Health-related factors predict return to custody in a large cohort of ex-prisoners: new approaches to predicting re-incarceration

Data linkage studies of primary care utilisation after release from prison: a scoping review

BACKGROUND

Primary care plays a central role in most, if not all, health care systems including the care of vulnerable populations such as people who have been incarcerated. Studies linking incarceration records to health care data can improve understanding about health care access following release from prison. This review maps evidence from data-linkage studies about primary care use after prison release.

METHODS

The framework by Arksey and O'Malley and guidance by the Joanna Briggs Institute (JBI) were used in this review. This scoping review followed methods published in a study protocol. Searches were performed (January 2012-March 2023) in MEDLINE, EMBASE and Web of Science Core Collection using key-terms relating to two areas: (i) people who have been incarcerated and (ii) primary care. Using eligibility criteria, two authors independently screened publication titles and abstracts (step 1), and subsequently, screened full text publications (step 2). Discrepancies were resolved with a third author. Two authors independently charted data from included publications. Findings were mapped by methodology, key findings and gaps in research.

RESULTS

The database searches generated 1,050 publications which were screened by title and abstract. Following this, publications were fully screened (n = 63 reviewer 1 and n = 87 reviewer 2), leading to the inclusion of 17 publications. Among the included studies, primary care use after prison release was variable. Early contact with primary care services after prison release (e.g. first month) was positively associated with an increased health service use, but an investigation found that a large proportion of individuals did not access primary care during the first month. The quality of care was found to be largely inadequate (measured continuity of care) for moderate multimorbidity. There were lower levels of colorectal and breast cancer screening among people released from custody. The review identified studies of enhanced primary care programmes for individuals following release from prison, with studies reporting a reduction in reincarceration and criminal justice system costs.

CONCLUSIONS

This review has suggested mixed evidence regarding primary care use after prison release and has highlighted challenges and areas of suboptimal care. Further research has been discussed in relation to the scoping review findings.

Immigrant background, incarceration history and recidivism among adults assessed for illicit substance use severity: Findings from a Swedish registry study

BACKGROUND

In Sweden, as in other countries, individuals with immigrant backgrounds are disproportionately represented within the incarcerated population. This study examined the association between immigrant background and future incarceration for individuals assessed for illicit substance use severity, while considering their prior incarceration history.

METHODS

Using data from Swedish Addiction Severity Index (ASI) assessments linked to register data from Statistics Sweden, we employed Zero-Inflated Negative Binomial (ZINB) regression models to analyse differences in incarceration histories within five years before and after ASI assessments based on immigrant backgrounds. Additionally, Cox proportional-hazard models were used to assess the likelihood of post-assessment incarceration among these groups.

RESULTS

Immigrant background was positively associated with pre- and post-assessment incarceration. First- and second-generation immigrants from the Global South had longer periods of incarceration in the five years before assessments compared to native Swedes. Post-assessment, first-generation immigrants showed longer periods of incarceration. Survival analyses supported these findings, indicating a higher risk of prolonged post-assessment incarceration among all immigrant groups, particularly first-generation immigrants from the Global South.

CONCLUSION

Among individuals assessed for illicit drug use within Swedish municipalities, those with immigrant backgrounds faced higher incarceration risks, even after controlling for substance use severity and prior incarceration. Tailored interventions and support systems are vital to prevent re-entry into the criminal justice system. Timely actions can break re-offending cycles, redirecting paths away from reoffending and towards legal reintegration, thereby reducing incarceration and recidivism rates.

People in community corrections are a population with unmet need for viral hepatitis care

To reach World Health Organization elimination targets for hepatitis C, different strategies are needed to reach people who have not yet been diagnosed and treated. In the context of declining treatment initiation rates, innovation in service design and delivery is necessary: testing and treatment needs to be offered to people in non-traditional settings. The community corrections (probation and parole) population is larger than the prison population, which has high prevalence of hepatitis C and-in some countries-established diagnosis and treatment programs. In this Viewpoint we identify a gap in hepatitis C care for people under community correctional supervision, a group who have either never been imprisoned or need continuity of healthcare provided in prison. We propose that offering hepatitis C screening and treatment would benefit this population, and accelerate progress to hepatitis C elimination.

Drug use and re-imprisonment: A prospective study of the Norwegian Offender Mental Health and Addiction (NorMA) cohort

Background

Re-imprisonments are common among people in prison who use drugs. This study aims to describe sociodemographic factors, mental health and level of pre-prison substance use in a cohort of people in prison, and to investigate re-imprisonment during follow-up according to their level of pre-prison drug use.

