Understanding and Improving the Health of People Who Experience Incarceration: An Overview and Synthesis

Experiences of Loneliness: COVID-19 Versus Incarceration

As the world comes to terms with the realities surrounding COVID-19, media sources have likened quarantine experiences to that of incarceration. Individuals who have experienced incarceration and individuals who have experienced the incarceration of loved ones (LO), have already experienced periods of time apart. We are exploring the experiences of individuals who have some experience with incarceration; whether they were personally incarcerated, or they experienced the incarceration of a LO. Utilizing snowball sampling, a mixed methods survey was circulated on social media. Survey items included demographic information, questions about incarceration, issues related to COVID-19 quarantines, and the UCLA Loneliness Scale. Results follow similar patterns to previous studies. However, this unique population argues that COVID-19 quarantines are not the same as periods of incarceration. Similarly, future research and community agencies need to examine the unique needs of those who have experienced the incarceration of a loved one.

Police perspectives on the economic considerations of providing healthcare in short-term custodial settings in Australia

Providing appropriate healthcare to people in short-term police custody settings (i.e. watch-houses) is challenging due to the complexity of detainee health needs and the limitations of the custodial environment. However, little is known about how detainee healthcare is managed in Australia, including economic considerations. This study had two aims: (1) to understand police perspectives on the costs associated with the delivery of healthcare to watch-house detainees in Queensland, Australia and (2) to scope the applicability of the Prison Healthcare Expenditure Reporting Checklist (PHERC) tool for the Australian watch-house context. The study employed an exploratory qualitative descriptive approach. A purposive sample comprised 16 watch-house staff from six regions in Queensland, Australia, interviewed between April and November 2021. A key finding was that police viewed healthcare expenditure as a major, but largely unavoidable cost for Australian watch-houses. Participants reported that direct expenditure comprised mostly of in-house healthcare services (of which there were a variety of models), but also costs of medication and health-related consumables. Indirect costs included costs of escorting and guarding detainees requiring transfer to hospital for health assessment and treatment. Participants reported that the PHERC was not applicable to the Australian watch-house context. Future research should explore the cost-effectiveness of different watch-house healthcare delivery models and how best to measure this.

Assertive community treatment as an alternative to incarceration for American pretrial detainees

In the United States and elsewhere around the world, people with serious mental illness (SMI) are overrepresented in the criminal justice system. Clinical interventions to divert such individuals out of correctional settings, including Assertive Community Treatment (ACT), have been shown to reduce rates of criminal justice recidivism when modified to allow for the use of court sanctions to encourage treatment adherence. However, these interventions are noted to be underutilized as alternative to incarceration (ATI) programs. This paper summarizes the results of a retrospective cohort study conducted in a New York State forensic psychiatric hospital of 87 pretrial detainees admitted after being found incompetent to stand trial between January 2019 and January 2022. Of these, 49 patients were referred to an ACT team that served as an ATI program. The study outcomes noted that patients referred to this ACT team were 20% less likely to remain in pretrial detention than those that were not. Moreover, patients referred to the ACT program were also 34% more likely to be granted an ATI plea bargain in the community that did not involve serving a prison term. These results suggest that pretrial detainees with SMI are more likely to be granted an ATI program that offers more intensive treatment services such as ACT, due to the capability of such programs to also provide more intensive outreach and community supervision than traditional outpatient mental health service providers.

Mental and physical health morbidity among people in prisons: an umbrella review

BACKGROUND

People who experience incarceration are characterised by poor health profiles. Clarification of the disease burden in the prison population can inform service and policy development. We aimed to synthesise and assess the evidence regarding the epidemiology of mental and physical health conditions among people in prisons worldwide.

METHODS

In this umbrella review, five bibliographic databases (Web of Science, PubMed, PsycINFO, Embase, and Global Health) were systematically searched from inception to identify meta-analyses published up to Oct 31, 2023, which examined the prevalence or incidence of mental and physical health conditions in general prison populations. We excluded meta-analyses that examined health conditions in selected or clinical prison populations. Prevalence data were extracted from published reports and study authors were contacted for additional information. Estimates were synthesised and stratified by sex, age, and country income level. The robustness of the findings was assessed in terms of heterogeneity, excess significance bias, small-study effects, and review quality. The study protocol was pre-registered with PROSPERO, CRD42023404827.

FINDINGS

Our search of the literature yielded 1909 records eligible for screening. 1736 articles were excluded and 173 full-text reports were examined for eligibility. 144 articles were then excluded due to not meeting inclusion criteria, which resulted in 29 meta-analyses eligible for inclusion. 12 of these were further excluded because they examined the same health condition. We included data from 17 meta-analyses published between 2002 and 2023. In adult men and women combined, the 6-month prevalence was 11·4% (95% CI 9·9-12·8) for major depression, 9·8% (6·8-13·2) for post-traumatic stress disorder, and 3·7% (3·2-4·1) for psychotic illness. On arrival to prison, 23·8% (95% CI 21·0-26·7) of people met diagnostic criteria for alcohol use disorder and 38·9% (31·5-46·2) for drug use disorder. Half of those with major depression or psychotic illness had a comorbid substance use disorder. Infectious diseases were also common; 17·7% (95% CI 15·0-20·7) of people were antibody-positive for hepatitis C virus, with lower estimates (ranging between 2·6% and 5·2%) found for hepatitis B virus, HIV, and tuberculosis. Meta-regression analyses indicated significant differences in prevalence by sex and country income level, albeit not consistent across health conditions. The burden of non-communicable chronic diseases was only examined in adults aged 50 years and older. Overall, the quality of the evidence was limited by high heterogeneity and small-study effects.

INTERPRETATION

People in prisons have a specific pattern of morbidity that represents an opportunity for public health to address. In particular, integrating prison health within the national public health system, adequately resourcing primary care and mental health services, and improving linkage with post-release health services could affect public health and safety. Population-based longitudinal studies are needed to clarify the extent to which incarceration affects health.

FUNDING

Research Foundation-Flanders, Wellcome Trust, National Institutes of Health.

An analysis of published study designs in PubMed prisoner health abstracts from 1963 to 2023: a text mining study

BACKGROUND

The challenging nature of studies with incarcerated populations and other offender groups can impede the conduct of research, particularly that involving complex study designs such as randomised control trials and clinical interventions. Providing an overview of study designs employed in this area can offer insights into this issue and how research quality may impact on health and justice outcomes.

METHODS

We used a rule-based approach to extract study designs from a sample of 34,481 PubMed abstracts related to epidemiological criminology published between 1963 and 2023. The results were compared against an accepted hierarchy of scientific evidence.

RESULTS

We evaluated our method in a random sample of 100 PubMed abstracts. An F1-Score of 92.2% was returned. Of 34,481 study abstracts, almost 40.0% (13,671) had an extracted study design. The most common study design was observational (37.3%; 5101) while experimental research in the form of trials (randomised, non-randomised) was present in 16.9% (2319). Mapped against the current hierarchy of scientific evidence, 13.7% (1874) of extracted study designs could not be categorised. Among the remaining studies, most were observational (17.2%; 2343) followed by systematic reviews (10.5%; 1432) with randomised controlled trials accounting for 8.7% (1196) of studies and meta-analysis for 1.4% (190) of studies.

CONCLUSIONS

It is possible to extract epidemiological study designs from a large-scale PubMed sample computationally. However, the number of trials, systematic reviews, and meta-analysis is relatively small - just 1 in 5 articles. Despite an increase over time in the total number of articles, study design details in the abstracts were missing. Epidemiological criminology still lacks the experimental evidence needed to address the health needs of the marginalized and isolated population that is prisoners and offenders.

Mortality in women with a history of incarceration in Norway: a 20-year national cohort study

BACKGROUND

Women carry a substantial burden of psychiatric, somatic and lifestyle-related morbidity in the prison context. By describing causes of death and estimating the risk and burden of mortality compared with the general population, this study investigates how mortality operates in this highly marginalized and under-researched population.

METHODS

In this registry-based study of all women incarcerated in Norwegian prisons from 2000 to 2019 (N = 11 313), we calculated crude mortality rates, years of lost life and, by using mortality in age-matched women from the general population as a reference, age-standardized mortality ratios and years of lost life rates.

RESULTS

Over a mean follow-up time of 10.7 years, at a median age of 50 years, 9% of the population had died (n = 1005). Most deaths (80%) were premature deaths from an avoidable cause. Drug-induced causes and deaths from major non-communicable diseases (NCDs) were most frequent (both 32%). Compared with women in the general population, women with a history of incarceration were more likely to die from any cause. Trends in annual age-standardized years of lost life rates suggest that the mortality burden associated with major NCDs has gradually replaced drug-induced causes.

CONCLUSIONS

Women with a history of incarceration die at a greater rate than their peers and largely from avoidable causes. The profile of causes contributing to the substantial burden of mortality placed on this population has changed over time and has important implications for future efforts to reduce morbidity and the risk of premature death following release from prison.

