The first topic, Barriers, provides a key insight into the challenges of oral health service provision and utilization in prisons, experienced by PLP and custodial staff. The two themes that emerged from the interviews comprise: organizational barriers related to the provision of services (inclusive of five sub-themes), and individual barriers related to the utilization of services.

Organizational barriers

The organizational barriers are presented under the following five sub-themes: lack of services; lack of knowledge and information; absence of prevention campaigns; lack of proper policies, and lack of preparedness during crisis.

Lack of services

The first and one of the most frequently discussed barriers mentioned in the interviews was the lack of oral health services in prison settings. The participants believed that in most countries, worldwide, oral health services are either unavailable or, if available, are offered with low accessibility, coverage, and quality. In some prisons that offer services, PLP are required to wait a long time to see a dentist and receive services. The interviewees mentioned four possible reasons associated with this issue:

The interviewees believe that most attention is given to the diagnosis, treatment, care, and support of infectious diseases such as HIV/AIDS, viral hepatitis, and tuberculosis, leaving oral health as a neglected issue in prison settings. One of the participants stated:

“… prison officers don’t see it (oral health) as a priority. Not all of them. There are some who are good, and they understand the importance, but a lot of prison officers don’t think to get them. What they have at the moment is more than enough. And anyone who wants to improve education or information, especially about health care, it is not a priority, not at all.” (DEC/LEP, Male, Europe)

The lack of sufficient resources, particularly budget and human resources, is another barrier to the availability, accessibility, and coverage of oral health services in prison settings, as underlined by the participants. One of the interviewees highlighted this issue as follows:

“…there is very little resources for providing health intervention in prison. You know, because there are few people not much received financial resources, but also because not many people want to go and work in prison, because they are a specific population and there is fear, which is I think more, how do you say… dangerous.” (DOC/MSM, Female, Europe)

Another participant pointed out the challenge of staffing prison settings:

“We don’t have a dentist always at the institution because they make good money on private and then it is hard to find a dentist to work in prison settings.” (DOC/MAM, Male, Europe)

According to the participants, the availability of dental extractions as a cheap and rapid treatment option may influence treatment decisions in resource-limited settings such as prisons. The reliance on dental extractions as the standard treatment option may convince prison policymakers that more expensive services are not required in prison settings, as the interviewees mentioned. One of the participants highlighted this issue as follows:

“They’ll only do the bare minimum, if you’re in pain. They’ll extract it. That’s it.” (DEC/LEP, Male, Europe)

Lack of knowledge and information

The lack of information was another barrier to providing quality oral health services in prison settings, as discussed by the interviewees. The participants mentioned the absence of two levels of information. First, there was a lack of detailed information about the status of oral health among PLP collected by prison healthcare staff members. Second, there was a paucity of research-based information about how to design, implement, and monitor oral health interventions. One of the participants highlighted this issue as follows:

“…better understanding of oral health needs, that it does require access in correctional facilities, particularly prisons, but also jails, which is where people are held for shorter periods of time, usually, for less serious crimes or awaiting trial. There’s really, really very limited research on this area….” (DEC, Male, Europe)

In addition to the issues mentioned above, a lack of information regarding how to access and utilize services within the prison system represents another structural barrier that hinders PLP from accessing oral health care. As one participant noted:

“…I would say there’s probably minimal information given to prisoners. It’s just, we have a dentist, or here you can apply to see the dentist. That’s it. The services that they offer you will find out when you get to see the dentist, but even then, it might be too late, or you might have done something yourself….” (DEC/LEP, Male, Europe)

Absence of prevention campaigns

Prevention campaigns can help to raise awareness among the target population about diseases and inform them about evidence-based preventive activities, as discussed by the interviewees. The lack of such campaigns was discussed as another organizational barrier, as highlighted by one of the participants:

“… and the only things is not only to ensure the presence of a dentist service but these dentists service is just doing these removing teeth… the point is to give prevention measures, sometimes at least once a year, a couple of times a year to make prevention campaign and they know they are not doing this….” (DOC, Male, Europe)

