# Incarcerated individuals’ experiences of COVID-19 in the United States

Carrie Pettus-Davis (College of Social Work, Florida State University, Tallahassee, Florida, USA)
Stephanie C. Kennedy (Institute for Justice Research and Development, Florida State University, Tallahassee, Florida, USA)
Christopher A. Veeh (School of Social Work, University of Iowa, Iowa City, Iowa, USA)

ISSN: 1744-9200

Article publication date: 24 March 2021

Issue publication date: 18 October 2021

926

## Abstract

### Purpose

This study aims to examine steps taken by correctional staff to prevent COVID-19 from spreading through correctional facilities and explores strategies used by incarcerated individuals to reduce their own risk of contracting COVID-19 during confinement.

### Design/methodology/approach

Data were drawn from interviews with 327 individuals incarcerated after March 16, 2020, in Midwest1, Midwest2 and Southeast state using a questionnaire developed for this purpose. All study participants were actively involved in a randomized controlled trial of a behavioral health reentry intervention and the human subjects board approved the supplement of this study on COVID-19; interviews were conducted from April 15 to November 19, 2020.

### Findings

Overall, 9.89% of participants contracted COVID-19. Most (68.50%) individuals learned about COVID-19 from television compared to official correctional facility announcements (32.42%). Participants wore face masks (85.02%), washed hands (84.40%) and practiced physical distancing when possible (66.36%). Participants reported that facilities suspended visitation (89.60%) and volunteers (82.57%), provided face masks (83.18%), sanitized (68.20%), conducted temperature checks (55.35%) and released individuals early (7.34%).

### Social implications

Longitudinal observational study on the implementation and effectiveness of public health guidelines in prisons and jails may identify best practices for containing the infectious disease. Maximizing transparent communications, as well as COVID-19 prevention and mitigation efforts, are critical to achieving universal best practices for virus containment and amplifying public health.

### Originality/value

Data presented indicate the early adoption of many Centers for Disease Control guidelines by individuals and correctional facilities, although broad variation existed. Data support the identification of containment strategies for feasible implementation in a range of correctional spaces.

## Citation

Pettus-Davis, C., Kennedy, S.C. and Veeh, C.A. (2021), "Incarcerated individuals’ experiences of COVID-19 in the United States", International Journal of Prisoner Health, Vol. 17 No. 3, pp. 335-350. https://doi.org/10.1108/IJPH-11-2020-0094

## Publisher

:

Emerald Publishing Limited

## Introduction

The USA has approximately 4% of the global population but holds nearly a quarter of the world’s incarcerated population and has reported more than a quarter of the world’s COVID-19 cases. As of January 27, 2021, the COVID Prison Project reports that 370,546 individuals incarcerated in federal or state prisons in the USA have contracted the 2019 novel coronavirus (SARS-CoV-2, which causes the disease COVID-19). Of those, 2,287 died from the virus. Further, 89,016 prison staff in the USA have also contracted the virus, of whom 141 have died. These publicly available data suggest that individuals incarcerated in US prisons are 289.65% more likely to die from COVID-19 than correctional staff. Scholars suggest that the disparate death rate can be attributed to the fact that many incarcerated individuals are in poor health and are at increased risk for preexisting chronic conditions, all of which complicate their experience of the virus (Nowotny et al., 2020). While these statistics may underrepresent the true disease burden among incarcerated individuals and correctional staff, it is clear that shared living spaces and limited space for physical distancing in correctional facilities fuel the spread of the virus (Nowotny et al., 2020). Additionally, correctional staff works in close proximity to each other and to incarcerated individuals; however, unlike those incarcerated, correctional staff return to families and communities after each shift, potentially carrying the virus from one space to the other (Barnert et al., 2020).

### Incarcerated individuals’ experience of COVID-19

Little empirical documentation exists of incarcerated individuals’ experiences of living in correctional settings during the COVID-19 pandemic. Although many anecdotal accounts have been featured in the media since March 2020, there are few coinciding empirical articles that document these experiences. The majority of scholarly articles either present prevalence data on the burden of COVID-19 among incarcerated populations at the time of this article’s publication (Jiménez et al., 2020; Njuguna et al., 2020; Saloner et al., 2020; Solis et al., 2020) or are conceptual in nature (Abraham et al., 2020; Alexander et al., 2020; Barnert et al., 2020; Nowotny et al., 2020; Desai et al., 2020; Franco-Paredes et al., 2020; Henry, 2020; Fair and Justice Prosecution, 2020; Johnson and Beletsky, 2020; Minkler et al., 2020; Nowotny et al., 2020; Vose et al., 2020). Articles which present prevalence data provide a glimpse into COVID-19 mortality among incarcerated individuals and provide a powerful historical timeline of the spread of the virus across multiple state and federal systems. While publicly available data documenting morbidity and mortality continues to evolve, research findings drawn from independent analyses underscore the increased risk of death among those incarcerated when compared to correctional staff and the public. However, what remains among scholarly literature is conjecture about what might be happening daily behind the walls as incarcerated individuals seek to manage and understand the COVID-19 virus and correctional staff responses to COVID-19.