Quality of Surgical Care Within the Criminal Justice Health Care System

Importance

Individuals who are incarcerated represent a vulnerable group due to concerns about their ability to provide voluntary and informed consent, and there are considerable legal protections regarding their participation in medical research. Little is known about the quality of surgical care received by this population.

Objective

To evaluate perioperative surgical care provided to patients who are incarcerated within the Texas Department of Criminal Justice (TDCJ) and compare their outcomes with that of the general nonincarcerated population.

Design, Setting, and Participants

This cohort study analyzed data from patients who were incarcerated within the TDCJ and underwent general or vascular surgery at the University of Texas Medical Branch (UTMB) from 2012 to 2021. Case-specific outcomes for a subset of these patients and for patients in the general academic medical center population were obtained from the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) and compared. Additional quality metrics (mortality index, length of stay index, and excess hospital days) from the Vizient Clinical Data Base were analyzed for patients in the incarcerated and nonincarcerated groups who underwent surgery at UTMB in 2020 and 2021 to provide additional recent data. Patient-specific demographics, including age, sex, and comorbidities were not available for analysis within this data set.

Main Outcome and Measures

Perioperative outcomes (30-day morbidity, mortality, and readmission rates) were compared between the incarcerated and nonincarcerated groups using the Fisher exact test.

Results

The sample included data from 6675 patients who were incarcerated and underwent general or vascular surgery at UTMB from 2012 to 2021. The ACS-NSQIP included data (2012-2021) for 2304 patients who were incarcerated and 602 patients who were not and showed that outcomes were comparable between the TDCJ population and that of the general population treated at the academic medical center with regard to 30-day readmission (6.60% vs 5.65%) and mortality (0.91% vs 1.16%). However, 30-day morbidity was significantly higher in the TDCJ population (8.25% vs 5.48%, P = .01). The 2020 and 2021 data from the Vizient Clinical Data Base included 629 patients who were incarcerated and 2614 who were not and showed that the incarcerated and nonincarcerated populations did not differ with regard to 30-day readmission (12.52% vs 11.30%) or morbidity (1.91% vs 2.60%). Although the unadjusted mortality rate was significantly lower in the TDCJ population (1.27% vs 2.68%, P = .04), mortality indexes, which account for case mix index, were similar between the 2 populations (1.17 vs 1.12).

Conclusions and Relevance

Findings of this cohort study suggest that patients who are incarcerated have equivalent rates of mortality and readmission compared with a general academic medical center population. Future studies that focus on elucidating the potential factors associated with perioperative morbidity and exploring long-term surgical outcomes in the incarcerated population are warranted.

Reimbursing incarcerated individuals for participation in research: A scoping review

BACKGROUND

Little is known about global practices regarding the provision of reimbursement for the participation of people who are incarcerated in research. To determine current practices related to the reimbursement of incarcerated populations for research, we aimed to describe international variations in practice across countries and carceral environments to help inform the development of more consistent and equitable practices.

METHODS

We conducted a scoping review by searching PubMed, Cochrane library, Medline, and Embase, and conducted a grey literature search for English- and French-language articles published until September 30, 2022. All studies evaluating any carceral-based research were included if recruitment of incarcerated participants occurred inside any non-juvenile carceral setting; we excluded studies if recruitment occurred exclusively following release. Where studies failed to indicate the presence or absence of reimbursement, we assumed none was provided.

RESULTS

A total of 4,328 unique articles were identified, 2,765 were eligible for full text review, and 426 were included. Of these, 295 (69%) did not offer reimbursement to incarcerated individuals. A minority (n = 13; 4%) included reasons explaining the absence of reimbursement, primarily government-level policies (n = 7). Among the 131 (31%) studies that provided reimbursement, the most common form was monetary compensation (n = 122; 93%); five studies (4%) offered possible reduced sentencing. Reimbursement ranged between $3-610 USD in total and 14 studies (11%) explained the reason behind the reimbursements, primarily researchers' discretion (n = 9).

CONCLUSIONS

The majority of research conducted to date in carceral settings globally has not reimbursed incarcerated participants. Increased transparency regarding reimbursement (or lack thereof) is needed as part of all carceral research and advocacy efforts are required to change policies prohibiting reimbursement of incarcerated individuals. Future work is needed to co-create international standards for the equitable reimbursement of incarcerated populations in research, incorporating the voices of people with lived and living experience of incarceration.

Effectiveness of interventions to reduce sexually transmitted infections and blood-borne viruses in incarcerated adult populations: a systematic review protocol

OBJECTIVE

This review will identify, synthesize, and make recommendations regarding the effectiveness of interventions to reduce sexually transmitted infections (STIs) and blood-borne viruses (BBVs) in incarcerated adult settings.

INTRODUCTION

High-risk sexual behaviors, intravenous drug use, piercing, and tattooing are well documented within incarceration environments. Despite the World Health Organization's Global Health Sector Strategy on Sexually Transmitted Infections 2016-2021 and the Global Health Sector strategies on, respectively, HIV, viral hepatitis, and sexually transmitted infections for the period 2022-2030, STI rates within adult incarceration environments continue to rise. Identifying and implementing best-practice interventions to prevent and manage STIs and BBVs will aid infection reduction in correctional settings. The review results will inform the development of educational programs, health promotion, and policies and procedures to improve health outcomes for incarcerated populations.

INCLUSION CRITERIA

This review will consider studies in any language from any adult incarceration facility. Studies set in juvenile facilities or detention centers will be excluded. Any intervention for preventing or reducing STI and/or BBV transmission will be included.

METHODS

This review will follow the JBI methodology for systematic reviews of effectiveness. Databases to be searched will include PubMed, CINAHL (EBSCO), Ovid Library, PsycINFO (EBSCO), Cochrane CENTRAL, and Scopus. Two independent reviewers will screen titles and abstracts and assess full-text citations against the inclusion criteria. Methodological quality will be appraised using JBI's standardized critical appraisal instruments. Where possible, studies will be pooled using meta-analysis. Where statistical pooling is not possible, findings will be presented in narrative format. Certainty of evidence will be ascertained using the GRADE approach.

REVIEW REGISTRATION

PROSPERO CRD42022325077.

Understanding the organisational influences on the quality of and access to primary care in English prisons: a qualitative interview study

BACKGROUND

Primary care for routine healthcare conditions is delivered to thousands of people in the English prison estate every day but the prison environment presents unique challenges to the provision of high-quality health care. Little research has focused on the organisational factors that affect quality of and access to prison health care.

AIM

To understand key influences on the quality of primary care in prisons.

DESIGN AND SETTING

This was a qualitative interview study across the North of England from 2019 to 2021.

METHOD

Interviews were undertaken with 43 participants: 21 prison leavers and 22 prison healthcare professionals. Reflexive thematic analysis was undertaken.

RESULTS

The overarching organisational issue influencing quality and access was that of chronic understaffing coupled with a workforce in flux and dependence on locum staff. This applied across different prisons, roles, and grades of staff, and was vocally discussed by both patient and staff participants. Intricately related to understaffing (and fuelled by it) was the propensity for a reactive and sometimes crisis-led service to develop that was characterised by continual firefighting. A persistent problem exacerbated by the above issues was unreliable communication about healthcare matters within some prisons, creating frustration. Positive commentary focused on the characteristics and actions of individual healthcare professionals.

CONCLUSION

This study highlights understaffing and its consequences as the most significant threat to the quality of and access to prison primary care. Strategies to address health care affecting prison populations urgently need to consider staffing. This issue should receive high-profile and mainstream attention to address health inequalities.

Beliefs about mental health in incarcerated males: a qualitative interview study

Introduction

Beliefs about mental health are shaped by the sociocultural context. Prisons have unique environmental and social features, and the prevalence of mental health problems in incarcerated populations is exceptionally high. These features make prisons especially interesting settings for exploring health beliefs. The aim of this study was to explore the conceptualizations of mental health and coping preferences in a prison environment.

Methods

Individual in-depth interviews were conducted with fifteen incarcerated males from three prisons in Northern Norway. The design draws on central elements from Grounded Theory.

Results

Mental health was perceived as distinct from mental illness by many of the participants. They coped with the prison environment by focusing on the things that gave them a sense of meaning and autonomy - this also formed their conceptualization of mental health. Furthermore, social interaction and activities were perceived as important to enhance and maintain mental well-being, however there were institutional barriers to using these coping strategies. The prison environment was integrated in the participants conceptualizations of mental health problems, and psychosocial stressors were emphasized in causal attributions. Biological and dispositional factors were less frequently mentioned. The participants preferred non-medical management for mental health problems and most displayed a reserved attitude towards psychotropic medications. The exception was attention-deficit hyperactivity disorder, for which they held neurobiological causal beliefs, together with a corresponding preference for medication as treatment.

Conclusion

The main finding was a firm integration of the prison context in in the participants' beliefs about mental health. We theorize that fusion of prison conditions and mental health beliefs were brought on by the processes of prisonization, observing mental distress in peers and attempts to protect self-esteem by externalizing the causes for mental health problems. Access to activities, social time, and "someone to talk to" were perceived to be crucial for improving and preserving mental health.

