A systematic review of randomized controlled trials of interventions to improve the health of persons during imprisonment and in the year after release

Utilising survey data and qualitative information to inform a logic model to support older people in custody with common mental and physical health problems: Addressing the physical and mental health needs of older prisoners (the PAMHOP study)

A growing number of older people remain in custody each year resulting in an increasing number of common mental and physical health concerns. No prior evidenced-based targeted psychological interventions support this group of people, and little is known about their needs, current activities, and health-related problems. We addressed these gaps through a project involving older prisoners, prison staff and a project advisory group in one male and one female prison site in the North of England. Systematic review evidence supports the development of an implementation tool kit addressing strategies to develop and deliver interventions that are sustainable, acceptable, and feasible in the prison environment. Prison strategies need to specifically address the needs of older people in custody. Relatively inexpensive activities, with some thought to delivery and flexibility have the potential to benefit common mental and physical health, increasing quality of life, reducing high economic and social cost, mortality, and reoffending in this age group.

Behavioural activation for people in custody with depression: A protocol for a feasibility randomised controlled study

People in custody are at high risk of developing depression. Accessing psychological treatments in a prison setting is a particular challenge, in part, due to difficulties accessing specialist mental health workers. Behavioural Activation (BA) may be helpful in improving health outcomes for people in custody experiencing depressive symptoms. The aim of this study is to establish the feasibility and acceptability of custodial health nurses delivering BA to improve depressive symptoms of people in custody. We will conduct a pilot randomised controlled trial with process observation examining the feasibility and acceptability of BA in treating people in custody with depressive symptoms. 60 people in custody presenting with depressive symptoms will be randomised to receive BA plus treatment as usual (TAU) or TAU provided by custodial health nurses. Eight custodial health nurses will be recruited, trained, and deliver BA. BA will be delivered twice a week for six weeks, with sessions lasting up to 30 minutes. Changes in depression and quality of life (QoL) will be assessed at baseline, 6 weeks, and 3 months post-intervention. Participants will be interviewed to understand feasibility and acceptability of BA in prison settings. The findings will inform the design of a randomised controlled trial to test the efficacy of BA for people in custody with depression. Findings will help determine whether BA for depression is suited to prison health care system and services. Improving depressive symptoms in people in custody has benefits beyond prison settings. The Central Adelaide Local Health Network Human Research Ethics Committee and University of South Australia Human Research Ethics Committee have approved the study. The trial results will be disseminated through peer-reviewed journals and scientific conferences and reported to local stakeholders and policy makers. If feasibility and acceptability is demonstrated, we will seek to progress to an effectiveness study. A potential strength of the trial model proposed, is in its scalability, with potential to increase the trial sites and locations. This trial has been prospectively registered with the Australian New Zealand Clinical Trials Registry (reference number: ACTRN12623000346673p). Trial registration ACTRN12623000346673p.

Characterizing the Use of Healthcare Access Supports Among People Who Use Drugs in Vancouver, Canada, 2017 to 2020: A Cohort Study

BACKGROUND

For structurally marginalized populations, including people who use drugs (PWUD), equitable access to healthcare can be achieved through healthcare access supports. However, few studies characterized utilization of formal (eg, outreach workers, healthcare professionals) and informal (eg, friends/family) supports. Therefore, we sought to estimate the prevalence of and factors associated with receiving each type of support among PWUD.

METHODS

We used data from 2 prospective cohort studies of PWUD in Vancouver, Canada, in 2017 to 2020. We constructed separate multivariable generalized linear mixed-effects models to identify factors associated with receiving each of the 3 types of supports (ie, healthcare professionals, outreach workers/peer navigators, and informal supports) compared to no supports.

RESULTS

Of 996 participants, 350 (35.1%) reported receiving supports in the past 6 months at baseline, through informal supports (6.2%), outreach workers (14.1%), and healthcare professionals (20.9%). In multivariable analyses, HIV positivity, chronic pain, and avoiding healthcare due to the past mistreatment were positively associated with receiving supports from each of healthcare professionals and outreach workers. Men were less likely to receive any types of the supports (all P < .05).

CONCLUSIONS

Utilization of healthcare access supports was relatively low in this sample. However, formal supports appeared to have reached PWUD exhibiting more comorbidities and experiencing discrimination in healthcare. Further efforts to make formal supports more available would benefit PWUD with unmet healthcare needs, particularly men.

Addressing the Harms of Structural Racism on Health in Incarcerated Youth Through Improved Nutrition and Exercise Programs

Every year, hundreds of thousands of youth across the country enter the juvenile legal system. A significantly disproportionate number of them are youth of color. While youth arrests have declined over the past several decades, racial disparities have increased and persist at every stage of the system. Many youth of color enter the juvenile legal system with a history of trauma and stress that compromises their health and well-being. Arrest, prosecution, and incarceration exacerbate these poor health outcomes. This paper examines several of the health impacts of structural racism in the policing and incarceration of youth of color. The paper begins by highlighting some of the most pressing social determinants of adolescent health and then considers how youth detention and incarceration contribute to unhealthy weight, hypertension, diabetes, and cardiovascular disease through unhealthy food environments, limited physical activity, and the added stress of the incarceration setting. This paper adds to the existing literature on the harms of youth detention and advocates for harms elimination strategies grounded in a public health approach to public safety and community-based alternatives to detention. For those youth who will remain in detention, the authors offer suggestions to reduce harms and improve the health of systems-involved youth, including opportunities for research.