Conceptual articles on COVID-19 identified correctional facility settings as potential disease vectors at the very beginning of the pandemic. Scholars offer recommendations to control the spread of COVID-19 in correctional facilities including performing mass releases to quickly reduce the facility population (Abraham et al., 2020; Desai et al., 2020; Henry, 2020; Fair and Justice Prosecution, 2020; Minkler et al., 2020; Vose et al., 2020). Many authors also suggest quarantining releasing individuals (whether during custody prior to release or in the community after release) to ensure that they will not bring the virus to their next living situation (whether group-based or at home with their families; Johnson and Beletsky, 2020), although no such recommendations have been made to quarantine correctional staff between shifts. Further, the extant conceptual literature also highlights the unique needs of special populations in incarcerated settings including the elderly (Prost et al., 2020) and youth (Barnert, 2020; Gagnon, 2020). Additionally, one study presented field notes drawn from unstructured telephone and social media communications about COVID-19 between study staff and 35 of the 474 justice-involved women participating in a larger study about women’s health and cervical cancer risk (Ramaswamy et al., 2020). These community-based, justice-involved women expressed a range of concern about COVID-19, with the majority following guidelines issued by the Centers for Disease Control (CDC) as best as they were able. They also expressed difficulty in navigating other health issues (e.g. cancer, pulmonary disease, and mental health and substance use disorders) during the pandemic. Many were experiencing homelessness or otherwise living in suboptimal or unstable housing conditions.

Thus far, only one empirical study in a peer-reviewed journal has been conducted from the perspective of incarcerated individuals on their experiences of the COVID-19 pandemic in the USA. Study authors conducted mixed-methods, in-depth phone interviews with 31 high-security incarcerated men in segregated housing (solitary confinement) in one Oregon Department of Corrections prison between April 3 and May 18, 2020, to understand their experiences and perspectives on COVID-19 risks and responses (Pyrooz et al., 2020). Eight COVID-related questions explored respondent’s beliefs about whether individuals at the facility would become infected with COVID-19, the likelihood of their own infection and whether being housed in segregation reduced their risk. In addition, the eight questions covered whether incarcerated respondents believed correctional administrators and staff were capable of preventing an outbreak, taking the virus seriously and providing adequate treatment to those incarcerated. Reported results by Pyrooz et al. (2020) suggest that many incarcerated individuals felt resigned to contracting the virus. Additionally, while respondents believed that COVID-19 was being taken seriously by prison officials, some lacked confidence that an outbreak of the virus could be prevented as correctional officers continued to move between the prison and the community. Respondents also expressed doubt that incarcerated individuals who became ill could be effectively treated in the prison milieu. At the time of this manuscript submission, we were not able to locate any other empirical articles that presented the perspective of incarcerated individuals during the COVID-19 pandemic.

### Incarcerated individuals’ experience of other infectious disease

More is known about incarcerated individuals’ experiences of other infectious diseases including human immunodeficiency virus (HIV), Hepatitis B and C, tuberculosis and influenza (Beaudry et al., 2020; Bourdillon et al., 2017; Crowley et al., 2019; Dolan et al., 2016; Jack et al., 2020; Kamarulzaman et al., 2016; Maruschak et al., 2009; Rich et al., 2016; Santos and Moita, 2014; Van’t Hoff et al., 2009). An international meta-analysis suggests that of the estimated 10.2 million people incarcerated worldwide on any given day, 3.8% have HIV, 15.1% have Hepatitis C, 4.8% have chronic Hepatitis B and 2.8% have active tuberculosis (Dolan et al., 2016). Results from the meta-analysis suggest that intraprison transmission of all four diseases are rare, with the exception of outbreaks (Dolan et al., 2016). Thus, much of the literature focuses on improving testing and clinical services (Hammett, 2006; Rich et al., 2016) and providing education on disease processes and transmission (Adane et al., 2017). Gaps in access to quality medical services for both chronic and infectious disease during incarceration and as individuals are released back into the community are also noted (Binswanger et al., 2011; Condon et al., 2007).

Correctional facilities are identified as presenting both challenges and opportunities for the testing, prevention and treatment of many infectious diseases such as HIV, viral hepatitis and tuberculosis (Bick, 2007; World Health Organization, 2014). Further, the intersection of HIV and correctional facilities are well explored in the literature. Much of this literature focuses on increasing testing and psychoeducation on risk reduction methods for incarcerated individuals and identifying strategies to decrease stigma toward those who contract diseases such as HIV during incarceration and after their release to the community (Kemnitz et al., 2017; Muessig et al., 2016; Sprague et al., 2017).