"You can get a couple of ramen noodle packs for a BusparⓇ": A qualitative examination of medication access, policy, and procedures in southern jails

BACKGROUND

Jails in the United States are required to provide health care to the over 10 million people entering jails each year, a significant portion of whom need medications. Yet little is known about the processes by which medications are prescribed, obtained, and administered to incarcerated persons in jails.

OBJECTIVE

To describe medication access, policy, and procedures in jails.

METHODS

Semi-structured interviews were conducted with administrators and health workers from 34 jails (of 125 contacted) across 5 states in the southeastern United States. The interview guide covered all aspects of healthcare in jails from entry to release; however, the present study focused on responses relating to medications. Interviews were thematically coded using a combination of deductive and inductive coding guided by the research objective.

RESULTS

Four processes described medication use chronologically from intake to release: jail entry and health screening, pharmacy and medication protocols, protocols specific to medication dispensing and administration, and medications at release. Many jails had procedures for using medications brought from home, though some declined to use these medications. Medication decision-making in jails was primarily performed by contracted healthcare providers, and most medications were obtained from contract pharmacies. Almost all jails banned narcotics; however, other medication restrictions varied by jail. Most jails charged a copay for medications. Participants discussed various privacy practices related to medication distribution, as well as approaches to diversion prevention including "crushing and floating" medications. Finally, the pre-release medication management process included transition planning that ranged from no planning to sending additional prescriptions to the patient's pharmacy.

CONCLUSIONS

Medication access, protocols, and procedures in jails varies considerably, and there is a need for further adoption of existing standards and guidelines for the use of medications in jails, such as the Assess, Plan, Identify, and Coordinate (APIC) model of community re-entry.

Record linkage studies of primary care utilisation after release from prison: A scoping review protocol

INTRODUCTION

There is a need to improve the implementation and provision of continuity of care between prison and community in order that people who have been in prison and have a history of low engagement with services or who are vulnerable receive appropriate and timely health care and treatment. Observational studies using record linkage have investigated continuity of care after release from prison but this type of research evidence has not been synthesised.

OBJECTIVE

This paper presents a protocol designed to review record linkage studies about primary care utilisation after prison release in order to inform future research and guide service organisation and delivery towards people who are at-risk following release from prison.

METHODS

This scoping review will follow the framework by Arksey and O'Malley (5 stages) and guidance developed by the Joanna Briggs Institute (JBI). MEDLINE, EMBASE and Web of Science Core Collection will be searched (January 2012-March 2023) using terms relating to (i) 'former prisoners' and (ii) 'primary care'. The review will focus on observational studies that have investigated this topic using linked data from two or more sources. Two authors will independently screen titles and abstracts (step 1) and full publications (step 2) using predefined eligibility criteria. Data will be extracted from included publications using a piloted data charting form. This review will map the findings in this research area by methodology, key findings and gaps in research, and current evidence will be synthesised narratively given the expected considerable heterogeneity across studies.

DISCUSSION

This review is part of a work programme on health in prison (Administrative Data Research Centre, Northern Ireland). This work may be used to inform future research, policy and practice. Findings will be shared with stakeholders, published in a peer-reviewed journal and presented at relevant conferences. Ethical approval is not required.

Meanings and Experiences of Prisoners and Family Members Affected by the COVID-19 Pandemic in a Brazilian Prison Unit: A Grounded Theory Analysis

Worldwide, the COVID-19 pandemic represented a health emergency for prisons. This study sought to understand the meanings and experiences through the narratives of prisoners and family members affected by the COVID-19 pandemic in the context of a maximum-security state penitentiary complex in southern Brazil. For this purpose, a qualitative study was developed based on the methodological framework of constructivist grounded theory. Data were collected between February and August 2022 through individual in-depth interviews and field notes. The sample consisted of 41 participants: 28 male prisoners, and 13 family members. Guided by the Charmaz method of grounded theory analysis, the study afforded the core category "Feeling trapped in prison during the COVID-19 pandemic" with three interrelated phases: "Triggering", "Escalating", and "Readjustment". The "Triggering" phase refers to COVID-19-related elements or events that triggered certain reactions, processes, or changes in prison. During the "Escalating" phase, participants became overwhelmed by the suffering caused by incarceration and the pandemic crisis. The "Readjustment" phase involved adapting, reorienting, or reformulating previous approaches or strategies for dealing with a specific situation. Prisons faced complex challenges during the pandemic and were forced to prioritize protecting public health. However, the measures adopted must be carefully evaluated, ensuring their needs and that they are based on scientific evidence. The punitive approach can undermine inmate trust in prison authorities, making it difficult to report symptoms and adhere to preventive measures.

The impact of supported accommodation on health and criminal justice outcomes of people released from prison: a systematic literature review

BACKGROUND

Supported accommodation intends to address challenges arising following release from prison; however, impact of services, and of specific service components, is unclear. We describe key characteristics of supported accommodation, including program components and outcomes/impact; and distil best-evidence components.

METHODS

We conducted a systematic review, searching relevant databases in November 2022. Data were synthesised via effect direction plots according to the Synthesis Without Meta-analysis guidelines. We assessed study quality using the McGill Mixed Methods Appraisal Tool, and certainty in evidence using the GRADE framework.

RESULTS

Twenty-eight studies were included; predominantly cross-sectional. Program components which address life skills, vocational training, AOD use, and mental health appear to positively impact criminal justice outcomes. Criminal justice outcomes were the most commonly reported, and while we identified a reduction in parole revocations and reincarceration, outcomes were otherwise mixed. Variable design, often lacking rigour, and inconsistent outcome reporting limited assessment of these outcomes, and subsequently certainty in findings was low.

CONCLUSION

Post-release supported accommodation may reduce parole revocations and reincarceration. Despite limitations in the literature, the findings presented herein represent current best evidence. Future studies should clearly define program components and measure their impact; use analyses which reflect the high risk of adverse outcomes, such as time-to-event analyses; and consider outcomes which reflect the range of challenges faced by people leaving prison.

REGISTRATION

PROSPERO registration CRD42020189821.

Advancing cross-sectoral data linkage to understand and address the health impacts of social exclusion: Challenges and potential solutions

The use of administrative health data for research, monitoring, and quality improvement has proliferated in recent decades, leading to improvements in health across many disease areas and across the life course. However, not all populations are equally visible in administrative health data, and those that are less visible may be excluded from the benefits of associated research. Socially excluded populations - including the homeless, people with substance dependence, people involved in sex work, migrants or asylum seekers, and people with a history of incarceration - are typically characterised by health inequity. Yet people who experience social exclusion are often invisible within routinely collected administrative health data because information on their markers of social exclusion are not routinely recorded by healthcare providers. These circumstances make it difficult to understand the often complex health needs of socially excluded populations, evaluate and improve the quality of health services that they interact with, provide more accessible and appropriate health services, and develop effective and integrated responses to reduce health inequity. In this commentary we discuss how linking data from multiple sectors with administrative health data, often called cross-sectoral data linkage, is a key method for systematically identifying socially excluded populations in administrative health data and addressing other issues related to data quality and representativeness. We discuss how cross-sectoral data linkage can improve the representation of socially excluded populations in research, monitoring, and quality improvement initiatives, which can in turn inform coordinated responses across multiple sectors of service delivery. Finally, we articulate key challenges and potential solutions for advancing the use of cross-sectoral data linkage to improve the health of socially excluded populations, using international examples.

Developing best practice principles for the provision of programs and services to people transitioning from custody to the community: study protocol for a modified Delphi consensus exercise

INTRODUCTION

There is a lack of standard nomenclature and a limited understanding of programmes and services delivered to people in prisons as they transition into the community to support their integration and reduce reoffending related risk factors. The aim of this paper is to outline the protocol for a modified Delphi study designed to develop expert consensus on the nomenclature and best-practice principles of programmes and services for people transitioning from prison into the community.

METHODS AND ANALYSIS

An online, two-phase modified Delphi process will be conducted to develop an expert consensus on nomenclature and the best-practice principles for these programmes. In the preparatory phase, a questionnaire was developed comprising a list of potential best-practice statements identified from a systematic literature search. Subsequently, a heterogeneous sample of experts including service providers, Community and Justice Services, Not for Profits, First Nations stakeholders, those with lived experience, researchers and healthcare providers will participate in the consensus building phase (online survey rounds and online meeting) to achieve consensus on nomenclature and best-practice principles. Participants will indicate, via Likert scale, to what extent they agree with nomenclature and best-practice statements. If at least 80% of the experts agree to a term or statement (indicated via Likert scale), it will be included in a final list of nomenclature and best-practice statements. Statements will be excluded if 80% experts disagree. Nomenclature and statements not meeting positive or negative consensus will be explored in a facilitated online meeting. Approval from experts will be sought on the final list of nomenclature and best-practice statements.

ETHICS AND DISSEMINATION

Ethical approval has been received from the Justice Health and Forensic Mental Health Network Human Research Ethics Committee, the Aboriginal Health and Medical Research Council Human Research Ethics Committee, the Corrective Services New South Wales Ethics Committee and the University of Newcastle Human Research Ethics Committee. The results will be disseminated via peer-reviewed publication.

