At a crossroads: reentry challenges and healthcare needs among homeless female ex-offenders

The Feasibility and Acceptability of a Diabetes Survival Skills Intervention for Persons Transitioning from Prison to the Community

Community evidenced-based diabetes self-management education (DSME) models have not been examined for feasibility, acceptability, or effectiveness among persons transitioning from prison to the community to independent diabetes self-management (DSM). In a non-equivalent control group design with repeated measures, we examined the feasibility, acceptability, and preliminary effect of a 6-week, 1-h per week Diabetes Survival Skills (DSS) intervention on diabetes knowledge, distress, self-efficacy, and outcome expectancy for transitioning incarcerated males. Of the 92 participants (84% T2D, 83% using insulin, 40% Black, 20% White, 30% Latino, 66% high school or less, mean age 47.3 years, 84% length of incarceration ≤4 years ), 41 completed the study (22 control/19 intervention [TX]). One-way repeated measures ANOVAs revealed significant changes in diabetes knowledge within each group (C, p = .002; TX, p = .027) at all time points; however, a two-way repeated measures ANOVA showed no differences between groups. Additionally, both groups showed improvement in diabetes-related distress and outcome expectancy with the treatment group experiencing greater and sustained improvement at the 12-week time point. Analysis of focus group data (Krippendorf) revealed acceptance of and enthusiasm for the DSS training and low literacy education materials, the need for skill demonstration, and ongoing support throughout incarceration and before release. Our results highlight the complexity of working with incarcerated populations. After most of the sessions, we observed some information sharing between the intervention and the control groups on what they did in their respective sessions. Due to high attrition, the power to detect effects was limited. Yet, results suggest that the intervention is feasible and acceptable with an increased sample size and refined recruitment procedure. NCT05510531, 8/19/2022, retrospectively, registered.

The associations between social determinants of health, mental health, substance-use and recidivism: a ten-year retrospective cohort analysis of women who completed the connections programme in Australia

BACKGROUND

Women with substance-use issues are overrepresented in prison. Research on women's recidivism often focuses on offending behaviour rather than the health and social circumstances women are experiencing when reimprisonment occurs. This study examines the relationship between social determinants of health (SDOH), mental health, substance-use and recidivism among women exiting prison with histories of substance-use.

METHODS

A retrospective cohort study of women exiting prison who completed the transitional support programme "Connections" between 2008 and 2018. Recidivism was measured up to two years post-release. Women's support needs were measured at baseline (4 weeks pre-release) and follow-up (four weeks post-release). Ongoing needs in relation to well-established SDOH were calculated if: (1) at baseline women were identified as having a re-entry need with housing, employment, finances, education, domestic violence, child-custody and social support and (2) at follow-up women reported still needing help in that area. Women's self-reported substance-use and mental health since release were captured at follow-up. Descriptive statistics were calculated for all measures. Associations between SDOH, mental health, substance-use and recidivism were estimated by multiple logistic regression, adjusting for potential confounders. We also evaluated the mediating effects of mental health on the relationship between SDOH and substance-use.

RESULTS

Substance-use was associated with increased odds of recidivism (adjusted odds ratio (AOR) 1.8, 95% confidence interval (CI) 1.1-2.9; p = 0.02). Poor mental health (AOR 2.9, 95% CI 1.9-4.6; p =  < 0.01), ongoing social support (AOR 3.0, 95% CI 1.9-5.0; p =  < 0.01), child-custody (AOR 1.9, 95% CI 1.0-3.3 p = 0.04), financial (AOR 2.0, 95% CI 1.3-3.2; p =  < 0.01) and housing (AOR 1.8, 95% CI 1.1-2.9; p = 0.02) needs were individually associated with increased odds of substance-use. Mediation analysis found mental health fully mediated the effects of ongoing housing (beta efficiency (b) = - 033, standard error (SE) 0.01; p = 0.05), financial (b = 0.15, SE 0.07; p = 0.05), child-custody (b = 0.18, SE 0.01; p = 0.05) and social support (b = 0.36, SE 0.1; p = 0.05) needs onto substance-use, and partially mediated the effects of domestic violence (b = 0.57, SE 0.23; p = 0.05) onto substance-use.

CONCLUSION

This study underscores the critical importance of addressing the interplay between SDOH, mental health, substance-use and recidivism. An approach that targets SDOH holds the potential for reducing mental distress and substance-use, and related recidivism.