Key differences exist, however, between infectious diseases such as HIV, Hepatitis B and C, tuberculosis, influenza and COVID-19. Unlike HIV and Hepatitis viruses, COVID-19 is an airborne pathogen spread by droplets rather than by blood contact or sexual activity. Among those incarcerated, HIV and Hepatitis cluster among intravenous drug users and require different risk mitigation strategies (Mukherjee and El-Bassel, 2020). Further, although tuberculosis is an airborne respiratory disease, it requires longer exposure for contraction than COVID-19 and the bacterium are activated principally among those with weakened immune systems. Tuberculosis has long been an issue within correctional facilities (Melchers et al., 2013; Santos and Moita, 2014), however, it has yet to reach pandemic levels in the same way as COVID-19 as correctional staff have a lower risk of contracting and spreading the disease within the facility and in the community. Scholars have warned against the potential for an influenza pandemic to disproportionately affect incarcerated individuals (Van’t Hoff et al., 2009) as influenza may spread rapidly among individuals housed in close proximity to one another (Balicer et al., 2005). However, COVID-19 is more contagious than seasonal influenza due, in part, to longer symptom onset and an extended window for virus shedding among infected individuals (Centers for Disease Control, 2020). Further, COVID-19 has been associated with more severe symptoms and associated illnesses when compared to influenza (Centers for Disease Control, 2020). Therefore, COVID-19 remains a significant threat to the health and well-being of millions of incarcerated individuals in the USA and across the globe.

### Study purpose

To best contain the spread of COVID-19, compliance with safety protocols among all stakeholders is important. Incarcerated individuals are particularly at risk for infection because of their lack of control over containment strategies, therefore, we sought to understand incarcerated individuals’ experiences and responses and adoption of strategies to contain COVID-19. The purpose of this study is to explore strategies used by correctional administrators and staff to keep COVID-19 from entering correctional facilities and to reduce disease transmission among the incarcerated population and to understand what measures individuals incarcerated in state prisons in the USA took to reduce their risk of contracting COVID-19. This study fills a critical gap in the field’s understanding of the experiences of the COVID-19 virus for those incarcerated in the USA during the pandemic and their experiences are important to document to develop a comprehensive understanding of how to best manage the spread of COVID-19 and other future highly contagious diseases in prisons.

## Methodology

### Sample

Data were drawn from individuals recruited into a randomized controlled trial of a behavioral health reentry intervention being conducted in 38 state-run correctional facilities across two Midwestern states and one southeastern state. Participants were identified for study recruitment based on eligibility criteria defined by the research team and shared with the department of corrections in each of the three states. Eligibility criteria included being: 18 years of age or older, incarcerated in a correctional facility study site, approximately six-months from release from prison and releasing from prison to a county study site. The department of corrections in each state sent the research team a list of incarcerated individuals who met eligibility criteria monthly. The research team then set up private interviews with eligible individuals to complete informed consent procedures, beginning with those individuals who had the soonest release dates. Potential participants were informed about the nature of the study and their rights as participants, including the right to decline participation outright, to terminate the interview whenever they wished and to not answer any questions that they did not want to answer. Once an individual provided informed consent, a baseline research interview was completed. Following the baseline interview, study participants were randomized into either the treatment group to receive a behavioral health-focused reentry intervention or into the comparison group to receive existing services during incarceration and following release to the community. Research team members conducted post-release interviews with all study participants. Participants received compensation of $40 per follow-up research interview and$5 per month to update location-tracking information. Participants received no compensation while incarcerated.

Across the 3 states, 117 individuals were interviewed during their incarceration in state prison. An additional 210 individuals were interviewed in the community after their release from incarceration in state prison. On average, these participants had been released from incarceration 27.70 days prior to being interviewed by a research team member. Among the 210 individuals released from state prison prior to being interviewed, three participants completed their interview in a state-level correctional facility (where recruitment and baseline interviews were conducted) but following their re-admission into another controlled environment. Two of the three participants completed the interview from a department of corrections work release center; the third participant completed the interview from a residential substance use disorder treatment program.

On March 16, 2020, the research team had to suspend all face-to-face data collection, both in correctional facilities and in the community, across the three states due to the COVID-19 pandemic. As study participants were released on a rolling basis, 59 participants had already been released to the community prior to March 16, 2020. To systematically capture participant’s experiences of COVID-19, the research team developed a new measure related to experiences with COVID-19 and added it to the data collection packet with approval from the university human subjects review board to add this supplemental questionnaire. For the current analysis, 327 study participants responded to the COVID-19 survey. Individuals who had already been released to the community prior to March 16, 2020, and thus who were not incarcerated during COVID-19 outbreaks were excluded from the current analysis (n =59). All study protocols were approved by the Florida State University institutional review board.