Health of Convicted Persons in the Third Generation of the Longitudinal Cambridge Study in Delinquent Development

Research suggests that convicted persons are more likely than non-convicted persons to suffer poor health. However, few longitudinal studies have investigated associations between health and offending across generations. Using the Cambridge Study in Delinquent Development, this article prospectively investigates the relationship between health and offending across generations and between genders. At the average age of 25, third generation convicted males and females reported a higher incidence of serious drug use than non-convicted persons. Convicted males reported a higher incidence of mental illness and self-harm, whereas convicted females reported a lower incidence of physical illness, mental illness, self-harm and hospitalizations when compared to non-convicted females. Convicted males reported a higher incidence of industrial accidents, sports injuries and fight injuries, but a lower incidence of road accidents, whereas convicted females were more likely to report road accidents. Like their fathers, convicted males show worse health compared to non-convicted individuals.

The predictive validity of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) for moderate- to high-risk cannabis, methamphetamine and opioid use after release from prison

BACKGROUND AND AIMS

Illicit substance use is common among people entering prisons, as is returning to substance use after release from prison. We aimed to assess the predictive validity of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) for returning to substance use after release from prison.

DESIGN

A longitudinal design with baseline survey conducted between 2008 and 2010 in the 6 weeks before expected prison release and up to three follow-up surveys in the 6 months after release.

SETTING

Prisons in Queensland, Australia.

PARTICIPANTS

A total of 1054 adults within 6 weeks of expected release from prison.

MEASUREMENTS

The ASSIST was used to assess problematic use of cannabis, methamphetamine, heroin and other non-prescribed opioids in the 3 months before incarceration. Post-incarceration substance use was measured at 1, 3 and 6 months after release. We calculated the area under the receiver operating characteristic curve (AUROC) and the optimal ASSIST cut-off score for each substance, using Youden's index (J).

FINDINGS

Forty-one per cent (n = 434) of the cohort reported any substance use during follow-up: 33% (n = 344) used cannabis, 20% (n = 209) methamphetamine, 10% (n = 109) heroin and 9% (n = 97) illicit other opioids. The optimal ASSIST cut-off score was ≥ 4 for heroin, methamphetamine and cannabis and ≥ 1 for other opioids. Using these cut-offs, the AUROC was highest for heroin in predicting both any use (AUROC = 0.82) and weekly use (AUROC = 0.88) in the past 4 weeks. AUROCs for other drugs ranged from 0.73 to 0.79.

CONCLUSIONS

The ASSIST shows promise as an accurate and potentially scalable tool that may be useful for predicting a return to substance use after release from prison and could inform service delivery. The substantial rates of returning to substance use after release from prison suggest that prison serves to interrupt rather than cease substance use.

The association between drug use and mortality in a norwegian prison cohort: a prospective cohort study

BACKGROUND

Elevated mortality rates are found among people who have experienced incarceration, even long after release from prison. The mechanisms related to this excess mortality are complex products of both individual and situational factors. The aim of this study was to describe all-cause and cause-specific mortality among people with a history of imprisonment, and to examine both individual and situational factors associated with mortality.

METHODS

In this prospective cohort study we used baseline survey data from the Norwegian Offender Mental Health and Addiction (NorMA) study (N = 733) linked with data from the Norwegian Cause of Death Registry during eight years of follow-up (2013-2021).

RESULTS

At end of follow-up, 56 persons (8%) of the cohort were deceased; 55% (n = 31) due to external causes such as overdoses or suicides, and 29% (n = 16) to internal causes such as cancer or lung disease. Having a score > 24 on the Drug Use Disorders Identification Test (DUDIT), indicating likely drug dependence was highly associated with external causes of death (OR 3.31, 95% CI 1.34-8.16), while having a job before baseline imprisonment had a protective effect on all-cause mortality (OR 0.51, ,95% CI 0.28-0.95).

CONCLUSIONS

High DUDIT score at baseline were highly associated with external causes of death, even years after the DUDIT screening was done. Screening incarcerated people using validated clinical tools, such as the DUDIT, together with initiation of appropriate treatment, may contribute to reduced mortality in this marginalized population.

Measuring everyday adaptation after imprisonment: The post-release living inventory for ex-prisoners (PORLI-ex)

Background

The number of ex-prisoners worldwide has constantly been increasing in recent years. Currently, little is known about post-release daily adaptation, not to mention valid and reliable instruments for post-release daily routines pertinent to mental health.

Objective

This study aims to develop and validate a self-report instrument, hereafter referred to as Post Release Living Inventory for Ex-prisoners (PORLI-ex).

Methods

Three separate samples of ex-prisoners were recruited to complete an online survey (N=1,277, age range=17-89 years, 53.2% male, 72% white).

Results

The final model evidenced acceptable goodness-of-fit and consisted of 45 items on nine dimensions, which loaded on three second-order factors: Consolidation (three dimensions; e.g., Institutional Routines), Replacement (two dimensions; e.g., Maladaptive Behaviors), and Addition (four dimensions; e.g., Socializing with Ex-prisoner Friends) (α=.695-.915). Convergent validity was demonstrated in the positive correlations with IADL, SOLI, MLQ, GSE-6, and MSPSS. Discriminant validity was demonstrated in the weak correlations with the LEC-5 and perceived social and personal cost of punishment. Criterion-related validity was demonstrated in the correlations with psychiatric symptoms and crime-related outcomes and incremental validity in the correlations with these measures independent of the scores on IADL, SOLI, MLQ, GSE-6, and MSPSS.

Conclusion

This study calls for more resources on fostering psychological strengths and resilience through regularizing basic daily life experiences on top of traditional interventions for risk management among the ex-prisoners.

Is use of opioid agonist treatment associated with broader primary healthcare use among men with recent injecting drug use histories following release from prison? A prospective cohort study

BACKGROUND

A precipitous decline in health status among people recently released from prison is common. In Victoria, Australia, opioid agonist treatment (OAT) in the community involves frequent contact with primary care, potentially facilitating broader use of primary healthcare services. Among a cohort of men who injected drugs regularly pre-imprisonment, we estimated differences in rates of primary healthcare use and medication dispensation between people who did and did not receive OAT post-release.

METHODS

Data came from the Prison and Transition Health Cohort Study. Three-month post-release follow-up interviews were linked with primary care and medication dispensation records. Generalised linear models were fit with one exposure (OAT: none/partial/complete) for 13 outcomes relating to primary healthcare use, pathology testing, and medication dispensation, adjusted for other covariates. Coefficients were reported as adjusted incidence rate ratios (AIRR).

RESULTS

Analyses included 255 participants. Compared to no OAT use, both partial and complete OAT use were associated with increased rates of standard (AIRR: 3.02, 95%CI: 1.88-4.86; AIRR: 3.66, 95%CI: 2.57-5.23), extended (AIRR: 2.56, 95%CI: 1.41-4.67; AIRR: 2.55, 95%CI: 1.60-4.07) and mental health-related (AIRR: 2.71, 95%CI: 1.42-5.20; AIRR: 2.27, 95%CI: 1.33-3.87) general practitioner (GP) consultations, total medication (AIRR: 1.88, 95%CI: 1.19-2.98; AIRR: 2.40, 95%CI: 1.71-3.37), benzodiazepine (AIRR: 4.99, 95%CI: 2.81-8.85; AIRR: 8.30, 95%CI: 5.28-13.04) and gabapentinoid (AIRR: 6.78, 95%CI: 3.34-13.77; AIRR: 4.34, 95%CI: 2.37-7.94) dispensations, respectively. Partial OAT use was also associated with increased after-hours GP consultations (AIRR: 4.61, 95%CI: 2.24-9.48) and complete OAT use? with increased pathology utilisation (e.g. haematological, chemical, microbiological or immunological tissue/sample testing; AIRR: 2.30, 95%CI: 1.52-3.48).

CONCLUSION

We observed higher rates of primary healthcare use and medication dispensation among people who reported partial and complete OAT use post-release. Findings suggest that access to OAT post-release may have a collateral benefit in supporting broader health service utilisation, underscoring the importance of retention in OAT after release from prison.

SARS-CoV2 Infection and Comorbidity in Inmates: A Study of Central Italy

BACKGROUND AND OBJECTIVE

The presence of multiple chronic diseases is associated with an increase in mortality when related to COVID-19 infection.

THE AIMS OF OUR STUDY WERE

(i) to evaluate the association between the severity of the COVID-19 disease, defined as symptomatic hospitalized in prison or symptomatic hospitalized out of prison, and the presence of one or more comorbidities in two prisons in central Italy: L'Aquila and Sulmona; (ii) to describe the profiles of inmates using multiple correspondence analysis (MCA).

METHODS

A database was created including age, gender and clinical variables. The database containing anonymized data was password-protected. The Kruskal-Wallis test was used to evaluate a possible association between diseases and the severity of COVID-19 stratified by age groups. We used MCA to describe a possible characteristic profile of inmates.