"People say you're going home, but I don't have a home": Housing After Prison

Recidivism in Australia is high, especially in the Australian Capital Territory (ACT). While high-quality stable housing has been shown to reduce recidivism, people released from prison face many barriers in obtaining housing. This paper reports on a qualitative study exploring the housing experiences of 11 people released from prison in the ACT. Participants felt the importance of housing for reintegration and avoiding recidivism, but reported many challenges, including issues relating to lack of pre-release planning, income and employment, drug use, difficulties and delays with accessing social housing, and complying with parole or bail conditions. We recommend increased investment in services to assist people in prison with organizing housing before release. Furthermore, as housing is a foundational need for reintegration and drug use is high among the prison population in the ACT, Housing First initiatives may be the most appropriate model for providing accommodation and reducing recidivism.

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.

Addressing the complex substance use and mental health needs of people leaving prison: Insights from developing a national inventory of services in Canada

Internationally, transitions from prison to the community are often precarious experiences for people who are living with substance use and mental health concerns. In Canada, a continuing opioid overdose crisis and overlapping challenges related to the COVID-19 pandemic have generated urgency for scaling up community-based services that can meet the complex substance use and mental health needs of people leaving prison. In this commentary, we reflect on our experience with and knowledge gained by developing a national inventory of substance use and mental health services for criminal justice-involved persons who are re-entering the community. We learned that there is a scarcity of such community-based services specific to criminal justice-involved populations and a glaring lack of information about culturally safe and appropriate supports. Stakeholders from organisations across Canada identified that communities need a comprehensive array of low-barrier services, inclusive of harm reduction and substance use treatment services, to meet the diverse needs of people leaving prison. We recommend building greater investment in and awareness of community-driven, local programs, as well as enhancing efforts to engage people with lived and living experience in service design and provision. We also briefly describe a few programs to highlight examples of how to operationalise the themes that we observed to emerge while developing a national inventory of community-based substance use and mental health services for criminal justice-involved persons.

Post-Traumatic Bio-Behavioral Rehabilitation of Adult Female Victims

Objective

To determine if low resting basal AM cortisol and flat diurnal cortisol slope that has been reported in female abuse victims, which is dysregulated in the same way in female violent perpetrators, could be corrected and if healthier diurnal cortisol patterns are associated with less aggression in adult female victims.

Design and Methods

A non-experimental, naturalistic study evaluated if bio-behavioral rehabilitation could occur for females living in a Delaware homeless mission and participating in their programs. Basal salivary cortisol (AM, PM & slope), aggression, neurological conditions, general health, alcohol use, having been a victim of abuse, religion, spirituality and forgiveness were evaluated over one month between 2018 and 2019.

Results

T tests revealed significant improvement in mean cortisol (AM, PM & slope), aggression, emotional/ behavioral dyscontrol, and health over one month while participating in the mission’s programs. Paired t-tests however were only significant for aggression and health. Healthier cortisol was significantly correlated with greater time since last alcohol, greater time since last abuse, less aggression, better health and greater religion, spirituality and forgiveness.

Conclusion

Community programs could be cost effective methods of post-traumatic bio-behavioral rehabilitation. Forgiveness may play a critical role for abuse victims. A larger sample and more settings are needed, although these findings are promising.

Transitioning into the Community: Perceptions of Barriers and Facilitators Experienced By Formerly Incarcerated, Homeless Women During Reentry-A Qualitative Study

Formerly incarcerated, homeless women on parole or probation experience individual-and structural-level barriers and facilitators as they prepare to transition into the community during reentry. A qualitative study was undertaken using focus group methods with formerly incarcerated, currently homeless women (N = 18, M_age = 37.67, SD 10.68, 23-53 years of age) exiting jail or prison. Major themes which emerged included the following: (1) access to resources-barriers and facilitators during community transition, (2) familial reconciliation and parenting during community transition, and (3) trauma and self-care support during community transition. These findings suggest a need to develop multi-level interventions at the individual, program and institutional/societal level with a gender-sensitive lens for women who are transitioning to community reentry. It is hoped that providing such resources will reduce the likelihood of homelessness and reincarceration.

Healthcare beliefs, health information seeking, and healthcare setting preferences among women who inject drugs by community supervision status

OBJECTIVE

Women on community supervision who inject drugs have significant unmet healthcare needs. However, it remains unclear how the intersection of community supervision and injection drug use influences healthcare experiences and service setting preferences. The present study examines whether the intersection of community supervision and injection drug use is associated with differences in women's healthcare beliefs, healthcare experiences, and service setting preferences.

METHODS

A secondary analysis was conducted on a previously collected sample of women who inject drugs recruited from a syringe exchange and social service organization for a cross-sectional survey. Participants (N = 64) were mostly White (75%), and more than a quarter were currently on probation or parole (26%).