Inconsistent policies

According to the interviewees, the presence of clear and consistent policies is essential for the effective implementation of healthcare interventions across all sectors, including the prison system. In countries with federal political systems, regional policies may conflict with one another. Additionally, existing policies might be restrictive, such as those limiting the provision of certain products like dental floss to incarcerated individuals. As one participant noted:

“One of the kind of challenges is that each state has their own procedures. And so it’s hard to put an extensive statement on what does access to root canals or something look like in prisons in the [name of the country redacted], because likely looks very different in [name of the cities redacted] versus [name of the city redacted].” (PHR, Male, North America)

Lack of preparedness during crisis

The participants believe that most prisons, worldwide, are not adequately prepared to function adequately during times of crises. In most prisons, the primary focus during the pandemic was on controlling the spread of the disease, thus reducing the availability of funding for human resources for other sectors, including oral health services. One of the interviewees highlighted this issue:

“I don´t tell data but for sure I can tell you that there was a decline in the number of people in the dentist care, but on the paper all the specialist activities have been confirmed.” (DOC/IDE, Male, Europe)

Individual barriers

The second set of barriers discussed by participants were the individual barriers faced by PLP towards accessing and utilizing oral health services. The themes emerged from this topic include mistrust; pre-imprisonment neglect of oral health; stigma; and language barrier.

Mistrust

From the participant’s perspective, mistrust in the prison system, healthcare services, and healthcare providers is a significant factor contributing to the underutilization of services among incarcerated individuals. Many PLP do not trust the system that has deprived them of their liberties. Additionally, there is often a cultural issue of distrust towards female healthcare providers (e.g., physicians, dentists, and nurses) among male PLP, as the interviewees discussed. One participant highlighted this issue, stating:

“…when I take a tooth out, they ask did you take it all? Because they don’t trust a woman can do this job….” (DEN, Female, Europe)

Pre-imprisonment neglect of oral health

The interviewees believe that incarcerated individuals may have neglected their health, particularly oral health, even before imprisonment. This issue may be linked to a low perception of risk or severity of oral health conditions among PLP; this can also be associated with the lack of affordability of oral health services for lower socioeconomic groups of the community, where the majority of PLP come from. In this regard one of the participants stated:

“My perception is that oral health is important only for the layers of population that can afford it.” (DOC, Male, Europe)

Intersecting vulnerabilities

The participants believe that specific groups of PLP, including youths and older persons, are at an increased risk of poor oral health. Young people may neglect their oral health due to low perceived risks, while older people may already have poor oral health due to long-standing risk factors, as the participants discussed. This issue highlights the importance of focusing on at-risk populations, such as youths and older PLP, when providing and accessing oral health services in prison settings:

“…we accredited dentists coming to prison, we also regulated prosthetic dental care for vulnerable prisoners. If these steps had been approved earlier, more of them could have benefited from better care….” (DOC, Female, Europe)

Stigma

Stigma and the fear of discrimination may deter incarcerated individuals from seeking and utilizing oral health services, as they might wish to avoid receiving standard care. These issues are complex and require a comprehensive approach, as recommended by the interviewees. Such an approach should cover a variety of activities, including education for both PLP and healthcare providers. In this regard, one participant noted:

“A lot of them [PLP] don’t have nice teeth, because they come from [name of the region redacted], and don’t have this level of health provision as the [name of the continent redacted], so they need education.” (DEN, Female, Europe)

Language barrier

According to participants, for migrant and foreign national PLP, language barriers can be one of the main and most significant barriers affecting access and utilization of healthcare services. Due to the impaired ability to communicate, key oral health promotion messages including the availability and accessibility of oral health services in prisons may not have been received. In relation to access, PLP may experience challenges in communicating their oral health concerns to healthcare providers and receive appropriate care, as the respondents suggested. This issue is of great importance given many prisons lack financial support to provide access to interpreters:

“…we have people from other countries, I want to explain that a tooth can’t be saved, it needs to be extracted, but they don’t always understand, or maybe they believe it can be fixed. I don’t always know their culture, and they don’t always trust what I’m saying.” (DEN, Female, Europe)