RESULTS

Our results show that in the 25-50-year-old age group (COVID-19-negative) in the L'Aquila prison, 19/62 (30.65%) were without comorbidity, 17/62 (27.42%) had 1-2 comorbidities and only 3.23% had >2 diseases. It is interesting to note that in the elderly group, the frequency of 1-2 or >2 pathologies was higher than in the younger group, and only 3/51 (5.88%) inmates did not have comorbidities and were COVID-19 negative (p = 0.008). The MCA identified the following profiles: the prison of L'Aquila showed a group of women over 60 with diabetes, cardiovascular and orthopedic problems, and hospitalized for COVID-19; the Sulmona prison presented a group of males over 60 with diabetes, cardiovascular, respiratory, urological, gastrointestinal and orthopedic problems, and hospitalized or symptomatic due to COVID-19.

CONCLUSIONS

our study has demonstrated and confirmed that advanced age and the presence of concomitant pathologies have played a significant role in the severity of the disease: symptomatic hospitalized in the prison; symptomatic hospitalized out of the prison.

Health of Young Adults Experiencing Social Marginalization and Vulnerability: A Cross-National Longitudinal Study

People who experience social marginalization and vulnerability have uniquely complex health needs and are at risk of poor health outcomes. Regression analyses using longitudinal data from a cross-national, population-based sample of young adults participating in the International Youth Development Study, tested associations between social marginalization and vulnerabilities and physical health, mental health, and substance use outcomes. Participants from Victoria, Australia, and Washington State in the US were surveyed at ages 25 (2014) and 29 years (2018; N = 1944; 46.7% male). A history of adverse childhood experiences (ACEs), LGBT identity, financial insecurity, and justice system involvement at age 25 predicted poor health outcomes at age 28, including lower perceived health status, risk for chronic illness, depression and anxiety symptoms, and diagnosed mental health/substance use disorders. Tests of model equivalence across states showed that a history of ACEs was more strongly related to health status and serious injury at age 28 and justice system involvement at age 25 was more strongly related to age 28 serious injury in Victoria than in Washington State. Findings strengthen the case for future population-based research identifying life-course interventions and state policies for reducing poor health and improving health equity among members of socially marginalized groups.

Interventions to improve the implementation of evidence-based healthcare in prisons: a scoping review

BACKGROUND

There are challenges to delivering high quality primary care within prison settings and well-recognised gaps between evidence and practice. There is a growing body of literature evaluating interventions to implement evidence-based practice in the general population, yet the extent and rigour of such evaluations in incarcerated populations are unknown. We therefore conducted a scoping literature review to identify and describe evaluations of implementation interventions in the prison setting.

METHODS

We searched EMBASE, MEDLINE, CINAHL Plus, Scopus, and grey literature up to August 2021, supplemented by hand searching. Search terms included prisons, evidence-based practice, and implementation science with relevant synonyms. Two reviewers independently selected studies for inclusion. Data extraction included study populations, study design, outcomes, and author conclusions. We took a narrative approach to data synthesis. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance for scoping reviews.

RESULTS

Fifteen studies reported in 17 papers comprised one randomised controlled trial, one controlled interrupted time series analysis and 13 uncontrolled before and after studies. Eight studies took place in the US and four in the UK. Ten studies evaluated combined (multifaceted) interventions, typically including education for staff or patients. Interventions most commonly targeted communicable diseases, mental health and screening uptake. Thirteen studies reported adherence to processes of care, mainly testing, prescribing and referrals. Fourteen studies concluded that interventions had positive impacts.

CONCLUSIONS

There is a paucity of high-quality evidence to inform strategies to implement evidence-based health care in prisons, and an over-reliance on weak evaluation designs which may over-estimate effectiveness. Whilst most evaluations have focused on recognised priorities for the incarcerated population, relatively little attention has been paid to long-term conditions core to primary care delivery. Initiatives to close the gaps between evidence and practice in prison primary care need a stronger evidence base.

Perceived health status and satisfaction with healthcare services of detained male individuals: a survey in Italy

OBJECTIVES

This study investigated the perceived health status and satisfaction with prison healthcare services of detained male individuals in Italy.

STUDY DESIGN

A cross-sectional study was performed between March and June 2021.

METHODS

Of 800 male detained individuals who were invited to participate in the study, 632 returned the self-administered questionnaire, resulting in a response rate of 79%.

RESULTS

Overall, 72.8% of participants reported that they were moderately or completely satisfied with their health status, and 27.2% stated that they were not at all satisfied. Moreover, 66.2% of participants reported that they had at least one health problem or disease, compared with 34% at the time of incarceration, with 35% reporting multiple health problems/diseases. In total, 10.1% of participants requested healthcare when a health problem occurred, and 12.4% were always satisfied with the healthcare that they received. Significant determinants of dissatisfaction with health status were older age, reported health problems/diseases, suicide attempts, emotional problems and no working activity in prison. Significant determinants of dissatisfaction with healthcare services were younger age, health problems at incarceration, suicide attempts and multiple experiences of incarceration.

CONCLUSIONS

This study shows that detained male individuals have multiple and frequently unmet health needs. Some of the reported health problems or diseases were present at the time of incarceration, but these often worsened and/or increased during detention. This study highlights the need to promote evidence-based intervention to strengthen the role of healthcare services provided in prisons.

Sex differences in suicide, suicidal ideation, and self-harm after release from incarceration: a systematic review and meta-analysis

PURPOSE

People released from incarceration are at increased risk of suicide compared to the general population. We aimed to synthesise evidence on the incidence of and sex differences in suicide, suicidal ideation, and self-harm after release from incarceration.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, Web of Science and PubMed between 1 January 1970 and 14 October 2021 for suicide, suicidal ideation, and self-harm after release from incarceration (PROSPERO registration: CRD42020208885). We calculated pooled crude mortality rates (CMRs) and standardised mortality ratios (SMRs) for suicide, overall and by sex, using random-effects models. We calculated a pooled incidence rate ratio (IRR) comparing rates of suicide by sex.

RESULTS

Twenty-nine studies were included. The pooled suicide CMR per 100,000 person years was 114.5 (95%CI 97.0, 132.0, I² = 99.2%) for non-sex stratified samples, 139.5 (95% CI 91.3, 187.8, I² = 88.6%) for women, and 121.8 (95% CI 82.4, 161.2, I² = 99.1%) for men. The suicide SMR was 7.4 (95% CI 5.4, 9.4, I² = 98.3%) for non-sex stratified samples, 14.9 for women (95% CI 6.7, 23.1, I² = 88.3%), and 4.6 for men (95% CI 1.3, 7.8, I² = 98.8%). The pooled suicide IRR comparing women to men was 1.1 (95% CI 0.9, 1.4, I² = 82.2%). No studies reporting self-harm or suicidal ideation after incarceration reported sex differences.

CONCLUSION

People released from incarceration are greater than seven times more likely to die by suicide than the general population. The rate of suicide is higher after release than during incarceration, with the elevation in suicide risk (compared with the general population) three times higher for women than for men. Greater effort to prevent suicide after incarceration, particularly among women, is urgently needed.

Enhancing community integration after incarceration: findings from a prospective study of an intensive peer support intervention for veterans with an historical comparison group

BACKGROUND

The transition to the community after incarceration presents challenges for returning citizens, including the immediate need to secure housing, employment, and income. Additionally, health care is essential for this population due to high rates of chronic physical health and mental health problems and substance use disorders. There is growing recognition of the need for interventions that support returning citizens as they navigate community reintegration while simultaneously tending to physical and behavioral health needs. We developed and pilot tested a peer support intervention designed to provide social, emotional, and logistic support and promote linkage and engagement in healthcare for returning citizens. We tested the intervention with US military veterans in Massachusetts who were being released from prison and jail. Outcomes related to linkage to and engagement in healthcare were evaluated using an historical comparison group. Engagement in peer support, housing status, and reincarceration rates were monitored for the intervention group.

RESULTS

There were 43 veterans in the intervention group, and 36 in the historical comparison group. For linkage to primary care within 90 days of release, there were no statistically significant differences between the intervention and comparison groups (58% versus 67%). Intervention participants were significantly more likely to receive substance use treatment than the comparison group (86% versus 19%, p < .0001) and the mean monthly substance use visits was greater in the intervention group (0.96 versus 0.34, p < .007). Engagement in mental health services was greater for the intervention group than the comparison group (93% versus 64%, p < .003). There were no significant differences between groups for emergency department use and hospitalization. At the end of the study period, the majority of intervention participants who had been released for over a year were living in permanent housing (84%). Recidivism among the was low, with 7% re-arrested during the study period.

CONCLUSIONS

Augmenting reentry support through intensive peer support appears to have substantial benefits for veterans in terms of engaging them in health care and contributing to their longer-term stability, including housing and recidivism. Flexible reentry support such as this intervention may be well suited to meet the widely varying needs of returning citizens.