RESULTS

Independent samples t-tests and chi-square tests revealed no significant differences on sociodemographic variables by community supervision status. There were no significant differences by community supervision status across seven indicators of healthcare confidence (ps > .05). However, results revealed significant differences in past experiences and beliefs about healthcare, health information seeking, and healthcare setting preferences by community supervision status (ps < .05), where women on community supervision less frequently sought health information and medical care outside of emergency departments.

CONCLUSIONS

Findings provide preliminary evidence about differences in the healthcare experiences and setting preferences of women who inject drugs on community supervision.

Contexts and mechanisms that promote access to healthcare for populations experiencing homelessness: a realist review

Objective

The objective of this study was to identify and understand the health system contexts and mechanisms that allow for homeless populations to access appropriate healthcare when needed.

Design

A realist review.

Data sources

Ovid MEDLINE, embase.com, CINAHL, ASSIA and grey literature until April 2019.

Eligibility criteria for selecting studies

The purpose of the review was to identify health system patterns which enable access to healthcare for people who experience homelessness. Peer-reviewed articles were identified through a systematic search, grey literature search, citation tracking and expert recommendations. Studies meeting the inclusion criteria were assessed for rigour and relevance and coded to identify data relating to contexts, mechanisms and/or outcomes.

Analysis

Inductive and deductive coding was used to generate context–mechanism–outcome configurations, which were refined and then used to build several iterations of the overarching programme theory.

Results

Systematic searching identified 330 review articles, of which 24 were included. An additional 11 grey literature and primary sources were identified through citation tracking and expert recommendation. Additional purposive searching of grey literature yielded 50 records, of which 12 were included, for a total of 47 included sources. The analysis found that healthcare access for populations experiencing homelessness is improved when services are coordinated and delivered in a way that is organised around the person with a high degree of flexibility and a culture that rejects stigma, generating trusting relationships between patients and staff/practitioners. Health systems should provide long-term, dependable funding for services to ensure sustainability and staff retention.

Conclusions

With homelessness on the rise internationally, healthcare systems should focus on high-level factors such as funding stability, building inclusive cultures and setting goals which encourage and support staff to provide flexible, timely and connected services to improve access.

Making healthcare accessible for single adults with complex needs experiencing long-term homelessness: A realist evaluation protocol

Background: Over the last several years, homelessness has increased in Ireland and across Europe. Rates have recently declined since the coronavirus disease 2019 (COVID-19) pandemic, but it is unclear whether emergency housing measures will remain in place permanently. Populations experiencing long-term homelessness face a higher burden of multi-morbidity at an earlier age than housed populations and have poorer health outcomes. However, this population also has more difficulty accessing appropriate health services. A realist review by the authors found that important health system contexts which impact access are resourcing, training, funding cycles, health system fragmentation, health system goals, how care is organised, culture, leadership and flexibility of care delivery. Using a realist evaluation approach, this research will explore and refine key system-level factors, highlighted in our realist review, in a local health care system. Aim: The aim of this study is to understand how funding procedures and health system performance management impact service settings, staff, providers and their ability to make services accessible to populations experiencing homelessness. Methods: A realist evaluation will be undertaken to explain how funding and health system performance management impact healthcare accessibility for populations experiencing homelessness. Data will be collected using qualitative and realist interview techniques and focus group methodology. Secondary data such as policy documents and budgets will utilised. The analysis will follow Pawson and Tilley's iterative phases starting with building an Initial programme theory, then data collection, data analysis, synthesis and finally building a refined programme theory. Conclusion: Building on a realist review conducted by the same research team, this study will further test and refine findings that explain how health system factors impact healthcare accessibility for populations experiencing homelessness. The study has the potential to inform policy makers, health planners and managers of contextual factors that can be modified to increase healthcare accessibility.

How accessible is healthcare for single adults experiencing long-term homelessness and complex needs? A realist evaluation protocol

Background: Over the last several years, homelessness has increased in Ireland and across Europe. Rates have recently declined since the coronavirus disease 2019 (COVID-19) pandemic, but it is unclear whether emergency housing measures will remain in place permanently. Populations experiencing long-term homelessness face a higher burden of multi-morbidity at an earlier age than housed populations and have poorer health outcomes. However, this population also has more difficulty accessing appropriate health services. A realist review by the authors found that important health system contexts which impact access are resourcing, training, funding cycles, health system fragmentation, health system goals, how care is organised, culture, leadership and flexibility of care delivery. Using a realist evaluation approach, this research will explore and refine key system-level factors, highlighted in our realist review, in a local health care system. Aim: The aim of this study is to understand how funding procedures and health system performance management impact service settings, staff, providers and their ability to make services accessible to populations experiencing homelessness. Methods: A realist evaluation will be undertaken to explain how funding and health system performance management impact healthcare accessibility for populations experiencing homelessness. Data will be collected using qualitative and realist interview techniques and focus group methodology. Secondary data such as policy documents and budgets will utilised. The analysis will follow Pawson and Tilley's iterative phases starting with building an Initial programme theory, then data collection, data analysis, synthesis and finally building a refined programme theory. Conclusion: Building on a realist review conducted by the same research team, this study will further test and refine findings that explain how health system factors impact healthcare accessibility for populations experiencing homelessness. The study has the potential to inform policy makers, health planners and managers of contextual factors that can be modified to increase healthcare accessibility.