Methods

This was a prospective study using baseline data from the Norwegian Offender Mental Health and Addiction (NorMA) cohort (n = 733) recruited in 2013-2014 linked to data from the Norwegian Prison Registry and the Norwegian Cause of Death Registry. Self-reported drug use before imprisonment was measured at baseline using the Drug Use Disorder Identification Test (DUDIT). The outcome of interest was re-imprisonment examined using Cox regression. We excluded 32 persons because they were not released before the study ended. The study sample included 701 persons, with a total time-at-risk of 2479 person-years.

Results

Almost half of the study sample reported high-risk drug use before imprisonment (DUDIT score >24). During the study period, 43% (n = 267) were re-imprisoned. People with high-risk use had a hazard ratio (HR) of 4.20 (95% CI: 2.95-5.97) of re-imprisonment compared with people with low-risk use (DUDIT score <6). Older age and more education than primary school were associated with a reduced risk of re-imprisonment.

Conclusion

Compared with low-risk use, high-risk drug use is highly prevalent among people in prison and is associated with higher rates of re-imprisonment. This highlights the need for screening and treatment of drug use disorders among people in prisons.

Beyond "pains" and "gains": untangling the health consequences of probation

BACKGROUND

Research on the health consequences of criminal legal system contact has increasingly looked beyond imprisonment to understand how more routine forms of surveillance and punishment shape wellbeing. One of these sites is probation, the largest form of supervision in the U.S. Drawing on an interview study with 162 adults on probation in Hennepin County, MN, in 2019, we map how adults on probation understand the consequences of supervision for their health and how these self-reported health changes correlate with individual, social, and structural circumstances.

RESULTS

Roughly half of participants described their health as having improved since starting probation, while the remainder were split between no change and worsened health. Examining both closed-ended survey questions and open-ended interview prompts, we find that the "gains" of supervision were correlated with substance use treatment (often mandated), reduced drug and alcohol use, increased housing and food security, and perceptions of support from their probation officer. However, these potentially health-promoting mechanisms were attenuated for many participants by the significant "pains" of supervision, including the threat of revocation, which sometimes impacted mental health. In addition, participants in the most precarious circumstances were often unable to meet the demands of supervision, resulting in further punishment.

CONCLUSIONS

Moving beyond the "pains" and "gains" framework, we argue that this analysis provides empirical evidence for the importance of moving social services outside of punishing criminal legal system interventions. People with criminal legal contact often come from deeply marginalized socio-economic contexts and are then expected to meet the rigorous demands of supervision with little state aid for redressing structural barriers. Access to essential services, including healthcare, food, and housing, without the threat of further criminal legal sanctions, can better prevent and respond to many of the behaviors that are currently criminalized in the U.S. legal system, including substance use.

Association between contact with mental health and substance use services and reincarceration after release from prison

Objective

People released from prison who experience mental health and substance use problems are at high risk of reincarceration. This study aimed to examine the association between contact with mental health and substance use treatment services, and reincarceration, among adults released from prison.

Methods

Pre-release survey data from 1,115 adults released from prisons in Queensland, Australia were linked with administrative health and correctional records covering a median of 787 days post-release. We constructed marginal structural Cox proportional hazards models, adjusting for pre-release variables and time-varying indicators of emergent mental health and substance use problems, to examine the association between contact with mental health and substance use treatment services, and reincarceration.

Results

The adjusted hazard ratio (AHR) for reincarceration associated with mental health service contact was 1.76 (95%CI 1.23,2.51). Among those not on parole following release, the AHR for reincarceration associated with substance use treatment service contact was 3.16 (95%CI 2.09,4.77); we found no evidence for an association among those who were released on parole (AHR = 1.07; 95%CI 0.80,1.43).

Conclusions

Although we cannot eliminate the possibility of residual confounding, our findings suggest that infrequent or unsustained contact with community-based mental health and substance use treatment services is not protective against reincarceration, and may even be iatrogenic. Increased investment in high-quality and timely behavioural health services for people released from prison may simultaneously improve health outcomes, and reduce reincarceration.

Is There a Temporal Relationship between COVID-19 Infections among Prison Staff, Incarcerated Persons and the Larger Community in the United States?