### Measures

Data were collected using the COVID-19 Questionnaire for Correctional Populations (CQCP; Institute for Justice Research and Development, 2020). Items ask how study participants learned about COVID-19, the strategies that study participants and correctional staff members took to reduce COVID-19 risk during incarceration and incarcerated individuals’ symptoms of COVID-19. Because the questionnaire was designed for incarcerated individuals, the responses may not comprehensively describe strategies taken by correctional administrators and staff to mitigate risk. The CQCP was developed by the research team with input from a National Scientific Advisory Council comprising seven behavioral health, public health and criminal justice research experts (α = 0.81). One published questionnaire available in April 2020 informed the development of the items on the CQCP (Harkness, 2020). The modification of the study to add this new measure to the data collection packet was approved by the Florida State University institutional review on April 15, 2020 board prior to implementation.

### Data collection procedures

Data for the current study were collected between April 15 and November 19, 2020. Data were collected directly from all study participants during interviews conducted via telephone or videoconference either during an individual’s incarceration or within 45 days of an individual’s release from incarceration in state prison. Although some participants were no longer incarcerated at the time of the interview, they were asked to reflect on their experiences of COVID-19 during their incarceration in state prison. Data collectors read the questions out loud to study participants and then entered their responses directly into Research Electronic Data Capture, a secure, Web-based application designed to support validated data capture for research studies (Harris et al., 2009).

## Findings

### Demographics

The study sample was, on average, 37.82 years old. Nearly half of study participants self-reported their racial identity as Black (49.85%), although racial composition differed across study states. Ethnicity was largely Non-Hispanic at 93.58% of the total sample. The majority of the sample was male (88.07%). During their incarceration, 22.53% of the sample (n =73) believed that another incarcerated individual in their facility had died from COVID-19 (23.37% in Midwest1; 28.95% in Midwest2; and 18.63% in Southeast state). See Table 1.

One month into data collection, the research team added two items about whether individuals had tested positive for COVID-19 and whether they felt safer from the risk of infection in the prison or the community. Of the 327 total individuals in the sample, 275 had the opportunity to respond to these items because they were added later. Across the three states, 9.89% of the sample (n =27) tested positive for COVID-19, although there was state variation (7.50% in Midwest1; 30.43% in Midwest2; and 8.89% in Southeast state). See Table 1 for a breakdown of participants’ experience with many of the common symptoms associated with COVID-19. Additionally, 85.98% of the sample (n =233) said that they felt safer in the community compared to prison (87.97% in Midwest1; 100.00% in Midwest2; and 79.89% in Southeast state).

### How individuals learned about COVID-19 during their incarceration

During their incarceration, nearly one-third (32.42%) of study participants learned about COVID-19 through official announcements from correctional staff, although there was broad state variation (20.54% in Midwest1; 41.03% in Midwest2; and 50.49% in Southeast state). Over two-thirds, 68.50%, of participants across the three states received information from television news or other television programs (72.97% in Midwest1; 43.59% in Midwest2; and 69.90% in Southeast state). These two sources were the most frequently selected when participants were asked to identify their sources of information related to learning about COVID-19. See Table 2.

### Study participants’ strategies to reduce COVID-19 risk during incarceration

Across the three states, 74.01% of study participants agreed that they stayed in touch with news on the virus and guidelines for safety to know what strategies to implement. Study participants wore a face mask (85.02%) and reported washing their hands much more frequently (84.40%). Participants also agreed that they practiced physical distancing whenever possible (66.36%). Relatively few participants across the three states (15.90%) agreed that they had sought out a session with correctional health-care staff to learn more about COVID-19 and additional strategies they could implement to reduce their risk. Across the three states, 21.20% of participants had requested COVID-19 testing. See Table 3.

### Correctional staff strategies to reduce COVID-19 risk

Incarcerated participants indicated a variety of strategies used by correctional staff to prevent COVID-19 from entering the facility (Table 4). Across the three states, these strategies included reducing the number of outsiders entering the facility, such as suspending visitation from loved ones (89.60%), suspending professional visits (84.10%), suspending entry of volunteers (82.57%) and suspending in-prison education and training programming (74.62%). Participants also reported that facilities also increased cleaning and sanitizing procedures (68.20%), provided cleaning products (70.64%) and face masks (83.18%) to incarcerated individuals, conducted temperature checks (55.35%) and offered individual COVID-19 testing (40.67%).