Correlates of Posttraumatic Stress Symptoms among Formerly Incarcerated, Homeless Women

Posttraumatic stress symptoms are a pressing issue among women experiencing incarceration and homelessness. Baseline data were collected among formerly incarcerated homeless women (N = 130) who were on average 38.9 (SD = 11.36, range 19-64) years of age and recruited into a pilot randomized control trial (RCT) intervention program. A logistic regression was used to assess correlates of PTSD symptoms. The majority of the sample self-reported witnessing violence (85%) and had moderate PTSD symptoms (M = 1.61, SD = 1.62, range: 0-4). No past month drug use (p = 0.006), higher anger scores (p = 0.002), greater emotional support (p = 0.009), and psychological frailty (p = 0.02) were significantly associated with higher odds of PTSD symptoms. Moreover, women who experienced minor family conflicts had lower odds of PTSD symptoms relative to those that had family conflicts most of the time (p = 0.02). Similarly, controlling for all other variables, women who had a higher positive social interaction score also had lower odds of PTSD symptoms (p = 0.006). These findings are a call to action for academicians, service providers, and health practitioners to develop an intervention which integrates comprehensive PTSD screening, and discussion of ways to build coping skills, relationships with family and social networks, and utilizes a trauma-informed approach during reentry.

Expectations and Experiences of Women Imprisoned for Drug Offending and Returning to Communities in Thailand: Understanding Women’s Pathways Into, Through, and Post-Imprisonment

Thailand places a high priority on the gender-specific contexts out of which offending arises and the differential needs of women in the criminal justice system. Despite this, Thailand has the highest female incarceration rate in South East Asia and there has been substantial growth since the 1990s. This increase has been driven by punitive changes in drug law, criminal justice policy/practice which have disproportionately impacted women. As female representation in Thailand’s prisons grows, so does the number of women who return to communities. Thus, one of the challenges facing Thai society is the efficacious re-integration of growing numbers of formally incarcerated women. However, what is known about re-entry comes almost exclusively from studies of prisoners (usually men) returning home in western societies. Re-integration does not occur in a vacuum. Supporting women post-release necessitates knowledge of their pathways to, experiences of, and journeys out of prison. Utilising in-depth interviews with (n = 80) imprisoned/formally incarcerated women and focus groups with (n = 16) correctional staff, this paper reports findings from the first comprehensive study of women’s re-integration expectations and experiences in Thailand. Findings showed that women had multifaceted and intersectional needs which directed their pathways into, during, and out of prison.

What constitutes effective problematic substance use treatment from the perspective of people who are homeless? A systematic review and meta-ethnography

Background

People experiencing homelessness have higher rates of problematic substance use but difficulty engaging with treatment services. There is limited evidence regarding how problematic substance use treatment should be delivered for these individuals. Previous qualitative research has explored perceptions of effective treatment by people who are homeless, but these individual studies need to be synthesised to generate further practice-relevant insights from the perspective of this group.

Methods

Meta-ethnography was conducted to synthesise research reporting views on substance use treatment by people experiencing homelessness. Studies were identified through systematic searching of electronic databases (CINAHL; Criminal Justice Abstracts; Health Source; MEDLINE; PsycINFO; SocINDEX; Scopus; and Web of Science) and websites and were quality appraised. Original participant quotes and author interpretations were extracted and coded thematically. Concepts identified were compared to determine similarities and differences between studies. Findings were translated (reciprocally and refutationally) across studies, enabling development of an original over-arching line-of-argument and conceptual model.

Results

Twenty-three papers published since 2002 in three countries, involving 462 participants, were synthesised. Findings broadly related, through personal descriptions of, and views on, the particular intervention components considered effective to people experiencing homelessness. Participants of all types of interventions had a preference for harm reduction-oriented services. Participants considered treatment effective when it provided a facilitative service environment; compassionate and non-judgemental support; time; choices; and opportunities to (re)learn how to live. Interventions that were of longer duration and offered stability to service users were valued, especially by women. From the line-of-argument synthesis, a new model was developed highlighting critical components of effective substance use treatment from the service user’s perspective, including a service context of good relationships, with person-centred care and an understanding of the complexity of people’s lives.