Background: Our objective was to examine the temporal relationship between COVID-19 infections among prison staff, incarcerated individuals, and the general population in the county where the prison is located among federal prisons in the United States. Methods: We employed population-standardized regressions with fixed effects for prisons to predict the number of active cases of COVID-19 among incarcerated persons using data from the Federal Bureau of Prisons (BOP) for the months of March to December in 2020 for 63 prisons. Results: There is a significant relationship between the COVID-19 prevalence among staff, and through them, the larger community, and COVID-19 prevalence among incarcerated persons in the US federal prison system. When staff rates are low or at zero, COVID-19 incidence in the larger community continues to have an association with COVID-19 prevalence among incarcerated persons, suggesting possible pre-symptomatic and asymptomatic transmission by staff. Masking policies slightly reduced COVID-19 prevalence among incarcerated persons, though the association between infections among staff, the community, and incarcerated persons remained significant and strong. Conclusion: The relationship between COVID-19 infections among staff and incarcerated persons shows that staff is vital to infection control, and correctional administrators should also focus infection containment efforts on staff, in addition to incarcerated persons.

Characteristics and risk of incarceration among "hard-to-reach" people who use drugs: A five-year prospective cohort study combining self-reports and registry data

BACKGROUND

Incarcerations are associated with an increased risk of morbidity and mortality among people who use drugs (PWUD). In a sample of 884 PWUD, we examine and estimate the risk of incarcerations (i.e., number, duration, and most serious offense).

METHODS

In this prospective cohort study, PWUD were recruited from street- and low-threshold services in seven Norwegian cities in 2013 (Sept-Nov), and followed through the Correctional Service Registry until 20.12.2018. The risk of incarceration during follow-up was examined with multivariable logistic (no incarceration vs. at least one) and multinomial regression models ("no incarcerations", vs. "1″, "≥2″), while accounting for gender, age, homelessness/shelter use, opioid substitution treatment, illegal income sources, injecting behaviours, previous incarcerations, and recruitment city.

RESULTS

During follow-up, there were in total 662 incarceration episodes, and 44.7% of the participants were incarcerated at least once. Overall, 37.5% of those incarcerated had at least one episode due to a drug offense. The average incarceration duration was 65.2 days with 3.5% of the episodes lasting ≥one year. Gender (male), homelessness/shelter use, illegal income sources, injecting stimulants, and previous incarcerations increased the odds of incarceration, while older age decreased the odds. Gender (male), younger age, self-reported theft or theft and dealing, injecting stimulants or heroin and stimulants and previous incarcerations increased the risk of multiple incarcerations.

CONCLUSION

In a five-year prospective study of PWUD, incarcerations were common, and short-term sentences and recidivism were the norm. This is of concern as incarcerations add to an already elevated morbidity and mortality risk in this population.

Hearing and justice: The link between hearing impairment in early childhood and youth offending in Aboriginal children living in remote communities of the Northern Territory, Australia

BACKGROUND

High prevalence of chronic middle ear disease has persisted in Australian Aboriginal children, and the related hearing impairment (HI) has been implicated in a range of social outcomes. This study investigated the association between HI in early childhood and youth offending.

METHOD

This was a retrospective cohort study of 1533 Aboriginal children (born between 1996 and 2001) living in remote Northern Territory communities. The study used linked individual-level information from health, education, child protection and youth justice services. The outcome variable was a youth being "found guilty of an offence". The key explanatory variable, hearing impairment, was based on audiometric assessment. Other variables were: child maltreatment notifications, Year 7 school enrolment by mother, Year 7 school attendance and community 'fixed- effects'. The Cox proportional hazards model was used to estimate the association between HI and youth offending; and the Royston R2 measure to estimate the separate contributions of risk factors to youth offending.

RESULTS

The proportion of hearing loss was high in children with records of offence (boys: 55.6%, girls: 36.7%) and those without (boys: 46.1%; girls: 49.0%). In univariate analysis, a higher risk of offending was found among boys with moderate or worse HI (HR: 1.77 [95% CI: 1.05-2.98]) and mild HI (HR: 1.54 [95% CI:1.06-2.23]). This association was attenuated in multivariable analysis (moderate HI, HR: 1.43 [95% CI:0.78-2.62]; mild HI, HR: 1.37 [95% CI: 0.83-2.26]). No evidence for an association was found in girls. HI contributed 3.2% and 6.5% of variation in offending among boys and girls respectively. Factors contributing greater variance included: community 'fixed-effects' (boys: 14.6%, girls: 36.5%), child maltreatment notification (boys: 14.2%, girls: 23.9%) and year 7 school attendance (boys: 7.9%; girls 12.1%). Enrolment by mother explained substantial variation for girls (25.4%) but not boys (0.2%).

