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Abstract

For individuals in prisons, the management of diabetes and hypertension is resource-intensive and presents substantial challenges. This qualitative descriptive study explored the experiences of incarcerated individuals in accessing health-care resources for these conditions. In total, 60 participants (mean age = 44.3 ± 12.6 years), including 30 individuals at risk for and 30 diagnosed with diabetes and hypertension, were purposively enrolled by prison nurses. Data were collected through 12 focus group discussions and nonparticipatory observations conducted in 6 prisons in Thailand between September and December 2023. The data were analyzed using Braun and Clarke's thematic analysis framework. The findings revealed 3 key themes: “resource constraints,” reflecting struggles with inadequate provisions (such as dietary ones); “neglect,” reflecting inequalities in diabetes and hypertension screening and limited clinical monitoring; and “self-reliance,” reflecting how participants coped with stress and managed life-threatening situations on their own. In conclusion, the study highlights substantial inequalities in diabetes and hypertension management in prisons. Targeted strategies are urgently needed to improve chronic disease management in prison settings.

Keywords

inequality prisons diabetes hypertension qualitative

Introduction

Life in prison can have detrimental effects on one's health. In particular, a study reported a 39% prevalence of hypertension among older incarcerated individuals versus 27% in the general population.¹ Nonetheless, incarceration can improve health outcomes for certain individuals; the enforced abstention from smoking, alcohol, and overeating in prison may help prevent diabetes and hypertension.^2,3 In the United States, the prevalence of diabetes among incarcerated individuals was 5.6% versus 9.7% nationwide,⁴ and another study reported a prevalence of 4.8% versus 8.3% in the general population.⁵ In Australia, the prevalence of hypertension among incarcerated individuals aged 45 to 54 years was 24.4% versus 27.1% in the general population.⁶ These variations may be attributed to institutional factors such as smoking bans, meal options, and recreational activities.⁷

The management of diabetes and hypertension in prison requires substantial resources and is a source of substantial inequality in access to health-care services. For example, in Mexican prisons, only 10.6% of individuals with hypertension and 19.5% of those with diabetes received a special diet.⁸ In a Brazilian prison, individuals with hypertension were frequently served processed foods instead of fruits and vegetables.⁹ In the United States, many individuals who were recently released reported relying more on peers than on health-care professionals for disease-related information during incarceration.¹⁰ In UK prisons, only 37% of individuals with diabetes received eye screenings,¹¹ and in New York prisons, only 54.7% underwent regular HbA1c level monitoring.¹² By contrast, only one UK prison had provisions for individuals with a health condition, with 89% of individuals receiving food outside regular mealtimes and glucose tablets for clinical emergencies.¹¹ Inadequate management of these chronic conditions contributes to adverse health outcomes, delays in care, and life-threatening situations that require urgent attention.

Thailand, with 280 835 individuals in prisons, has one of the highest incarceration rates globally.¹³ Studies have indicated that 1.2% of incarcerated individuals in Thailand have diabetes and 3.3% have hypertension versus 9.5% and 26.7%, respectively, in the general population.^14,15 Although studies have highlighted the prevalence of disease and inequalities in health-care access in prisons, limited evidence is available on how the prison environment and wider health-care system affect chronic disease management. This study explored the experiences of incarcerated individuals in accessing diabetes and hypertension care. The findings of this study provide critical insights into health-care inequalities in prisons and are essential for informing effective improvements.

Method

Research Team

The second author served as the facilitator and led all 12 focus group discussions (FGDs). She is a PhD-trained nurse researcher with more than 25 years of experience in disease prevention and control in prison settings and has completed 45 hours of training in qualitative research methods. In each study site, where 2 FGDs were conducted, a female research assistant supported the facilitator by operating the audio recorder, obtaining informed consent, collecting the participants’ demographic data, and taking field notes.