Conclusion

This is the first meta-ethnography to examine the components of effective problematic substance use treatment from the perspective of those experiencing homelessness. Critical components of effective problematic substance use treatment are highlighted. The way in which services and treatment are delivered is more important than the type of treatment provided. Substance use interventions should address these components, including prioritising good relationships between staff and those using services, person-centred approaches, and a genuine understanding of individuals’ complex lives.

Narrative Inquiry Into Shelter-Seeking by Women With a History of Repeated Incarceration: Research and Nursing Practice Implications

Nurses who provide care in the community to women with a history of repeated incarceration may struggle to understand the full extent of the barriers faced by this population and as a result risk giving suboptimal care to an already underserved group. This narrative inquiry study of stories told by 10 women with histories of repeated incarceration fulfilled 2 purposes: to demonstrate how women's shelter-seeking stories exposed uniquely complex patterns of health opportunity and risk and to demonstrate how storytelling might serve as an informative mode of nursing health assessment for this population.

The role of the community health delivery system in the health and well-being of justice-involved women: a narrative review

BACKGROUND

Over seven million imprisoned and jailed women are released into the community each year and many are ill-equipped to meet the challenges of re-integration. Upon release into their community, women are faced with uncertain barriers and challenges using community services to improve their health and well-being and reuniting with families. Few studies have identified and described the barriers of the community health delivery system (CHDS)- a complex set of social, justice, and healthcare organizations that provide community services aimed to improve the health and well-being (i.e. safety, health, the success of integration, and life satisfaction) of justice-involved women. We conducted a narrative review of peer-reviewed and gray literature to identify and describe the CHDS and the CHDS service delivery.

RESULTS

Peer-reviewed and gray literature (n = 82) describing the CHDS organizations' missions, incentives, goals, and services were coded in three domains, justice, social, and healthcare, to examine their service delivery to justice-involved women and their efforts to improve the health and well-being of justice-involved women.

CONCLUSIONS

We found that the CHDS is fragmented, identified gaps in knowledge about the CHDS that serves justice-involved women, and offer recommendations to reduce fragmentation and integrate service delivery aimed to improve the health and well-being of justice-involved women.

Correlates of physical, psychological, and social frailty among formerly incarcerated, homeless women

Frailty is a deficit accumulation in physical, psychological and social domains. Correlates of frailty were explored among formerly incarcerated, homeless women (N = 130, Mage = 38.9). Significant correlates of physical frailty were age, years homeless, prior violence, witnessing less violence, drug dependence, PTSD symptoms and tangible support. Significant correlates of psychological frailty were age, years homeless, witnessed violence, jail time, divorced less, drug use/dependence, prison time, methamphetamine use, and bodily pain. Significant correlates of social frailty were drug use, emotional regulation, and daily alcohol use. Reentry interventions are needed for formerly incarcerated, homeless women who experience physical, psychological and social frailty.

Effectiveness of Dialectical Behavioral Therapy on Reduction of Recidivism Among Recently Incarcerated Homeless Women: A Pilot Study

The purpose of this pilot randomized controlled trial (RCT) was to compare the 6-month outcomes of a Dialectical Behavioral Therapy-Corrections Modified (DBT-CM) program versus a Health Promotion (HP) program on mitigating recidivism among 130 female parolees/probationers between baseline and 6-month follow-up. The effect of DBT-CM on reducing recidivism was greater among those who expressed a desire for help (risk ratio [RR] = 0.40; 95% confidence interval [CI] = [0.16, 1.00]; p = .050) and among homeless female ex-offenders (HFOs) who were younger (<50 years of age; RR = 0.46; 95% CI = [0.19, 1.11]; p = .085) and participants with Desire for Help score > 35 (Model 3; RR = 0.40; 95% CI = [0.16, 1.00]; p = .050). Findings from this pilot study suggest that the DBT-CM intervention may be effective in reducing reincarceration rates among some HFOs during reentry. Larger RCTs are needed to validate our findings.

Correlates of Treatment Readiness among Formerly Incarcerated Homeless Women

Treatment readiness is a key predictor of drug treatment completion, rearrest, and recidivism during community reentry; however, limited data exists among homeless, female ex-offenders (HFOs). The purpose of this study was to present baseline data from a randomized controlled trial of 130 HFOs who had been released from jail or prison. Over half (60.8%) of HFOs had a treatment readiness score of ≥ 40 (n = 79, μ = 40.2, SD = 8.72). Bivariate analyses revealed that methamphetamine use, psychological well-being, and high emotional support were positively associated with treatment readiness. On the other hand, depressive symptomology and depression/anxiety scores were negatively associated with the treatment readiness score. Multiple linear regression revealed that depressive symptomology was negatively associated with treatment readiness (β = -0.377; p = .001). Further analyses revealed that the effect of emotional support on treatment readiness was mediated by depressive symptomatology.

