooling were more likely to use medical health care service than inmates who can’t write and read (26). This finding substantiates the results from our study that depicted that inmates’ educational status is one of the significant factors in their medical care utilizations.
Inmates who are divorced were found to utilize more guidance and counseling services than inmates who are single. The study in Switzerland categorized inmates as married and unmarried where the former use less psychiatric services than the later (13). Differences in findings could be attributed to how the studies categorized inmates’ marital status. The negative effects of the divorce itself might have induced psychological problems and that in turn might have increased the odds of inmates in the present study to use the guidance and counseling services.
Length of stay is associated with psychiatric service utilizations where longer stay is associated with lower odds of psychiatric service utilizations. Similar to this finding, the study in Switzerland found an association between longer stay in prison with lower psychiatric service utilizations (13). From this findings it can be deduced that as inmates stay longer in prison they might adapt to the distresses because of the incarcerations thereby lower odds of using the psychiatric services.
The cross-sectional nature of the study alongside with the fact that the study includes three prisons only could be considered as the limitation of the study. Moreover, the researchers acknowledged that the study would have been better had it included additional variables like having children, place of residence, presence of illnesses, etc.