Study Design

This study employed a qualitative descriptive design.¹⁶ It was conducted in accordance with the Consolidated Criteria for Reporting Qualitative Research Checklist (COREQ).¹⁷

Settings

Out of 143 prisons in Thailand, 6 were purposively selected for this study because of logistical constraints. The northern, northeastern, central, and southern regions of the country were represented in this sample. The selected facilities also varied in capacity, ranging from 1000 to 5000 inmates, and were both medium- and maximum-security prisons. One facility housed only female inmates.

Participant Selection

The study included 60 incarcerated individuals: 30 at risk for diabetes and hypertension and 30 with diagnosed diabetes and hypertension. A sample size of 30 to 60 participants is considered sufficient for qualitative research.¹⁸ These 2 groups were chosen to capture a wider range of experiences related to disease prevention and management. Although both of these groups did not differ with respect to health education, diet, access to a weighing scale and blood pressure monitor, and access to behavior modification therapy, some key differences were noted. The FGDs for the at-risk group centered on disease screening, whereas those for the diabetes and hypertension group centered on disease monitoring and emergency care.

The inclusion criteria for the at-risk group were being 35 years or older and having with a body mass index of 25 kg/m² or higher. The participants in the diabetes or hypertension group had a confirmed diagnosis of diabetes or hypertension. Individuals who had been incarcerated for less than 1 year were excluded. The research team instructed prison nurses to purposively select participants who met the inclusion criteria and who collectively represented a range of ages, prison housing unit, and sentence durations. Only one person in the at-risk group declined to participate because of work obligations; a replacement was selected from eligible individuals in the same housing unit.

Data Collection Tools

The tools included: (1) demographic information form, (2) guiding questions developed from the literature (provided in the Supplement), (3) field notes, and (4) audio recorders. Four experts reviewed the demographic information form and interview questions to ensure comprehensive coverage.

Data Collection

FGDs were chosen over in-depth interviews because of security restrictions. The researchers were allowed a total of 2 hours for data collection—1 hour with individuals at risk and 1 hour with individuals diagnosed with diabetes or hypertension. Data were collected between September and December 2023. A total of 12 FGDs were conducted, comprising 6 groups of individuals at risk and 6 groups of individuals with diagnosed conditions. Each FGD group included 5 participants, and the FGDs were conducted in the ambulatory units of the prisons, with each facility hosting 1 group for at-risk individuals and 1 for those with diagnosed conditions. Each session lasted approximately 60 minutes. During each discussion, both the facilitator and research assistant took field notes and operated 2 audio recorders. In compliance with security regulations, a prison guard was present during each discussion. Participants did not receive compensation because financial incentives were not permitted.

Data Analysis

Four researchers analyzed the data by using Braun and Clarke's thematic analysis approach.¹⁹ They reviewed verbatim transcripts and field notes to familiarize themselves with the content. In the initial coding, the researchers identified key elements and systematically organized the data. The researchers then searched for recurring patterns and grouped related codes to develop themes. These themes were reviewed for coherence with the coded extracts and refined through ongoing analysis to enhance detail and ensure accurate characterization. The final report included illustrative examples that linked the findings to the study objectives and relevant literature. All themes and subthemes were evaluated for adequacy, and coding saturation was confirmed before the analysis was finalized. The FGDs were conducted in Thai, and all themes, subthemes, and participant quotes were subsequently translated into English for publication.

Rigor and Trustworthiness

This study followed Lincoln and Guba's criteria²⁰ to ensure rigor and dependability. To improve credibility, the researchers triangulated the interview data against interview reports and observations of the participant's body language during the interviews. The research team also collaborated in the analysis and coding process. To support transferability, the study provides a detailed account of the research context and procedures. Dependability was ensured by meeting criteria for credibility and through repeated examination and evaluation of the primary topics by the study team. Confirmability was maintained through comprehensive documentation. All interview recordings were transcribed and categorized by the entire research team.