Within each of the individual states, however, there was substantial variation in whether study participants reported the adoption of these health and safety practices. For example, 89.19% of participants in Midwest1 said the facility suspended professional visits compared to fewer than half (48.72%) of participants in Midwest2. A similar discrepancy between states is also evident in the decision to suspend programming in correctional facilities (84.32% in Midwest1, 46.15% in Midwest2 and 67.96% in Southeast state). Moreover, 88.65% of participants said that the facility provided face masks in Midwest1, although fewer than 60% of participants in Midwest2 and Southeast state said they were provided a face mask. The variation in the adoption of strategies warrants further exploration but was beyond the scope of this study.

Across all three states, 40.67% of incarcerated individuals indicated that the correctional facility offered testing for COVID-19 (36.76% in Midwest1, 30.77% in Midwest2 and 51.46% in Southeast state). Additionally, 29.05% of participants across the three states suggested that the facility hospitalized incarcerated individuals who became critically ill after contracting the COVID-19 virus (26.49% in Midwest1, 35.90% in Midwest2 and 31.07% in Southeast state). Finally, 11.31% of study participants indicated that the correctional facility had set up respiration aid to help incarcerated individuals who became seriously ill (7.03% in Midwest1, 23.08% in Midwest2 and 14.56% in Southeast state).

## Discussion

The 2019 novel coronavirus has created an unprecedented public health challenge for correctional facilities across the USA. Brinkley-Rubinstein and Cloud (2020) recently identified mass incarceration as a public health emergency because incarceration serves as a vector for the rapid spread of infectious respiratory diseases such as COVID-19 both within correctional facilities and the communities to which correctional staff and incarcerated individuals return. This paper describes how individuals who were incarcerated during the pandemic perceived correctional administrators and staff responses to this crisis and how the incarcerated individuals themselves managed their risks for contracting COVID-19. Our findings indicate that many of the strategies recommended by the CDC were followed in the study sites, even in the first months of the pandemic. The uptake of these strategies early in the pandemic reflects awareness by correctional administrators about the level of risk the virus presented to both correctional staff and the incarcerated individuals who live and work within the correctional facilities.

Individuals across all three states reported that most correctional administrators suspended visitation from loved ones, education and training programming and professional visits during the COVID-19 pandemic, although broad variation between states was detected. These measures were designed to reduce viral transmission risk by limiting the number of individuals moving between the community and prison and reflect prior analyses on institutional measures taken by departments of corrections. However, findings from the current analysis indicate inconsistent implementation of this policy at the facility level. Specifically, while more than 95% of the individuals incarcerated in Midwest1 had their visitation from loved ones suspended, less than two-thirds of individuals in Midwest2 made this same claim.

Unfortunately, there are potential unintended consequences associated with separating individuals from their support systems and limiting their engagement in education or training programs. For example, a recent meta-analysis reported that individuals who participated in correctional education programs (e.g. general equivalency diploma courses) were 13% more likely and participants in correctional vocational training were 28% more likely to secure employment after release (Davis et al., 2013). Likewise, other scholars have expressed concern about the unintended negative mental health effects of isolating individuals within correctional facility settings and separating them from their loved ones and support systems (Hewson et al., 2020; Kothari et al., 2020). In particular, these authors raised alarm about potential increases in incarcerated individuals’ symptoms of depression and increased self-harm which may result from reduced social contact in the correctional space. However, given that correctional staff continues to move between the facility and the community, thus increasing the risk for spreading COVID-19 in both spaces (Barnert et al., 2020), the suspension of these formal and informal in-person sources of support may have only a limited impact on virus transmission.

During the pandemic, some correctional facilities have increased the use of virtual visitation with loved ones to allow incarcerated individuals access to their support systems. Although virtual visitation was effectively used as a supplement – rather than a replacement – of in-person visitation with incarcerated individuals and their children prior to the pandemic (Charles et al., 2020), technology issues and the associated costs of virtual visitation and video calls have often created unintended barriers for incarcerated individuals’ loved ones at home (Murdoch and King, 2020; Sitren et al., 2020). In addition to the noted barriers created by virtual visitation among incarcerated individuals’ loved ones, many correctional facilities have limited technological capacity and exist in internet deserts, complicating their ability to build or expand access to virtual visitation. Therefore, while virtual visitation may mitigate many of the unintended behavioral health consequences of isolation both during and after the COVID-19 pandemic and be expanded to increase contact with loved ones after the pandemic ends, infrastructure to support wide-scale access will need to be developed in correctional facilities across the nation.