Understanding health and social service accessibility for young people with problematic substance use exiting prison in Australia

Incarcerated young people (aged 18-24) with a history of problematic substance use are a particularly vulnerable group, with a higher risk of mortality and return to custody compared to their older counterparts. Yet, there is limited research investigating service accessibility for this population. This study aimed to address this gap by investigating the characteristics of young people exiting prison on the 'Connections Program' (Connections) and their access to support services. Connections is a transitional program with a remit to link people with problematic substance use exiting prison in New South Wales, Australia, to health and social services in the community. We used an explanatory sequential mixed methods approach including (1) a retrospective cohort study of young people on Connections (n = 359), utilising self-reported data collected in a routine pre-release questionnaire from January 2008 to February 2015 and (2) a qualitative survey with Connections caseworkers (n = 10). In stage one, descriptive statistics were calculated to produce a profile of sociodemographic and health characteristics of young people with problematic substance use exiting prison. In stage two, qualitative data were thematically analysed to explore the accessibility of services to meet young people's needs from the perspective of caseworkers. The study found young people experienced substantially poorer mental health than the general population, and the vast majority had received treatment for a mental health issue (96.5%). Illicit substance use prior to incarceration was common (91.5%). Caseworkers reported substantial barriers to service accessibility in the community related to intersecting social disadvantage and co-occurring mental distress and substance use. Caseworkers have front-line knowledge of how gaps and barriers in services impact transition from prison and identified longer-term case coordination, inter-agency collaboration and holistic care as vital strategies to support young people in transition from prison to community.

Factors Associated with patient satisfaction towards a prison detention Clinic Care among male drug-using inmates

This study assessed patient satisfaction and its associated factors among male drug-using inmates utilizing a prison detention clinic in Taiwan. A cross-sectional design and structured questionnaire were employed to recruit 580 drug-using inmates into the study. The Patient Satisfaction Questionnaire Short Form (PSQ-18), developed by the RAND Corporation, was used as the basis for the short scale of patient satisfaction, and the research data were analyzed using the SPSS for Windows 20.0 statistical software package. The results showed that the research subjects had low patient satisfaction in all the factors assessed compared with the scale’s general norms. Among the original seven satisfaction subscales in this study, the highest score was for the financial aspects, and the lowest was for the amount of time spent with doctors. This study also investigated satisfaction with medical lab exams and the pharmacy at the prison’s clinic, and the satisfaction scores were higher than the original seven subscales. In multiple logistic regression analyses, the final model indicated that the inmates undergoing observed rehabilitation (OR = 13.837, 95% CI = 2.736–69.983) were more likely satisfied with prison detention clinic c than those serving prison sentences. Those inmates with custodial deposits (high vs. low; OR = 1.813, 95% CI = 1.038–3.168), and meet their physical health needs (met vs. unmet; OR = 4.872, 95% CI = 2.054–11.560) had significant correlated with detention clinic care satisfactory level. Although there is only one study setting cannot give a generalizability for people who are incarcerated in Taiwan, this study highlights that the prison authorities should scrutinize factors associated with detention clinic care satisfaction, such as the type of inmate, economic status in the prison, self-reported health status, and their physical health needs, to increase the level of patient satisfaction.

Criminal Justice Involvement after Release from Prison following Exposure to Community Mental Health Services among People Who Use Illicit Drugs and Have Mental Illness: a Systematic Review

Illicit drug use and mental illness are common among people in prison and are associated with higher rates of reoffending and reimprisonment. We conducted a systematic review, searching MEDLINE, Embase, and PsycINFO to January 10, 2022, for studies reporting criminal justice involvement following exposure to community mental health services among people released from jail or prison who use illicit drugs and have mental illness. Our search identified 6954 studies; 13 were eligible for inclusion in this review. Studies were separated into three broad categories based on community mental health service type. Eleven of 13 studies reported a reduction in criminal justice involvement among participants exposed to community mental health services compared to a comparison group. Findings indicate a need to expand and improve integration and referral mechanisms linking people to community mental health services after jail or prison release, alongside a need for tailored programs for individuals with complex illicit drug use and mental health morbidities.

Barriers and opportunities to accessing social support in the transition from community to prison: a qualitative interview study with incarcerated individuals in Northern Norway

BACKGROUND

Incarcerated individuals have poor mental health compared to the general population. Social support has a beneficial effect on mental health. The buffering model proposes that social support facilitates coping under stressful conditions, while the main effects model suggests that belonging to social networks and having positive social interactions are beneficial for mental health. Prisons are a highly interesting context for studying social support, as imprisonment is perceived as stressful and disrupts social relationships and the availability of support. This study aims to explore incarcerated individuals' perceptions of social support from various sources in the transition from community to prison, its perceived significance for mental health, and the opportunities and barriers to accessing social support in a Norwegian prison context.

METHODS

The experiences of eight incarcerated individuals from a prison in Northern Norway were gathered through conducting individual in-depth interviews. The data analysis was inspired by Charmaz's version of Grounded Theory.

RESULTS

Social support from peers was perceived to be important for the well-being and preserving of mental health in prison. Support from informal sources outside prison and prison officers were not granted the same significance by the participants. Although prison life was perceived as stressful, social support in the form of companionship, the feeling of belonging, shared activities, and everyday conversations were more important for the participants than support focusing on coping with the stress of incarceration.

CONCLUSIONS

Peers are perceived to be the most important source of social support, and vital for well-being and mental health in prison. Barriers to support from family, friends and prison officers may amplify the significance of support from peers.

Opioid agonist treatment uptake within provincial correctional facilities in British Columbia, Canada

BACKGROUND AND AIMS

Multiple interventions and policy changes related to opioid agonist treatment (OAT) have been introduced in British Columbia, Canada to increase engagement and retention in OAT. We aimed to estimate the impact of policy changes and the announcement of the opioid overdose-related public health emergency on the use of OAT for incarcerated individuals with opioid use disorder.

DESIGN

Interrupted time-series analysis. Events of interest included the expansion of buprenorphine/naloxone into provincial health-care insurance coverage in October 2015 and the public health emergency declared in April 2016.

SETTING AND PARTICIPANTS

Our study included 9220 incarcerated individuals from 12 provincial corrections facilities in British Columbia, Canada for a total of 75 649 calendar months of incarceration.

MEASUREMENTS

Monthly measures of OAT use during incarceration from 1 January 2013 to 30 September 2017. We estimated changes in OAT use, controlling for individual and facility-level factors, using a general estimating equation, specified with a logit link and an autoregressive correlation matrix.

FINDINGS

After the provincial health insurance coverage expansion, a sharp increase in OAT use during incarceration was observed [adjusted odds ratio (aOR) = 1.16, 95% confidence interval (CI) = 1.13, 1.19]. The public health emergency coincided with an immediate but temporary increase in OAT receipt (aOR = 1.34, 95% CI = 1.22, 1.47). During the entire study period, we estimated a 10-fold increase in the adjusted odds of OAT use during incarceration (aOR = 10.10, 95% CI = 8.98, 11.37).

CONCLUSION

Following an expansion of health-care insurance coverage to include buprenorphine/naloxone, receipt of opioid agonist treatment (OAT) within correctional facilities in British Columbia, Canada increased, largely driven by an increase in buprenorphine/naloxone prescriptions among individuals without recent OAT experience.

PriSUD-Nordic-Diagnosing and Treating Substance Use Disorders in the Prison Population: Protocol for a Mixed Methods Study

Background

A large proportion of the prison population experiences substance use disorders (SUDs), which are associated with poor physical and mental health, social marginalization, and economic disadvantage. Despite the global situation characterized by the incarceration of large numbers of people with SUD and the health problems associated with SUD, people in prison are underrepresented in public health research.

Objective

The overall objective of the PriSUD (Diagnosing and Treating Substance Use Disorders in Prison)-Nordic project is to develop new knowledge that will contribute to better mental and physical health, improved quality of life, and better life expectancies among people with SUD in prison.

Methods

PriSUD-Nordic is based on a multidisciplinary mixed method approach, including the methodological perspectives of both quantitative and qualitative methods. The qualitative part includes ethnographic fieldwork and semistructured interviews. The quantitative part is a registry-based cohort study including national registry data from Norway, Denmark, and Sweden. The national prison cohorts will comprise approximately 500,000 individuals and include all people imprisoned in Norway, Sweden, and Demark during the period from 2000 to 2019. The project will investigate the prison population during three different time periods: before imprisonment, during imprisonment, and after release.

Results

PriSUD-Nordic was funded by The Research Council of Norway in December 2019, and funding started in 2020. Data collection is ongoing and will be completed in the first quarter of 2022. Data will be analyzed in spring 2022 and the results will be disseminated in 2022-2023. The PriSUD-Nordic project has formal ethical approval related to all work packages.

Conclusions

PriSUD-Nordic will be the first research project to investigate the epidemiology and the lived experiences of people with SUD in the Nordic prison population. Successful research in this field will have the potential to identify significant areas of benefit and will have important implications for ongoing policy related to interventions for SUD in the prison population.

International Registered Report Identifier (IRRID)

DERR1-10.2196/35182

Quality indicators and performance measures for prison healthcare: a scoping review

BACKGROUND

Internationally, people in prison should receive a standard of healthcare provision equivalent to people living in the community. Yet efforts to assess the quality of healthcare through the use of quality indicators or performance measures have been much more widely reported in the community than in the prison setting. This review aims to provide an overview of research undertaken to develop quality indicators suitable for prison healthcare.