Ethical Consideration

This study received approval from the Research Ethics Review Committee for Research Involving Human Research Participants, Group I, Chulalongkorn University (Study No. 660056, dated July 14, 2023). Prior to performing the Focus Group Discussion, the researchers provided participants with clear and comprehensive information on the purpose and details of the study. Additionally, all participants willingly granted their consent to participate. All participants were granted permission to use tape recorders and were guaranteed that their data would only be utilized with their consent.

Results

This study included 60 participants, and their characteristics are presented in Table 1. Three themes emerged from the data, as listed in Table 2: (1) resource constraints, (2) neglect, and (3) self-reliance. Supporting quotes are identified in parentheses. For example, “(ID151)” refers to a quote from the first focus group conducted at Prison 5, provided by participant 1.

Table 1.

Demographic Characteristics of Participants.

Characteristics	Participants at risk of diabetes and hypertension	Participants with diabetes and hypertension
Total	30	30
Age (years)
21 to 40	19	8
41 to 60	6	18
61 or older	5	4
Range	23–70	29–75
Mean (SD)	41.7 (13.7)	47.0 (11.0)
Sex
Male	20	20
Female	10	10
Education level
Elementary	13	13
Junior high school	11	9
High school	4	6
Bachelor's degree	2	2
Length of stay in prisons (years)
less than 5	24	26
5 to 10	6	4
11 or longer	0	1
Range	1-9	1-12

Table 2.

Themes and Subthemes of the Study.

Themes	Subthemes
Resource constraints	A lack of priority given to health education
	Eating from the same menu, without dietary provisions
	Shortage of weighing scales and blood pressure monitors
Neglect	Unequal screening for diabetes and hypertension
	Remote clinical monitoring for diabetes and hypertension
Self-reliance	Managing stress and anxiety on their own
	Self-care during clinical emergency

Theme 1: Resource Constraints

This theme is on the limited resources available for managing diabetes and hypertension in prison and comprises 3 subthemes.

Subtheme 1.1: A Lack of Priority given to Health Education

Video programs are broadcast in prisons between 17:00 and 21:00, primarily offering entertainment such as music, movies, game shows, and comedy. However, educational content related to health, such as nutrition, stress reduction, self-monitoring of body weight and blood pressure, and exercise, is not prioritized in the programming. Several participants commented on the nature of the video programs.

Last night's programs included game shows and movies. (ID111)

Last night's programs were music videos, movies, a cooking class that made me hungry. (ID122)

Last night's programs included cartoon movies, comedy, concerts, a health talk on diabetes, and boxing. (ID144)

Health programs are rarely seen in the video program. (ID151)

Subtheme 1.2: Eating from the Same Menu, without Dietary Provisions

Prison menus are planned a year in advance to comply with government procurement requirements. In 2023, the daily meal budget was US$2 per person, which resulted in every inmate eating the same meal regardless of their health status, including chronic conditions such as diabetes and hypertension. Meals are served at 7:00, 12:00, and 15:00. The long interval between dinner and breakfast can be particularly difficult for individuals with diabetes who may experience nocturnal hypoglycemia. Although the food is intended to be low in salt and mildly seasoned, participants reported modifying their meals by adding condiments purchased from the prison store, a practice that could adversely affect their health. One participant shared the following:

I like to add fish sauce to make my dish salty, and I add sugar in everything, including instant noodles, chili dip, and coffee. (ID113)

Participants could purchase additional food and condiments from the prison store using their prison-managed account, which relatives deposited money into. This access might lead to unhealthy dietary habits and worsen the diabetes and hypertension. One participant mentioned:

Ordering food in prison is easy; I simply choose from the menu. (ID161)

Subtheme 1.3: Shortage of Weighing Scales and Blood Pressure Monitors

Regular monthly weight checks and blood pressure monitoring are crucial for individuals in prisons, particularly those who are at risk or already diagnosed with diabetes or hypertension, because these measures are useful for disease prevention and control. However, participants reported a lack of access to weighing scales and blood pressure monitors:

Scales or blood pressure monitors are available only in the prison infirmary, not in the confinement area. (ID111)

The confinement area has two blood pressure monitors and thermometers but no scales. (ID124)

Theme 2: Neglect

This theme is about the difficulties that some participants faced in accessing screening and care and is explored through 2 subthemes.