In line with Novisky et al. (2020) findings on the institutional measures taken by correctional administrators to reduce COVID-19 risk in correctional facilities, the current analysis uncovered broad jurisdictional variation in the types of policies implemented and whether and how those policies were enacted at the facility level, ranging from the provision of masks and cleaning supplies to the suspension of visits and programming. Although data on the official correctional policy was not collected as part of this study, in our work with state departments of corrections and correctional administrators over the past several decades, we have noted that while central office staff in departments of corrections typically sets state-wide policy, the implementation of that policy tends to vary by the correctional facility in any given state. We have also noted that variations in the implementation of policies and practices also tend to occur within units or cell blocks of correctional facilities. For example, a minimum-security unit has more degrees of freedom than a maximum-security unit or administrative segregation; even size and space allocations within a correctional facility may impact how a policy is enacted or enforced. Although prior research indicates that while more than half of the departments of corrections jurisdictions provided some form of face coverings or personal protective equipment to the individuals incarcerated in their facilities by mid-April 2020 (Novisky et al., 2020), distribution and guidelines on the use of this equipment varied widely. This finding is supported by the results of the current study; nearly 90% of individuals in Midwest1 were provided with a face mask compared to fewer than 60% of participants in Midwest2 and Southeast state.

Nearly a quarter of the incarcerated individuals across all three states believed that another individual in their facility had died from COVID-19 complications during their incarceration. In Midwest2, which experienced a high volume of COVID-19 cases within the prison system, 23% of study participants believed someone had died. Although we cannot confirm these beliefs with data, correctional management strategies that clearly and transparently elucidate morbidity and mortality might help to ensure that incarcerated individuals are correctly perceiving the risk and outcomes of COVID-19 within the prison setting. Accurate information shared from correctional administrators to incarcerated individuals can facilitate shared understanding about what is being done to protect individual’s health and safety within the correctional facility and the true scope of impact. Novisky et al. (2020) noted how the COVID-19 morbidity and mortality data posted across state and federal correctional jurisdictions were not comprehensive and often lacked transparency. Findings from the current study underscore how mitigation of COVID-19 will require cooperation from all individuals who live or work within correctional facility settings. Data further suggest that opening communication channels between correctional administrators and incarcerated individuals may facilitate the adoption and consistent implementation of containment strategies by both staff and incarcerated individuals.

Across the three study states, nearly 90% of study participants said that they felt safer from COVID-19 in the community than in prison. In Midwest2, 100% of incarcerated individuals said that they felt safer in the community. We included this question in the protocol because although public opinion might suggest that individuals would feel safer in any location besides a prison regardless of whether or not individuals were experiencing a pandemic, this has not been explored in a systematic way. Data collected through surveying those directly impacted reflect individuals’ concern for their health during their period of incarceration. As the majority (64.22%) of individuals in the sample had been released from incarceration and were living in the community at the time of the interview, they had the ability to compare their actual feelings of safety in prison and in the community during the pandemic.

The current analysis uncovered important variations between the study sites. As the pandemic continues to affect states and regions differently, exploring differential responses by state and by correctional facility provides an opportunity to identify the most effective containment practices. In this way, state departments of corrections can learn from one another and operate like natural experiments to test risk reduction measures. Standardizing data collection procedures across state departments of corrections allows for an examination of the effectiveness and outcomes of the varied COVID-19 mitigation strategies implemented in prisons across the nation. Further, although Novisky et al. (2020) noted that most state departments of corrections advertised measures they had taken to reduce the incarcerated population through early releases, findings from the current project indicate that mass releases did not occur in the three study states. Specifically, the rate of early release across study states was similar and ranged from 5%–11%, suggesting that while early releases were granted to some individuals, the level of these releases was likely not capable of creating large-scale decarceration or of alleviating the issues of overcrowding and lack of space for physical distancing. However, creating a vehicle for collecting and comparing data across states may allow for cross-jurisdictional analysis of the impact of early releases on public health and public safety in those cases in which it does occur. Engaging public health researchers may help correctional administrators to structure data collection procedures around current and future mitigation strategies for infectious diseases.

## Limitations

The current analysis should be considered in the context of its limitations. First, the data provided by individuals are anchored to the COVID-19 burden in each state when the individual was incarcerated. For example, COVID-19 entered the prisons in Midwest2 early in the pandemic and did not arrive in the Southeast state at the same magnitude until weeks later. Additionally, data are only reflective of incarcerated individuals’ perceptions of the strategies used by correctional administrators and staff to reduce the risk of COVID-19 transmission and therefore may not encompass the scope of measures used by the facility. In particular, we lack confidence about the accuracy of study participants’ responses to items describing whether correctional facilities: offered individual testing for COVID-19, set up respiration aid for critically ill incarcerated individuals and hospitalized critically ill incarcerated individuals.