Achieving Drug and Alcohol Abstinence Among Recently Incarcerated Homeless Women: A Randomized Controlled Trial Comparing Dialectical Behavioral Therapy-Case Management With a Health Promotion Program

BACKGROUND

Homeless female ex-offenders (homeless female offenders) exiting jail and prison are at a critical juncture during reentry and transitioning into the community setting.

OBJECTIVE

The purpose of the study was to compare the effect of a dialectical behavioral therapy-case management (DBT-CM) program with a health promotion (HP) program on achieving drug and alcohol abstinence among female parolees/probationers residing in the community.

METHODS

We conducted a multicenter parallel randomized controlled trial with 130 female parolees/probationers (aged 19-64 years) residing in the community randomly assigned to either DBT-CM (n = 65) or HP (n = 65). The trial was conducted in four community-based partner sites in Los Angeles and Pomona, California, from February 2015 to November 2016. Treatment assignment was carried out using a computer-based urn randomization program. The primary outcome was drug and alcohol use abstinence at 6-month follow up.

RESULTS

Analysis was based on data from 116 participants with complete outcome data. Multivariable logistic regression revealed that the DBT-CM program remained an independent positive predictor of decrease in drug use among the DBT-CM participants at 6 months (p = .01) as compared with the HP program participants. Being non-White (p < .05) and having higher depressive symptom scores (p < .05) were associated with lower odds of drug use abstinence (i.e., increased the odds of drug use) at 6 months.

DISCUSSION

DBT-CM increased drug and alcohol abstinence at 6-month follow-up, compared to an HP program.

The Relationship Between Gambling Severity and Risk of Criminal Recidivism

Individuals involved with the criminal justice system have the highest prevalence of gambling disorder. Yet, this is an understudied area, especially in relation to postrelease functioning and recidivism risk. Participants (N = 100) were recruited from a local nonprofit organization and a federal probation office. Participants completed both self-report and interviewer-administered questionnaires assessing past-year and lifetime gambling behaviors and problems, legal history, health, and risk of recidivism. Past-year (8%) and lifetime (18%) rates of gambling disorder among the current sample are significantly greater than those of the general population and similar to rates found in incarcerated populations. Furthermore, 13% of individuals reported a direct relationship between their gambling and crime, and analyses revealed that increased gambling severity was a significant predictor of increased recidivism risk. Results suggest the need for screening and intervention efforts and call for policy reform among incarcerated and ex-offender populations.

Drug Use and Multiple Sex Partners Among Homeless Ex-Offenders: Secondary Findings From an Experimental Study

BACKGROUND

Transitioning into society after release from incarceration presents real challenges for male offenders; in California, up to 60% return to prison within 3 years after release. The risk for ongoing drug use and having sex with multiple partners is a significant challenge for ex-offenders preparing to enter the community.

OBJECTIVES

The aims are to describe drug use and sexual behavior (sex with multiple partners) prior to incarceration and 6 and 12 months after study enrollment using data obtained as part of a randomized controlled trial.

METHODS

This is a planned secondary analysis of data obtained as part of a randomized controlled trial designed to study the effects of intensive peer coaching and nurse case management, intensive peer coaching, and brief nurse counseling on hepatitis A and B vaccination adherence compared to a usual care control treatment that also included brief peer coaching and brief nurse counseling. Self-report data from subjects enrolled at one residential drug treatment facility in Los Angeles were captured at three time points: baseline and 6- and 12-month follow-up.

RESULTS

Findings showed substantive and significant reductions in drug use and engaging in sex with multiple partners 6 months after enrollment into the study compared to the baseline data, but results did not differ by study condition. At 12-month follow-up, drug use and sex with multiple partners increased but remained less than at baseline levels.

DISCUSSION

Sustaining reductions in drug use and engaging in sex with multiple partners remains a challenge after incarceration.

On the Frontlines: Perspectives of Providers Working With Homeless Women

Homeless service providers (HSPs) are on the frontlines of caring for the most vulnerable populations to help them navigate out of homelessness and access health and social services. The purpose of this qualitative study was to understand, from the perspectives of HSPs ( N = 19; age range, 27-58 years; SD = 10.37), their account and experiences in working with homeless women (HW), and opportunities for intervention development and integration. Five focus groups were conducted with HSPs in Central City East, Los Angeles. Five main themes emerged which included (a) seeking to establish a therapeutic relationship, (b) internal and external drivers of change, (c) navigating systems, (d) targeted outreach, and (e) program design recommendations. Within these themes, individual- and structural-level characteristics emerged. To better equip HW, HSPs' perspectives need to be considered in future interventions to aid women traverse homelessness.