Subtheme 2.1: Unequal Screening for Diabetes and Hypertension

The Ministry of Public Health has implemented a policy to screen high-risk individuals, defined as those aged 35 years or older or with a body mass index of 25 kg/m² or higher, for diabetes and hypertension. This policy includes individuals in prison. However, its implementation varies across facilities depending on the hospitals responsible for conducting the screenings. Consequently, some participants reported receiving regular screenings, whereas others indicated that such services were unavailable in their facilities:

I have annual health checkups that include a chest x-ray, blood pressure measurement, and blood sugar test. (ID124)

Blood sugar is tested regularly, and everyone gets finger pricks. (ID142)

I don’t have any health checkups this year, and neither did others in this prison. (ID151)

Subtheme 2.2: Remote Clinical Monitoring for Diabetes and Hypertension

In prisons, nurses collected blood samples for clinical monitoring and obtained medication from hospitals, meaning that individuals with diabetes and hypertension did not visit a hospital themselves. In addition to receiving blood tests, individuals with diabetes should receive annual checkups for complications affecting the eyes, feet, and teeth, whereas those with hypertension should be examined annually for complications involving the eyes, brain, and heart. Individuals serving shorter sentences were more likely to see a doctor outside the prison, whereas those with longer sentences or housed in maximum-security facilities were less likely to do so due to the increased risk of escape during hospital transfers. Participants shared their experiences with clinical monitoring:

I visit the hospital every month. (ID261)

I haven't been to the hospital in 2 years. (ID235)

My last visit to the hospital was in 2018, 4 years ago. (ID233)

I have never visited the hospital. (ID253)

Individuals with diabetes and hypertension may experience adverse drug reactions when their medication regimens are adjusted; however, long waiting lists for hospital visits often limit timely care. Several participants reported symptoms following changes in their medication:

If medication doses are adjusted or there are adverse reactions, it is difficult to visit the hospital sooner due to a full appointment schedule. (ID263)

I experienced fainting and sweating after my medication regimen was changed. (ID262)

I felt low blood sugar after the doctors adjusted my medication dose. The prison nurse had to complete a security clearance to allow me to carry a small bag of sugar for when I am in my cell at night. Living in prison is difficult because dinner is scheduled early, and the time spent in the cell (4 PM to 7 AM) is longer than that in the confinement area where I have access to food. So I have to eat as much as I can before returning the cell. (ID263)

Theme 3: Self-Reliance

This theme explores how participants responded to their health conditions and is presented through 2 subthemes.

Subtheme 3.1 Managing Stress and Anxiety on their Own

Stress and anxiety affect blood pressure control. Although each prison provided access to a psychologist for counseling services, each participant had their unique perspective about using these services:

I think that people in this prison who seek counseling or help from a psychologist are viewed as psychiatric patients. If I’m stressed, I prefer to distract myself with activities like drawing or reading a book rather than meeting with a psychologist. (ID141)

If I’m stressed, I talk to a close friend. I never use the psychologist's services because they’re for psychiatric patients. (ID145)

Although participants experienced stress, they often tried to manage it on their own:

I sit alone to calm myself down. (ID155)

I tell myself that it will pass. (ID142)

I think about moments when I was happy. (ID161)

Subtheme 3.2: Self-care During Clinical Emergency

People in prisons are prohibited from bringing food or medication to the cell at night. This restriction poses challenges for individuals with diabetes who have no access to food for many hours. Several participants experienced hypoglycemia and explained how they managed these clinical emergencies:

I experienced fainting and sweating, and I learned that these are symptoms of low blood sugar. (ID261)