## Foregrounding correctional facilities in planning for the next pandemic

Based on this descriptive analysis of how incarcerated individuals experienced the COVID-19 pandemic in three states, there are important public health implications that need to be considered. The variation in the adoption of basic public health guidelines to stop the spread of COVID-19 suggests that correctional officials need tailored approaches to how guidelines should be implemented within incarceration settings. Important issues like how to control the spread of infectious diseases should not be left to the decision-making of correctional officials or front-line correctional staff who often have no or limited training with infectious disease or epidemiology. We recommend forging collaborations between the state department of corrections, individual correctional facilities and public health agencies to catalyze transparent communications and amplify prevention and mitigation efforts. Public policy should be used to implement a nationwide strategy for how correctional facilities should approach not just the next pandemic but also the disproportionate burden of disease borne by individuals who are incarcerated.

Although many of the conceptual articles published on the intersection of incarcerated populations and COVID-19 advocate for correctional systems to perform mass releases (Abraham et al., 2020; Desai et al., 2020; Henry, 2020; Minkler et al., 2020), care must be taken to ensure that individuals have access to safe quarantine conditions to reduce the risk of spreading the virus between the correctional facility and community. Likewise, unless mass releases are paired with a major-scale up of community-based reentry services (Fair and Justice Prosecution, 2020), individuals leaving incarceration during the pandemic may not have access to needed supports and resources in the community. There is an urgent need for coordinated and transparent communication, prevention and mitigation strategies to ensure success.

Further, it is vital for both correctional and public health officials to consider how to best administer any vaccine to a correctional population once it becomes available. Incarcerated individuals are likely less noticed within the larger debate about who should receive a vaccine and scholars have noted the complex ethical factors related to including incarcerated individuals in vaccine trials (Kronfli and Akiyama, 2020; Wang et al., 2020). These factors stem from a long history of medical exploitation of incarcerated populations and they complicate the ability of researchers to target public health initiatives in correctional spaces both in the USA and abroad (Ahalt et al., 2018; Ako et al., 2020; Appleman, 2020) and have resulted in decreased trust among some incarcerated individuals about medical treatments more broadly (Alagood, 2015). Given the explosive rates of transmission documented within correctional facilities across the USA, many experts are calling for incarcerated individuals to be vaccinated as quickly as possible (Siva, 2020). These expert opinions are bolstered by the fact that nearly 615,000 individuals are released from state and federal prisons every year into communities across the USA (Carson, 2020) and nearly 12 million individuals cycle through local jails annually (Minton et al., 2015). Therefore, halting the transmission of COVID-19 between correctional facilities and communities is likely critical to improving public health more broadly as facilities are porous and entwined with communities. Further, Kronfli and Akiyama (2020) note that expanding vaccine trials and access into correctional facilities will allow for pilot-testing the infrastructure needed to screen and treat other infectious disease like HIV, hepatitis and tuberculosis of which incarcerated individuals carry a disproportionate burden. Likewise, Kinner et al. (2020) note that approximately 30 million individuals are released from incarceration globally, situating correctional facilities as a vector for community transmission that will continue to disproportionately affect already marginalized communities. Without a vaccine plan that includes incarcerated individuals, correctional facilities will likely continue to be a robust source of COVID-19 infections long after vaccines become widely available in communities in the USA and around the world.

Incarcerated individuals in the USA have experienced a disproportionate disease burden when compared to non-incarcerated individuals in the USA and those incarcerated globally (Novisky et al., 2020). Future research is needed to build upon the presented results to understand which policies and guidelines are the most effective at curbing the spread of an infectious respiratory disease like COVID-19 within correctional facilities. Once the pandemic has been adequately controlled, longitudinal observational research on the implementation and effectiveness of public health guidelines in prisons and jails, such as wearing a face mask or physical distancing, may be used to identify best practices for containing other infectious respiratory diseases within incarceration settings. Likewise, research is needed to understand how any identified best practices can be implemented with fidelity at the state, correctional facility and unit or cell block level to maximize public health.

## Table 1

Characteristics of study sample

Mean (SD) or %
Characteristic Midwest1 (n =185) Midwest2 (n =39) Southeast (n =103) Total (n =327)
Interview completed in community
Yes 69.19% 100% 41.74% 64.22%
No 30.81% 0% 58.25% 35.78%
Time since release (days) 20.27 (25.87) 45.46 (51.03) 33.72 (34.82) 27.70 (34.97)
Age (years) 35.65 (10.41) 38.97 (12.37) 39.89 (11.89) 37.82 (11.28)
Race
Black 56.22% 48.72% 38.83% 49.85%
White 27.57% 25.64% 55.34% 36.09%
Multi-racial 9.73% 20.51% 3.88% 9.17%
Other 6.49% 5.13% 1.94% 4.89%
Ethnicity
Non-Hispanic 93.51% 92.31% 94.71% 93.58%
Hispanic 6.49% 7.69% 4.85% 6.12%
Gender
Male 88.11% 97.44% 84.47% 88.07%
Female 11.89% 2.56% 15.53% 11.93%
Symptoms of COVID-19
Cough 18.92% 2.56% 11.65% 14.68%
Fever 12.43% 5.13% 9.71% 10.70%
Shortness of breath 6.49% 5.13% 6.80% 6.42%
Chills 14.05% 5.13% 12.62% 12.54%
Muscle pain 12.97% 5.13% 7.77% 10.40%
Sore throat 5.95% 2.56% 8.74% 6.42%
Loss of taste or smell 14.59% 2.56% 8.74% 11.31%
Tested positive for COVID-19 (n =275) 7.50% 30.43% 8.89% 9.89%