CONCLUSION

There was evidence, in univariate analysis, for an association between HI and youth offending for boys however this association was not evident after controlling for other factors. Our findings highlight a range of risk factors that underpin the pathway to youth-offending, demonstrating the urgent need for interagency collaboration to meet the complex needs of vulnerable children in the Northern Territory.

Emergency health service contact and reincarceration after release from prison: A prospective cohort study

BACKGROUND

Adults released from prison often have complex health needs. They are at high risk of poor health outcomes and reincarceration, with health service use unlikely to be planned.

AIMS/HYPOTHESES

To determine the incidence of emergency health service (EHS) use, ambulance attendance and/or emergency department presentation, among 1,181 adults released from Australian prisons. We hypothesised that EHS contact would be associated with increased reincarceration risk.

METHODS

Baseline surveys were conducted within 6 weeks before release. Postrelease EHS contacts and reincarceration were identified through prospective data linkage. For each participant, EHS contacts within a 24-hour period were combined to make an episode. We used Cox proportional hazards regression to examine the relationship between EHS episodes and reincarceration, controlling for covariates.

RESULTS

More than half (53.3%) of participants had at least one EHS contact over a median of 25.6-month follow-up. In adjusted analyses, compared to those with no EHS contacts, the hazard of reincarceration was greater for participants who had one to three EHS episodes (hazard ratio [HR] = 1.84; 95% confidence interval [CI] [1.48, 2.29]) or four or more (HR = 2.35; 95% CI [1.67, 3.29]).

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Emergency department attendance by people with a history of imprisonment may be indicative of wider decompensation. Improved management of such patients may improve health outcomes and have collateral benefits for reducing reincarceration.

Injecting drug use is an independent risk factor for reincarceration after release from prison: A prospective cohort study

INTRODUCTION AND AIMS

Once involved in the criminal justice system, people who inject drugs (PWID) have a high probability of multiple system encounters. Imprisonment typically fails to rehabilitate PWID, who upon return to the community are at considerable risk of returning to injecting drug use (IDU) and poor health and social outcomes. We examined the effect of IDU resumption, and a suite of other sociodemographic, criminogenic, health and behavioural indicators, on the timing of reincarceration among adults with a history of IDU following release from prison.

DESIGN AND METHODS

Structured interviews were conducted with 561 PWID in Queensland, Australia prior to release from prison and approximately 1, 3 and 6 months post-release. Data were linked prospectively with correctional records and the National Death Index. Data collected at multiple time-points were treated as time-varying covariates. Kaplan-Meier survival estimates and Cox proportional hazards models were used to estimate the rate and hazards of reincarceration.

RESULTS

Sixty-eight percent of participants (n = 350) were reincarcerated over a combined observation time of 1043.5 years, representing a rate of 33.5 per 100 person-years (95% confidence interval [CI] 30.2-37.2). Time-invariant predictors of reincarceration in PWID were: male gender (adjusted hazard ratio [AHR] = 1.62, 95% CI 1.19-2.21), older age at release (AHR = 0.97, 95% CI 0.95-1.00), previous adult (AHR = 2.00, 95% CI 1.41-2.84) or juvenile (AHR = 1.78, 95% CI 1.27-2.49) imprisonment, shorter imprisonment (≤90 days vs. >365 days, AHR = 2.09, 95% CI 1.30-3.34), release on parole (AHR = 2.29, 95% CI 1.82-2.88) and drug-related sentence (AHR = 1.84, 95% CI 1.34-2.53). Time-varying predictors included resumption of IDU (AHR = 2.04, 95% CI 1.60-2.61), unemployment (AHR = 1.53, 95% CI 1.07-2.19) and low perceived social support (AHR = 1.41, 95% CI 1.05-1.90). Very-high psychological distress at the most recent interview was protective against reincarceration (AHR = 0.65, 95% CI 0.44-0.95).

DISCUSSION AND CONCLUSIONS

Efforts to prevent resumption of IDU and address disadvantage, social inclusion and health service access in ex-prisoners through the scale-up and integration of prison-based and post-release interventions are likely to reap both public health and criminal justice benefits.