The effect of incarceration on housing stability among homeless and vulnerably housed individuals in three Canadian cities: A prospective cohort study

OBJECTIVES

The objective of the study is to characterize the associations between a history of incarceration and subsequent housing stability over a two-year follow-up period among a sample of homeless and vulnerably housed individuals.

METHODS

The study was a prospective cohort study of homeless and vulnerably housed adults in three Canadian cities. Between 2009 and 2012, data were collected using structured, in-person interviews at baseline and two follow-up interviews. Generalized estimating equations were employed to determine the association between reported incarceration within the past 12 months and being housed during the subsequent year over a two-year follow-up period.

RESULTS

Baseline data were available for 1,189 homeless and vulnerably housed adults. Recent incarceration was reported by 337 (29%) individuals at baseline. In adjusted analyses, incarceration in the past 12 months was independently associated with a decreased likelihood of being housed during the subsequent year over the two-year follow-up period (adjusted odds ratio = 0.67, 95% confidence interval: 0.50-0.90).

CONCLUSION

Homeless and vulnerably housed individuals reporting recent incarceration were less likely to be housed over a two-year follow-up period. These findings highlight the importance of assisting individuals experiencing incarceration with securing stable housing during discharge and post-release planning.

Violent Crime in the Lives of Homeless Female Ex-Offenders

The cyclical pattern of violence in the lives of homeless female ex-offenders may precipitate ongoing substance use and recidivism; all of which have shown to be mounting public health issues affecting successful reentry. This paper, which analyzed baseline data from a longitudinal study of 126 female ex-offenders in Los Angeles and Pomona, California, highlighted the factors found to be associated with violent crime among homeless female ex-offenders. A multiple logistic regression model for whether or not the last conviction was for a violent offense indicated that poor housing (p = .011) and self-reported anger or hostility (p < .001) were significant correlates. An ordinal regression model for the number of violent offenses also indicated that affectionate support was associated with committing fewer number of violent crimes (p = .001), while positive social interactions (p = .007), and anger/hostility (p = .015) were associated with greater number of violent crimes. Implications for developing a comprehensive array of strategies that can mitigate the pattern of violence often seen in the lives of homeless female who have recently exited jails and prisons is discussed.

Risk Profiles of Women Experiencing Initial and Repeat Incarcerations: Implications for Prevention Programs

Incarcerated women experience myriad individual, interpersonal, and structural factors leading to arrest and rearrest. This study examined risk profiles of women experiencing initial and repeat incarcerations. The sample included 521 women recruited from two prisons in North Carolina and enrolled in a HIV/STD risk-reduction intervention trial. Variables included socio-demographics, structural/economic factors, sexual and substance use behaviors, STDs, victimization history, and depressive symptoms. Bivariate and multivariable analyses identified risk differences. Compared to women incarcerated for the first time, women with repeat incarcerations reported significantly greater economic instability, substance use and sexual risk behaviors, laboratory-confirmed STDs, and victimization during childhood and adulthood. Multivariable logistic regression found women with repeat incarcerations experienced greater unstable housing, injection drug use, crack cocaine use, concurrent sex partners, and childhood sexual victimization. Findings can inform the development of prevention programs by addressing economic instability, sexual risk, and substance use among women prisoners.

Mental Health Issues of Women After Release From Jail and Prison: A Systematic Review

The aim of this review article is to gain an understanding of the mental health issues of women released from jail or prison. Thirty-six studies were synthesized using the biopsychosocial model. Results indicate that released women's mental health issues include psychiatric diagnoses, psychological trauma, substance use disorders; access to psychological medications and services; and motherhood challenges, support, access to basic needs, and criminalized behaviors. Nurses can promote released women's mental health through pre-release assessment and treatment of mental health issues and ensuring access to post-release resources.  Future research should examine released women's mental health experiences.

Female Ex-Offender Perspectives on Drug Initiation, Relapse, and Desire to Remain Drug Free

Recently released homeless women residing in temporary residential drug treatment (RDT) programs are at a critical juncture in the process of recovery, transition, and reentry. The purpose of this study was to explore factors influencing initial use of drugs and relapse triggers among a sample of incarcerated women exiting jails and prisons, residing in an RDT program, and preparing for reentry into their communities. Among this population, relapse to drug use and recidivism are common. A qualitative study was conducted utilizing focus groups to understand the perspectives of formerly incarcerated, currently homeless women residing in an RDT program. Content analysis generated the development of three broad categories: (a) factors associated with first drug use, (b) factors involved in relapse, and (c) factors influencing desire to remain drug free. A discussion follows highlighting the importance of targeted interventions at RDT sites that integrate physical, psychological, and social needs to optimize reentry into communities. This includes a focus on building self-esteem and life skills and providing access to resources such as housing, employment, and healthcare.