## Table 2

CQCP item Midwest1 (n = 185) (%) Midwest 2 (n = 39) (%) Southeast (n = 103) (%) Total (n = 327) (%)
Official announcements from correctional staff 20.54 41.03 50.49 32.42
Written materials supplied by the correctional facility 16.22 35.90 39.81 25.99
Informal discussions with correctional staff 18.38 25.64 31.07 23.24
Correctional facility health-care staff or chaplains 8.11 28.21 18.45 13.76
Television 72.97 43.59 69.90 68.50
Internet or email communications 12.97 25.64 5.83 12.23
Other incarcerated individuals 14.59 15.38 33.01 20.49
Family 20.00 17.95 37.86 25.38
Note:
*

Totals exceed 100% because respondents were able to select multiple categories

## Table 3

Participants’ strategies to reduce COVID-19 risk*

CQCP item Midwest1 (n = 185) (%) Midwest2 (n = 39) (%) Southeast (n = 103) (%) Total (n = 327) (%)
Stayed in touch with news on the virus and guidelines for safety 81.08 74.36 61.17 74.01
Sought out session with healthcare staff to learn more about how to protect yourself 15.68 25.64 12.62 15.90
Wore a face mask (facility-issued, purchased or handmade) 87.57 71.79 85.44 85.02
Washed hands much more frequently 85.95 61.54 90.29 84.40
Stayed 6 feet away from others if possible 64.32 71.79 67.96 66.36
Talked to other incarcerated individuals to get them to agree to social distancing as much as possible 34.05 61.54 26.21 34.86
Requested testing for COVID-19 22.70 28.21 15.53 21.20
Note:
*

Totals exceed 100% because respondents were able to select multiple categories

## Table 4

Participants’ reports of correctional facility strategies to reduce COVID-19 risk*

CQCP item Midwest1 (n = 185) (%) Midwest2 (n = 39) (%) Southeast (n = 103) (%) Total (n = 327) (%)
Suspended visitation from loved ones 95.14 64.10 89.32 89.60
Suspended volunteers coming in 84.86 64.10 85.44 82.57
Suspended professional visits 89.19 48.72 88.35 84.10
Suspended programming 84.32 46.15 67.96 74.62
Moved individuals into segregated housing 9.73 7.69 21.36 13.15
Moved individuals to different facilities to reduce crowding 2.16 2.56 7.73 3.98
Released individuals ahead of their scheduled release date 5.95 5.13 10.68 7.34
Frequently disinfected hard surfaces 69.73 71.79 64.08 68.20
Provided face masks to incarcerated individuals 88.65 58.97 82.52 83.18
Provided soap and cleaning products and instructed incarcerated individuals to wash hands often 81.62 56.41 56.31 70.64
Advised incarcerated individuals to practice social distancing as much as possible 54.59 51.28 66.99 58.10
Increased medical monitoring by correctional facility healthcare staff 34.59 38.46 28.16 33.03
Conducted temperature checks 52.43 48.72 63.11 55.35
Gave information on how to get tested for COVID-19 26.49 23.08 23.30 25.08
Offered individual testing for COVID-19 36.76 30.77 51.46 40.67
Set up respiration aid in the correctional facility for seriously ill incarcerated individuals 7.03 23.08 14.56 11.31
Hospitalized critically ill incarcerated individuals 26.49 35.90 31.07 29.05
Note:
*

Totals exceed 100% because respondents were able to select multiple categories

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## Acknowledgements

The authors wish to thank the individual who participated in the study. The current study was supported by a grant from the Charles Koch Foundation.

## Corresponding author

Carrie Pettus-Davis can be contacted at: cpettusdavis@fsu.edu

Carrie Pettus-Davis is based at the College of Social Work, Florida State University, Tallahassee, Florida, USA.

Stephanie C. Kennedy is based at Institute for Justice Research and Development, Florida State University, Tallahassee, Florida, USA.

Christopher A. Veeh is based at the School of Social Work, University of Iowa, Iowa City, Iowa, USA.