When I experience low blood sugar, I drink a lot of water and rest; then, I feel better. (ID263)

I experience sweating, but there's nothing I can do except drink a lot of water until the symptom disappears. If the symptoms become severe, I would call the correctional officer for assistance, but I never have. I also feel faint, so I stay still until I feel better. (ID262)

Discussion

This study indicates persistent gaps in diabetes and hypertension management among individuals in prisons in a middle-income country, highlighting challenges related to resource constraints, neglect, and self-reliance. The findings reveal a higher level of inequality than that reported in the literature, and several aspects of such inequality pose life-threatening risks. Most studies in this area have been conducted in high-income countries and focused on specific aspects of diabetes and hypertension management, such as health education,²⁰ medical appointments,^12,22 and financial problems.²³ Only one study examined peer support for diabetes in a low-income country, namely Mali.²⁴ However, other essential components of diabetes and hypertension management, such as access to nutritious meals, disease monitoring equipment, regular screening, mental health services, and clinical emergency care, are frequently overlooked in studies addressing health-care inequality. A comprehensive understanding of these factors is critical for informing effective strategies to improve chronic disease management in prison settings.

The first theme illustrates the extent of resource limitations in managing diabetes and hypertension in prisons. Although staff shortages²⁵ and cost-related problems^23,26 have been well documented, this study revealed more severe constraints. Health education, which is essential for promoting self-care, remains underutilized despite the availability of video broadcasting slots between 5:00 pm and 9:00 pm This underuse is attributed to the lack of technical expertise in prisons to develop appropriate content, whereas local health programs are often not tailored to the prison context and thus cannot readily fill this gap. Previous studies have reported that video-based education in prisons can improve health behaviors^10,21,27 and strengthen trust in health-care providers.²⁸ Essential equipment such as weighing scales and blood pressure monitors are also not readily available. Another study conducted in Ghana similarly reported such shortages.²⁹ Another problem is a lack of dietary provisions. With a budget of only US$2 per person per day, prisons cannot afford dietary provisions for individuals with chronic health conditions. Although prisons in high-income countries have reported that their meals generally meet nutritional standards,³⁰ other studies have identified persistent dietary inadequacies.^31–33

The second theme highlighted how some individuals in prisons were overlooked and did not receive appropriate management for diabetes and hypertension. Incarcerated individuals are often excluded from national health information systems and accreditation measures,^34,35 making it difficult to monitor the quality of care.³⁶ Although Thai health policies mandate annual screenings for at-risk individuals aged 35 years or older, their implementation in prisons was found to be inconsistent. Monitoring primarily relied on laboratory tests, whereas other essential hospital-based examinations, such as eye, dental, and heart assessments, were not consistently provided. One study reported that telemedicine consultations can support diabetes care in prison settings; however, these consultations were typically limited to a review of laboratory results.¹² Although remote services offer some benefits, they are not a substitute for necessary in-person clinical examinations.

The third theme indicated that individuals in prisons often manage health-related challenges independently, primarily due to distrust of the health-care system or fear of negative consequences.^26,37 Stress and anxiety are common, affecting 28% of incarcerated individuals in Ethiopia³⁸ and 61.7% of women in Thai prisons.³⁹ In the present study, participants reported that they used a trial-and-error approach to manage stress, which they found effective, an observation consistent with findings from Cambodian prisons.⁴⁰ Evidence-based stress management strategies, such as mindfulness-based stress reduction,^41–43 muscle relaxation therapy,⁴⁴ guided self-help support,⁴⁵ and exercise,⁴⁶ should be adapted to suit incarcerated individuals’ preference for self-management. Education is also needed to help individuals recognize warning signs, such as persistent sadness, feelings of hopelessness, or depression, that may indicate the need to seek help.⁴⁷ Because counseling services are often perceived as stigmatizing or reserved for patients with psychiatric illnesses, it is essential to raise awareness and shift attitudes so that seeking counseling is viewed as a positive and proactive step.⁴⁸