Impact of an intervention for recently released homeless offenders on self-reported re-arrest at 6 and 12 months

A randomized controlled trial was conducted with 600 paroled men, homeless prior to incarceration, to assess varying levels of peer-coach and nurse-partnered interventions on re-arrest at 6 and 12 months. Findings revealed that positive predictors of re-arrest at 12 months included having received social support from drug users and non-drug users, as well as having used marijuana at least once a week prior to their most recent incarceration. In terms of protective factors, those who participated in a substance abuse program contract within a residential drug treatment program or spent 90 days or greater in a residential drug treatment program were less likely to have been re-arrested within 12 months.

Identifying Those Whom Health Promotion Hardly Reaches: A Systematic Review

To understand what circumstances lend groups to be recognized as hardly reached by health services and research, we systematically reviewed studies that identified their priority populations as hard to reach. We classified attributes of hardly reached groups into cultural/environmental, individual, and demographic domains. Of the 334 identified studies, 78.74% used attributes that were classified into the cultural/environmental, 74.85% the individual, and 50% the demographic domain to identify those hardly reached. Of all possible combinations of domains, the most common was the use of all three domains (28.74%). Overall, papers were more likely to use attributes to identify their hardly reached population that fell into more than one domain (74.85%) compared to only one domain (25.15%; χ(2), p < .0001). Through this review, we identified the attributes of those who have been identified as hardly reached in published research. No single attribute is used to identify those who are hardly reached. This reflects a socioecological perspective, emphasizing that both intrapersonal and external elements may cause interventions to fail to reach those intended. Moreover, the focus not on populations hardly reached but on the attributes of those hardly reached suggests objectives for interventions to reach them better.

Understanding Health Needs and Perspectives of Middle-Aged and Older Women Experiencing Homelessness

OBJECTIVES

Middle-aged and older homeless women have unique health and social service delivery needs; yet, limited research has been conducted in this area. The purpose of this study was to assess perspectives among prefrail and frail, middle-aged and older homeless women.

DESIGN AND SAMPLE

Focus group methodology was conducted to assess perspectives among these homeless women (N=20) aged 43 to 62.

MEASURES

Sociodemographic and frailty characteristics were assessed by structured instruments, along with mobility, assistive device use and falls.

RESULTS

The average age was 53.4; the majority of the sample was African-American (70%). In total, 60% reported living in a shelter for the last 30 days, while 20% were unsheltered. The majority of the sample reported walking independently (80%) and not using an assistive device (65%). Over one third (35%) fell in the last 30 days and 70% fell in the last year. Content analysis revealed several themes that included (1) health care needs and challenges experienced; (2) perspectives on sexual decision making; (3) employment difficulties; (4) existing support systems; and (5) development of future program planning.

CONCLUSIONS

Future research development and implications are discussed.

Unmet physical and mental healthcare needs among stimulant-using gay and bisexual homeless men

The aim of this study was to gain a greater understanding of predictors of the unmet physical and mental healthcare needs of homeless, stimulant-using, gay and bisexual (G/B) men. This study correlated baseline self-reported unmet physical and mental healthcare needs among stimulant-using homeless G/B men (n = 422, 18-46 years of age). A structured questionnaire was administered at baseline and data were collected from October 2009 to January 2013. The study was approved by the University of California Human Subjects' Protection committee and the Friends Research Institute Human Research Protection Committee. Logistic regression revealed that those who self-reported ever being married, being in fair or poor health and in moderate-to-very severe pain, were more likely to experience unmet needs for physical health care. In terms of unmet mental health needs, those who self-reported moderate-to-very severe pain and/or those reporting having sex while high, were more likely to report unmet needs for mental health care. In contrast, those reporting receiving social support from others were less likely to have an unmet mental healthcare need. Research implications are discussed as they relate to access to healthcare needs among this vulnerable population.

Development of a frailty framework among vulnerable populations

Frailty is a public health issue that is experienced by homeless and other vulnerable populations; to date, a frailty framework has not been proposed to guide researchers who study hard-to-reach populations. The Frailty Framework among Vulnerable Populations has been developed from empirical research and consultation with frailty experts in an effort to characterize antecedents, that is, situational, health-related, behavioral, resource, biological, and environmental factors that contribute to physical, psychological, and social frailty domains and impact adverse outcomes. As vulnerable populations continue to age, a greater understanding of frailty will enable the development of nursing interventions.