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

The world prison population is growing at a rate that exceeds the rate of population growth. This issue of Epidemiologic Reviews comprises articles in which researchers summarize what is known about some of the key health issues facing people in prison, particularly in relation to human immunodeficiency virus and other blood-borne viral infections. A key recurring theme is that addressing the health needs of people in prison is important to reducing health inequalities at the population level—that prisoner health is public health. The reviews also highlight some critical evidence gaps, notably the lack of evidence from low- and middle-income countries, and the limited number of longitudinal studies in which health behaviors, health outcomes, or health service experiences after release from prison are documented. Despite growing evidence of the poor health of detained adolescents, none of the included reviews considered this population. Further research on the health of young people who cycle through juvenile detention should be a priority. Despite a rapidly growing literature on the health of people who experience incarceration, some critical health issues remain poorly understood, and there has been insufficient attention devoted to co-occurring health conditions and the consequent need for coordinated care. Key populations in custodial settings remain understudied, limiting capacity to develop targeted, evidence-based responses to their health needs. The quality of many studies is suboptimal, and although rigorous, independent research in correctional settings can be challenging, it is not impossible and is critical to laying the groundwork for evidence-based reform.

Balancing the Rights to Protection and Participation: A Call for Expanded Access to Ethically Conducted Correctional Health Research

Incarcerated individuals, over 95% of whom are eventually released, experience high burdens of chronic disease and behavioral health and social risk factors. Understanding the health needs of this population is critical to ensuring that general medicine physicians in prisons and in the community are adequately prepared to meet those needs. However, people in prison are significantly underrepresented in health research. In response to historical exploitation of prisoners in medical experimentation, federal guidelines appropriately require additional oversight for, and limit the scope of, research in prisons. Yet, according to a 2006 Institute of Medicine report, these requirements have produced inconsistent local regulations that often limit opportunities for incarcerated individuals to participate in research, and can slow the development of innovative medical interventions to improve their health. In this article, we describe the historical context surrounding regulations on research involving individuals in prison, the harms that can arise from excessive limitations to research in such settings, and the benefits of greater access to ethically conducted research in prison. We conclude with recommended actions that can be taken by general medicine researchers, correctional leaders, and policymakers to achieve consistent access to health research for incarcerated populations.

Student nurses' perceptions of clinical placements in Australian Prison Health Services: A mixed methods study

Increasing demands for clinical placements have forced tertiary institutions to look for alternative placements for third year nursing students. While Prison Health Services provide an opportunity for nursing students to engage in care of offender populations with significant chronic illnesses, there has been little evaluation of such placements. Third year undergraduate nurses (18/46) participated in a mixed methods study to provide evidence-based research on students' perceptions of clinical placements in Prison Health Services. Quantitative and qualitative data were collected via an anonymous survey and individual interview. Whilst the majority of students valued the opportunity to increase their knowledge and clinical skills and felt supported by preceptors, challenges included being psychologically ill-prepared for the physical and emotional aspects of placement, and witnessing poor attitudes and behaviours of staff, which impacted on the quality of their experience. Recommendations include changes to orientation programs and introduction of simulation to help students feel better prepared and supported during placements in prison settings. Refining the selection process for placements in this setting will also help to ensure student suitability for clinical placement in Prison Health Services.

Low-intensity case management increases contact with primary care in recently released prisoners: a single-blinded, multisite, randomised controlled trial

Background

The world prison population is large and growing. Poor health outcomes after release from prison are common, but few programmes to improve health outcomes for ex-prisoners have been rigorously evaluated. The aim of this study was to evaluate the impact of individualised case management on contact with health services during the first 6 months post-release.

Methods

Single-blinded, randomised, controlled trial. Baseline assessment with N=1325 adult prisoners in Queensland, Australia, within 6 weeks of expected release; follow-up interviews 1, 3 and 6 months post-release. The intervention consisted of provision of a personalised booklet (‘Passport’) at the time of release, plus up to four brief telephone contacts in the first 4 weeks post-release.

Results

Of 1179 eligible participants, 1003 (85%) completed ≥1 follow-up interview. In intention-to-treat analyses, 53% of the intervention group and 41% of the control group reported contacting a general practitioner (GP) at 1 month post-release (difference=12%, 95% CI 5% to 19%). Similar effects were observed for GP contact at 3 months (difference=9%, 95% CI 2% to 16%) and 6 months (difference=8%, 95% CI 1% to 15%), and for mental health (MH) service contact at 6 months post release (difference=8%, 95% CI 3% to 14%).

Conclusions

Individualised case management in the month after release from prison increases usage of primary care and MH services in adult ex-prisoners for at least 6 months post-release. Given the poor health profile of ex-prisoners, there remains an urgent need to develop and rigorously evaluate interventions to increase health service contact in this profoundly marginalised population.

Trial registration number

ACTRN12608000232336.