METHODS

An international scoping review of articles published in English was conducted between 2004 and 2021. Searches of six electronic databases (MEDLINE, CINAHL, Scopus, Embase, PsycInfo and Criminal Justice Abstracts) were supplemented with journal searches, author searches and forwards and backwards citation tracking.

RESULTS

Twelve articles were included in the review, all of which were from the United States. Quality indicator selection processes varied in rigour, and there was no evidence of patient involvement in consultation activities. Selected indicators predominantly measured healthcare processes rather than health outcomes or healthcare structure. Difficulties identified in developing performance measures for the prison setting included resource constraints, data system functionality, and the comparability of the prison population to the non-incarcerated population.

CONCLUSIONS

Selecting performance measures for healthcare that are evidence-based, relevant to the population and feasible requires rigorous and transparent processes. Balanced sets of indicators for prison healthcare need to reflect prison population trends, be operable within data systems and be aligned with equivalence principles. More effort needs to be made to meaningfully engage people with lived experience in stakeholder consultations on prison healthcare quality. Monitoring healthcare structure, processes and outcomes in prison settings will provide evidence to improve care quality with the aim of reducing health inequalities experienced by people living in prison.

A systematic review of post-release programs for women exiting prison with substance-use disorders: assessing current programs and weighing the evidence

BACKGROUND

The rising rates of women in prison is a serious public health issue. Unlike men, women in prison are characterised by significant histories of trauma, poor mental health, and high rates of substance use disorders (SUDs). Recidivism rates of women have also increased exponentially in the last decade, with substance related offences being the most imprisoned offence worldwide. There is a lack of evidence of the effectiveness of post-release programs for women. The aim of this systematic review is to synthesise and evaluate the evidence on post-release programs for women exiting prison with SUDs.

METHODS

We searched eight scientific databases for empirical original research published in English with no date limitation. Studies with an objective to reduce recidivism for adult women (⩾18 years) with a SUD were included. Study quality was assessed using the revised Cochrane Risk of Bias tool for randomized trials (RoB2) and the Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tools.

RESULTS

Of the 1493 articles, twelve (n = 3799 women) met the inclusion criteria. Recidivism was significantly reduced in five (42%) programs and substance-use was significantly reduced in one (8.3%) program. Common attributes among programs that reduced recidivism were: transitional, gender-responsive programs; provision of individualised support; providing substance-related therapy, mental health and trauma treatment services. Methodological and reporting biases were common, which impacted our ability to synthesize results further. Recidivism was inconsistently measured across studies further impacting the ability to compare results across studies.

CONCLUSIONS

Recidivism is a problematic measure of program efficacy because it is inconsistently measured and deficit-focused, unrecognising of women's gains in the post-release period despite lack of tailored programs and significant health and social disadvantages. The current evidence suggests that women benefit from continuity of care from prison to the community, which incorporated gender-responsive programming and individualised case management that targeted co-morbid mental health and SUDs. Future program design should incorporate these attributes of successful programs identified in this review to better address the unique challenges that women with SUDs face when they transition back into the community.

Prevalence of co-occurring mental illness and substance use disorder and association with overdose: a linked data cohort study among residents of British Columbia, Canada

AIMS

To estimate the treated prevalence of mental illness, substance use disorder (SUD) and dual diagnosis and the association between dual diagnosis and fatal and non-fatal overdose among residents of British Columbia (BC), Canada.

DESIGN

A retrospective cohort study using linked health, income assistance, corrections and death records.

SETTING

British Columbia (BC), Canada.

PARTICIPANTS

A total of 921 346 BC residents (455 549 males and 465 797 females) aged 10 years and older.

MEASUREMENTS

Hospital and primary-care administrative data were used to identify a history of mental illness only, SUD only, dual diagnosis or no history of SUD or mental illness (2010-14) and overdoses resulting in medical care (2015-17). We calculated crude incidence rates of non-fatal and fatal overdose by dual diagnosis history. Andersen-Gill and competing risks regression were used to examine the association between dual diagnosis and non-fatal and fatal overdose, respectively, adjusting for age, sex, comorbidities, incarceration history, social assistance, history of prescription opioid and benzodiazepine dispensing and region of residence.

FINDINGS

Of the 921 346 people in the cohort, 176 780 (19.2%), 6147 (0.7%) and 15 269 (1.7%) had a history of mental illness only, SUD only and dual diagnosis, respectively; 4696 (0.5%) people experienced 688 fatal and 6938 non-fatal overdoses. In multivariable analyses, mental illness only, SUD only and dual diagnosis were associated with increased rate of non-fatal [hazard ratio (HR) = 1.8, 95% confidence interval (CI) = 1.6-2.1; HR = 9.0, 95% CI = 7.0-11.5, HR = 8.7, 95% CI = 6.9-10.9, respectively] and fatal overdose (HR = 1.6, 95% CI = 1.3-2.0, HR = 4.3, 95% CI = 2.8-6.5, HR = 4.1, 95% CI = 2.8-6.0, respectively) compared with no history.

CONCLUSIONS

In a large sample of residents of British Columbia (Canada), approximately one in five people had sought care for a substance use disorder or mental illness in the past 5 years. The rate of overdose was elevated in people with a mental illness alone, higher again in people with a substance use disorder alone and highest in people with a dual diagnosis. The adjusted hazard rates were similar for people with substance use disorder only and people with a dual diagnosis.

Synthetic Cannabinoids in Prisons: Content Analysis of TikToks

Background

Synthetic cannabinoids are a significant public health concern, especially among incarcerated populations due to increased reports of abuse. Recent news reports have highlighted the severe consequences of K2/Spice, a synthetic cannabinoid, among the prison population in the United States. Despite regulations against cell phone use, inmates use TikTok to post K2/Spice-related content.

Objective

This study aimed to examine TikTok posts for use and illicit distribution of psychoactive substances (eg, K2/Spice) among incarcerated populations.

Methods

The study collected TikTok videos associated with the #k2spice hashtag and used a data collection approach similar to snowball sampling. Inductive coding was used to conduct content analysis of video characteristics. Videos were manually annotated to generate binary classifications related to the use of K2/Spice as well as selling and buying activities associated with it. Statistical analysis was used to determine associations between a video's user engagement and an intent to buy or sell K2/Spice.

Results

A total of 89 TikTok videos with the hashtag #k2spice were manually coded, with 40% (n=36) identified as displaying the use, solicitation, or adverse effects of K2/Spice among the prison population. Of them, 44.44% (n=16) were in a prison-based setting documenting adverse effects including possible overdose. Videos with higher user engagement were positively correlated with comments indicating an intent to buy or sell K2/Spice.

Conclusions

K2/Spice is a drug subject to abuse among prison inmates in the United States, including depictions of its harmful effects being recorded and shared on TikTok. Lack of policy enforcement on TikTok and the need for better access to treatment services within the prison system may be exacerbating substance use among this highly vulnerable population. Minimizing the potential individual harm of this content on the incarcerated population should be a priority for social media platforms and the criminal justice system alike.

Emergency department presentations in the first weeks following release from prison among men with a history of injecting drug use in Victoria, Australia: A prospective cohort study

OBJECTIVE

Rates of emergency department (ED) use are higher among people released from prison than in the general population. However, little is known about ED presentations specifically among people with a history of injecting drug use (IDU) leaving prison. We measured the incidence of ED presentation in the three months following release from prison, among a cohort of men with histories of IDU, and determined pre-release characteristics associated with presenting to an ED during this period.

METHODS

We analysed linked survey and administrative data from the Prison and Transition Health (PATH) study (N = 400) using multiple-failure survival analysis.

RESULTS

Twenty-one percent (n = 81/393) of the cohort presented to an ED at least once within the three months after release from prison. The incidence of ED presentation was highest in the first six days after release. Cox proportional hazards modelling showed that a history of in-patient psychiatric admission and housing instability were associated with increased hazard of an ED presentation, and identifying as Aboriginal and Torres Strait Islander was associated with decreased hazard.

CONCLUSIONS

In our study, ED presentations following release from prison among people with a history of IDU was linked to acute health risks related to known mental health and social vulnerabilities in this population. Greater collaboration and systems integration between prison and community health and support services is needed to reduce presentations to ED and associated morbidities among people with a history of IDU after release from prison.

Cause for concern: Australian youth engaged with alcohol and other drug services are falling behind our community progress in reducing tobacco use

AIM

Tobacco use is decreasing in the general youth population yet little evidence is tracking changes in young people who are engaged with youth alcohol and other drug (AOD) services that are often disengaged from school and wok settings.

METHOD

This study reviews tobacco use amongst 1823 young people engaged with youth AOD services in Victoria in 2013 and 2017 from the Youth Needs Census. This study contrasted use patterns over the three-year period against Australian population data.

RESULTS

The results show tobacco use is not declining in the youth AOD engaged population as observed with other young Australians. Further, reductions in tobacco use observed in the community sample were not evident in the youth AOD group. Finally, high rates of tobacco dependence are shown in the 2016 cohort.