For nighttime hypoglycemia, individuals with diabetes reported relying on self-care practices, such as drinking large amounts of water, because prison regulations prohibit them from bringing food into their cells. This finding is consistent with reports that low blood glucose frequently occurs at night, prompting some individuals to smuggle sugar packets into their units due to limited access to prison staff.¹⁰ However, individuals with diabetes and hypertension should not be left to manage these potentially life-threatening conditions on their own. A practical intervention would involve housing them in the same cell or unit,³⁶ which would facilitate peer support and reinforce that seeking help is acceptable. Additionally, they should be permitted to carry a small sugar packet to address hypoglycemic episodes that require immediate attention.

This study has several limitations. FGDs were selected over in-depth interviews due to security protocols in the prison setting. These contextual constraints may have limited the depth of the perspectives presented by the participants, particularly on sensitive topics related to their personal experiences. Nevertheless, conducting FGDs under these conditions in resource-limited prison environments yielded valuable insights that would have been difficult to obtain otherwise.

The findings are not intended as criticism but highlight crucial implications for improving health care in prisons. First, the study reveals a lack of health education, which is critical for raising awareness and promoting self-care. Prison authorities should address this gap by implementing video-based health education programs during the available evening broadcast hours from 5:00 pm to 9:00 pm Second, weighing scales and blood pressure monitors must be more accessible to allow incarcerated individuals to monitor their health regularly. In Thailand, where universal health coverage funds for prison health care are allocated to contract hospitals, such resources are often underutilized. Contract hospitals should be encouraged to support the provision of this equipment. Third, given the frequency of clinical emergencies, dedicated units for individuals with diabetes and hypertension should be established to ensure timely and appropriate care. Finally, policy changes are needed to implement disease-specific meal plans and reduce the stigma associated with mental health care, both of which are essential to improving health-care delivery in prison settings.

In conclusion, this study identified inequalities in access to diabetes and hypertension management in prisons. Health education, monitoring equipment, and appropriate dietary options were limited. Screening practices were inconsistent, and although some individuals received remote care, in-person clinical examinations were often unavailable. Widespread distrust in the prison health-care system discouraged individuals from seeking help for stress, anxiety, and emergencies. These findings highlight the urgent need for targeted strategies to improve chronic disease management and overall health-care delivery in prison environments.

Supplemental Material

sj-docx-1-jpx-10.1177_23743735251361778 - Supplemental material for Enduring Inequality in Diabetes and Hypertension Management in Thai Prisons: A Qualitative Study

Supplemental material, sj-docx-1-jpx-10.1177_23743735251361778 for Enduring Inequality in Diabetes and Hypertension Management in Thai Prisons: A Qualitative Study by Ratsiri Thato, PhD, RN, Sirinapha Jittimanee, PhD, RN, Chutima Charuenporn, MS, Krisada Hanbunjerd, MD, and Penpaktr Uthis, PhD, RN in Journal of Patient Experience

Footnotes

Acknowledgments

We acknowledge the contributions of participants in this study. This manuscript was edited by Wallace Academic Editing.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Approval

This study was approved by the Research Ethics Review Committee for Research Involving Human Research Participants, Group I, Chulalongkorn University (Study No. 660056, dated July 14, 2023). Before conducting the focus group discussion, the researchers provided participants with clear and comprehensive information regarding the study's purpose and procedures. All participants signed informed consent forms, granted permission for audio recording, and were assured that their data would be used only with their consent.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Health Systems Research Institution of Thailand [grant numbers 66-033, 2023] and the Center of Excellence for Enhancing Well-being in Vulnerable and Chronic Illness Populations, Chulalongkorn University, Thailand.

ORCID iDs

Ratsiri Thato

Sirinapha Jittimanee

Penpaktr Uthis

Supplemental Material

for this article is available online.

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