HALO moderator team with thank you card penned by participant in the program
Mass incarceration is a true epidemic.
It is also one fueled by social determinants, including race. Over the past four decades of “war on drugs” and “tough on crime” policies, the US incarceration rate has increased by over 500% [pdf]. There are over 2 million men and women in jails and prisons across the country and over 7 million people involved in the criminal justice system. Often poorly educated (over 70% have no high school diploma), this population is also overwhelmingly poor. And members of minority racial/ethnic groups are disproportionately represented.
Programs for jail-incarcerated persons rarely address the complicated factors that lead to criminal justice involvement. Even more rarely do such programs focus on helping incarcerated persons themselves understand how social determinants impact their lives and their health. With our HALO program, we attempted to do just that.
The lack of health care for people who are incarcerated
Health problems abound in incarcerated populations. Almost one-third of persons who spend time incarcerated have a physical impairment or mental condition. Compared to the general population, incarcerated men have higher rates of HIV infection, hepatitis C rates, and tuberculosis. The deinstitutionalization of patients who used to be treated in mental health hospitals has made jails and prisons de facto housing for persons with substance abuse problems and mental illness. At the same time, health care—especially in jails—tends to be minimal. Despite high rates of mental illness and substance use disorders, few treatment programs are available during jail incarcerations. And, as previously described at The Medical Care Blog, accessing these treatments increasingly comes with copayments that incarcerated individuals may not be able to afford.
Misplaced blame
Responsibility for involvement in the justice system, substance abuse and health problems is often assigned solely to the individual. This common approach suggests that behavioral decisions and their outcomes are simple. Don’t commit crimes, stop using substances, exercise more and eat healthy foods, and all problems will be solved. Such logic ignores the reality of social determinants of health. We know that structural racism, education, mental illness, social norms, community violence, and policing practices all impact a person’s ability to choose some paths over others.
Taking a different approach
We developed the Health Activism Literacy and Opportunity (HALO) program specifically for adult men held in short-term (jail) detention. HALO is based on the theory of Paolo Freire, a Brazilian educational theorist. Freire taught that education could be an empowering, transformational process. According to Freire, education is a source of social change rather than merely a form of individual enhancement. The most liberating form of learning takes place when people learn from each other based on critical examination of their collective experiences of oppression. Our program was based on Freire’s ideas and material from the Just Health Action project.
HALO curriculum
The HALO curriculum was designed to be delivered to small groups of incarcerated men in 2-hour sessions over 5 days. The goal of HALO was to lead participants in a collective process of recognizing the role of social determinants, like race, in their health and life experiences.
Using interactive activities, we led participants in critically distinguishing between root and proximal causes of health inequalities. For example, in one exercise, we used a case study to guide men in tracing an outcome (the death of a child) back through several layers of individual, family, community and society impact. The men additionally practiced distinguishing when “cause” and “effect” relationships were obscured by rhetoric designed to perpetuate oppression.
In all activities, we encouraged the men to see themselves as part of a social collective. We led them in focusing on both their experiences as individuals and as members of various communities. These communities included the incarcerated community, neighborhood communities, racial communities, gendered communities, family, recovery, urban/rural, etc.
In the final session, the men applied their new understanding by designing health action civic engagement projects for implementation in a community of their choice.
| Table 1. HALO Curriculum Session Objectives |
| Session 1: What is Health? |
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| Session 2: Health Inequities, Gender, Race |
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| Session 3: Incarceration in the United States; the Upstream Causes |
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| Session 4: What are the Upstream Causes? |
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| Session 5: Strategies for Action |
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HALO outcomes
In the fall of 2017, we piloted HALO with a group of six men in a minimum security Kansas City jail. When we surveyed the men at the outset, the group showed generally low levels of awareness about relationships between health and social conditions. In early sessions, the men often resisted or second guessed the role of social factors. That is, they frequently assigned blame to individuals, applying simple judgments such as “It’s their own fault” or “They’re just lazy.” We took these assessments seriously and led the men in exploring why the dominant discourses of personal accountability are so powerful. 
Over the course of the week, the participants did not abandon notions of individual responsibility. But they did become more skilled at also identifying underlying social disparities that might contribute to the development and persistence of unhealthy habits and choices. At the end of the week, the men acknowledged a change in outlook. In their evaluations, the men wrote that they were now “able to see not everything was black and white.” They also indicated that they felt they had more “knowledge of identifying problems in a community.” In describing their experience in the program, the men used adjectives such as stimulating, rewarding and inspirational.
Action plans
All of the HALO participants mentioned that they liked how the curriculum was not delivered using a traditional teacher-to-student methodology. Furthermore, all expressed appreciation for the dual focus on individual and collective empowerment. Finally and crucially, they voiced their motivation to bring about changes that would improve their own and their communities’ health.
The civic engagement action plans the participants developed on the final day of the program were designed to feature realistic objectives, community allies, specific activities, and measurable outcomes. The plans included an anti-drug relapse program for incarcerated males with transition to release. Another program detailed a re-entry jobs program for inmates. A third described a jail-to-school outreach program to prevent students from dropping out of high school.
Lessons learned
The Freirean teaching approach we used to engage incarcerated men in becoming aware of the social determinants of health in their own lives was largely successful. First, HALO created an environment where participants were able to build on their existing experiences and knowledge while building new skills in health literacy. Second, the approach capitalized on teachable moments. These moments functioned as opportunities for participants to discover where health and disparities are intertwined and create new ways to act on them. The men’s success in making those connections suggests the potential of HALO to foster an awareness of social determinants of health and apply these concepts to vulnerable groups.
HALO unbound
An enormous need exists for health education and promotion tailored to men and women in the criminal justice system. We would like to see such interventions move beyond traditional didactic lectures. Approaches like HALO directly provide tools to those in the criminal justice system to critically investigate and push back against the social forces that affect their health.
We would be happy to make the HALO curriculum available for use by others. We welcome comments and feedback about contents and outcomes. If you are interested in using this curriculum, please contact Megha Ramaswamy.
Amanda Emerson
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Megha Ramaswamy