CONCLUSION

The results highlight a need for the adoption of evidence-based tobacco early intervention programs in youth AOD services to address this significant health risk.

Epidemiology, Risk Factors, and Prevention of Suicidal Thoughts and Behaviour in Prisons: A Literature Review

Suicide is a global public health concern that affects all echelons of society, albeit not equally so. Compared with adults in the general population, incarcerated offenders are at increased risk to consider, attempt, and die by suicide, which represents a substantial burden of morbidity and mortality in prisons worldwide. This review synthesises recent literature pertaining to the epidemiology, risk factors, and prevention of suicidal thoughts and behaviour among prisoners, and outlines a framework which emphasises the interplay between individuals (importation) and their surroundings (deprivation). The available evidence suggests that prison-specific stressors may exacerbate risk of suicide in an already vulnerable population characterised by complex health and social care needs. Emerging data point to differential mechanisms through which prisoners come to think about suicide and subsequently progress to suicidal behaviour. As risk of suicide is determined by a complex web of synergistically interacting factors, its management and prevention demands a cross-sectoral policy and service response that includes targeted interventions aimed at high-risk prisoners in combination with population strategies that promote the health and wellbeing of all people in prison.

Violence-related deaths among people released from incarceration: systematic review and meta-analysis of cohort studies

BACKGROUND

People released from incarceration have an increased risk of violence-related death. As deaths from violence are a rare event, meta-analysis is needed to calculate reliable estimates of this risk. We examined the crude mortality rates (CMRs), standardised mortality ratios (SMRs), and predictive factors for violence-related deaths among people released from incarceration.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, PubMed, PsycINFO, Scopus, Web of Science, CINCH, and Criminal Justice Abstracts from inception to 14 September 2020 for cohort studies published in English that examined violence-related deaths occurring in the community following release from adult or youth incarceration. We used the Methodological Standard for Epidemiological Research (MASTER) scale to assess the quality of included studies. We conducted a random-effects meta-analysis to calculate pooled estimates of the CMRs and SMRs. Heterogeneity was assessed using univariable meta-regression. This review was registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42020209422).

FINDINGS

Our search identified 2,489 records, from which 11 studies met the eligibility criteria. The pooled CMR for violence-related deaths after release from incarceration was 78·7 per 100,000 person-years (95%CI 58·0-99·5). The pooled SMR was 7·6 (95%CI 2·4-12·8). The estimate of heterogeneity was high (I²≥99%) and the Cochran's Q test was significant (p<0·001) for the pooled CMR and SMR. Study design (prospective vs. retrospective; p=0·001) and type of incarceration facility (youth detention vs. prison; p=0·006) were identified as possible sources of heterogeneity for CMRs. Risk factors for violence-related death after release were reported in only five studies. These included being male (n=3), Black or Hispanic in the United States (n=3), and younger age at release from incarceration (n=2).

INTERPRETATION

People released from incarceration are almost eight times more likely to die from violence than the general population. Violence-related deaths are preventable, and the high rate at which they occur after release from incarceration represents an important public health issue requiring targeted, evidence-based response.

FUNDING

None.

A rapid review of early guidance to prevent and control COVID-19 in custodial settings

BACKGROUND

With over 11 million people incarcerated globally, prevention and control of COVID-19 in custodial settings is a critical component of the public health response. Given the risk of rapid transmission in these settings, it is important to know what guidance existed for responding to COVID-19 in the early stages of the pandemic. We sought to identify, collate, and summarise guidance for the prevention and control of COVID-19 in custodial settings in the first six months of 2020. We conducted a systematic search of peer-reviewed and grey literature, and manually searched relevant websites to identify publications up to 30 June 2020 outlining recommendations to prevent and/or control COVID-19 in custodial settings. We inductively developed a coding framework and assessed recommendations using conventional content analysis.

RESULTS

We identified 201 eligible publications containing 374 unique recommendations across 19 domains including: preparedness; physical environments; case identification, screening, and management; communication; external access and visitation; psychological and emotional support; recreation, legal, and health service adaptation; decarceration; release and community reintegration; workforce logistics; surveillance and information sharing; independent monitoring; compensatory measures; lifting control measures; evaluation; and key populations/settings. We identified few conflicting recommendations.

CONCLUSIONS

The breadth of recommendations identified in this review reflects the complexity of COVID-19 response in custodial settings. Despite the availability of comprehensive guidance early in the pandemic, important gaps remain in the implementation of recommended prevention and control measures globally, and in the availability of evidence assessing their effectiveness on reducing COVID-19 disease, impact on people in custody and staff, and implementation.

The Prison and Transition Health (PATH) cohort study: Prevalence of health, social, and crime characteristics after release from prison for men reporting a history of injecting drug use in Victoria, Australia

BACKGROUND

People who inject drugs are overrepresented in prison and have diverse and complex health needs. However, outcomes after release from prison are poorly understood, limiting effective interventions supporting community reintegration. We describe the prevalence of socio-demographics, physical and mental health, alcohol and other drug use, and crime characteristics of men with histories of injecting drug use after their release from prison in Victoria, Australia.

METHODS

Data come from the Prison and Transition Health (PATH) prospective cohort study. Interviews were undertaken approximately three, 12, and 24 months after release from their index prison episode and were completed in the community, or in prison for those reimprisoned during the study. We present cross-sectional descriptive statistics for each follow-up wave of the PATH study.

RESULTS

Among 400 men recruited into PATH, 85 % (n = 336) completed at least one follow-up interview; 162 (42 %) completed all three interviews. Participants reported social disadvantage and health inequity, including high rates of unemployment, homelessness, and physical and mental health morbidities at each follow-up time point. Rapid return to illicit substance use was common, as was overdose (ranging 9 %-13 %), receptive syringe sharing (ranging 20 %-29 %), involvement in crime-related activities (ranging 49 %-58 %), and reimprisonment (ranging 22 %-50 %) over the duration of follow-up.

CONCLUSION

Men in this study experienced substantial health and social challenges across a 24-month prospective follow-up period. Improved understanding of characteristics and experiences of this group after release from prison can inform more coordinated and continued care between prison and the community.

Health of people experiencing co-occurring homelessness, imprisonment, substance use, sex work and/or severe mental illness in high-income countries: a systematic review and meta-analysis

BACKGROUND

People affected by homelessness, imprisonment, substance use, sex work or severe mental illness experience substantial excess ill health and premature death. Though these experiences often co-occur, health outcomes associated with their overlap have not previously been reviewed. We synthesised existing evidence on mortality, morbidity, self-rated health and quality of life among people affected by more than one of these experiences.

METHODS

In this systematic review and meta-analysis, we searched Medline, Embase, and PsycINFO for peer-reviewed English-language observational studies from high-income countries published between 1 January 1998 and 11 June 2018. Two authors undertook independent screening, with risk of bias assessed using a modified Newcastle-Ottawa Scale. Findings were summarised by narrative synthesis and random-effect meta-analysis.

RESULTS

From 15 976 citations, 2517 studies underwent full-text screening, and 444 were included. The most common exposure combinations were imprisonment/substance use (31% of data points) and severe mental illness/substance use (27%); only 1% reported outcomes associated with more than two exposures. Infections were the most common outcomes studied, with blood-borne viruses accounting for 31% of all data points. Multiple exposures were associated with poorer outcomes in 80% of data points included (sign test for effect direction, p<0.001). Meta-analysis suggested increased all-cause mortality among people with multiple versus fewer exposures (HR: 1.57 and 95% CI: 1.38 to 1.77), though heterogeneity was high.

CONCLUSION

People affected by multiple exclusionary processes experience profound health inequalities, though there are important gaps in the research landscape. Addressing the health needs of these populations is likely to require co-ordinated action across multiple sectors, such as healthcare, criminal justice, drug treatment, housing and social security.

PROSPERO REGISTRATION NUMBER

CRD42018097189.

Physical health programs and interventions with women during incarceration: a scoping review

PURPOSE

The USA outpaces most other countries in the world in the rates at which it incarcerates its citizens. The one million women held in US jails and prisons on any day in the USA face many physical health challenges, yet interventional work to address physical health in carceral settings is rare. This study's purpose was to summarize the literature on programs and interventions implemented with women in US carceral settings (jail or prison) that primarily addressed a physical health issue or need.

DESIGN/METHODOLOGY/APPROACH

A scoping review was conducted. The authors searched databases, reference lists, individual journals and websites for physical health program descriptions/evaluations and research studies, 2000-2020, that included women and were set in the USA.

FINDINGS

The authors identified 19 articles and a range of problem areas, designs, settings and samples, interventions/programs, outcomes and uses of theory. The authors identified two cross-cutting themes: the carceral setting as opportunity and challenges of ethics and logistics.

RESEARCH LIMITATIONS/IMPLICATIONS

Much potential remains for researchers to have an impact on health disparities by addressing physical health needs of women during incarceration.

ORIGINALITY/VALUE

Interventional and programmatic work to address physical health needs of women during incarceration is sparse and diversely focused. This review uniquely summarizes the existing work in a small and overlooked but important area of research and usefully highlights gaps in that literature.