Predicting attrition of men with a history of violence from randomised clinical trials

Preventing dropout (attrition) from clinical trials is vital for improving study validity. Dropout is particularly important in justice-involved populations as they can be very challenging to engage and recruit in the first instance. This study identifies factors associated with dropout in a double-blind, placebo-controlled randomised control trial of a selective serotonin reuptake inhibitor (SSRI) aimed at reducing reoffending in highly impulsive men with histories of violent offending. Age, education, social support, psychiatric history, and length of previous incarceration were identified as factors that predict attrition. These findings are consistent with previous research examining variables associated with attrition in clinical trials for community and offender populations. We also explored referral source and treatment allocation as attrition predictors. Although neither significantly predicted attrition, we identified that there are discernible differences in the median time to attrition among the referral source subgroups. Understanding factors that predict treatment completion and attrition will allow researchers to identify participants for whom additional provisions may optimise retention and inform development of targeted interventions.

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.

Racial Differences in Self-Report of Mental Illness and Mental Illness Treatment in the Community: An Analysis of Jail Intake Data

Jails and prisons in the United States house people with elevated rates of mental health and substance use disorders. The goal of this cross-sectional study was to evaluate the frequency of racial/ethnic differences in the self-report of mental illness and psychiatric medication use at jail entry. Our sample included individuals who had been incarcerated between 2016 and 2020 at the Middlesex Jail & House of Correction, located in Billerica, MA. We used data from the "Offender Management System," the administrative database used by the jail containing data on people who are incarcerated, and COREMR, the electronic medical record (EMR) used in the Middlesex Jail & House of Correction. We evaluated two primary outcomes (1) self-reported mental illness history and (2) self-reported use of psychiatric medication, with the primary indicator of interest as race/ethnicity. At intake, over half (57%) of the sample self-reported history of mental illness and 20% reported the use of psychiatric medications. Among people who self-reported a history of mental illness, Hispanic (AOR: 0.73, 95% CI: 0.60-0.90), Black (AOR: 0.52, 95% CI: 0.43-0.64), Asian/Pacific Islander (Non-Hispanic) people (AOR: 0.31, 95% CI: 0.13-0.74), and people from other racial/ethnic groups (AOR: 0.33, 95% CI: 0.11-0.93) all had decreased odds of reporting psychiatric medications. Mental illness was reported in about one-half of people who entered jail, but only 20% reported receiving medications in the community prior to incarceration. Our findings build on the existing literature on jail-based mental illness and show racial disparities in self-report of psychiatric medications in people who self-reported mental illness. The timing, frequency, and equity of mental health services in both the community and the jail setting deserves further research, investment, and improvement.

Case example of a jail-based cancer prevention clinical trial: Social determinants of health framework, novel experimental design, and retention strategies to facilitate long-term follow-up of clinical trial participants

Clinical trials conducted with incarcerated populations are rare. We present a case example of one such jail-based cancer prevention clinical trial to demonstrate the importance of including a theory-driven approach to intervention framing, novel experimental designs to boost access to low-risk trials, and retention strategies for long-term follow-up of hard-to-reach populations. As such we offer a social determinant of health framework to ensure cancer prevention research is conducted through the lenses of health promotion and health equity. Deviations from the gold-standard randomized control design, transparent systematic allotment, and street-based outreach retention strategies contribute to the feasibility of conducting clinical trials in carceral settings and after people leave jail. Best practices presented can be used in design and conduct of future clinical trials with criminal legal system-involved populations.

Integrated Safety and Health Promotion among Correctional Workers and People Incarcerated: A Scoping Review

Improving safety and health for correctional workers and people who are incarcerated are widespread yet separate initiatives. Correctional workers and people who are incarcerated experience similar challenges involved with poor workplaces and living conditions, including mental health crises, violence, stress, and chronic health issues, and the available resources lack integration with respect to safety and health promotion. This scoping review sought to contribute to an integrated approach for correctional system safety and health resources and identify studies of correctional resources that address health promotion among correctional workers and people who are incarcerated. Guided by PRISMA, a search of gray literature, also termed peer-reviewed literature, published between 2013-2023 (n = 2545) was completed, and 16 articles were identified. Resources primarily targeted individual and interpersonal levels. At every level of intervention, resources improved the environment for both workers and those incarcerated, with trends of less conflict, more positive behaviors, and improved relations, access to care, and feelings of safety. The corrections environment is impacted by changes from both workers and people who are incarcerated and should be examined using a holistic approach. Future health and safety resources should target the larger correctional environment by utilizing practices, policies, and procedures to improve safety and health for incarcerated people and workers.

Serious mental illness in probation: A review

Research into serious mental illness and probation is reviewed. In addition, there is a specific review of the role of specialist mental health probation staff in the United States (US). In the discussion, we compare progress with the care of the seriously mentally ill within probation in Europe and the US. We conclude that the specialist role for probation staff developed in the US has significant advantages which have been well evaluated which should be implemented, in a large multi-centre trial, across Europe.

Community-Based Mental Health and Substance Use Services for People Leaving Prison: Equity and Inclusion Strengths and Limitations in Specialized Service Inventory Development

Community reentry from prison is a challenging process, especially for persons with lived and living experience of mental health concerns. Access to appropriate community-based care for those leaving prison is a key part of improving health equity for this population. Our work to develop a cross-Canada inventory of active community mental health and substance use services for criminal justice-involved persons represents a valuable example for others hoping to conduct projects that are similar in nature and scope. We describe the strengths and limitations of our health equity-informed, multi-pronged approach to service inventory development, highlighting the importance of considering and addressing search- and stakeholder-related biases. Investment of time and resources is critical to ensuring comprehensive and inclusive identification of community-based mental health services and meaningful resource development.

The Effectiveness of Trauma-Focused Interventions in Prison Settings: A Systematic Review and Meta-Analysis

BACKGROUND

Posttraumatic stress disorder (PTSD) is overrepresented in prison relative to community populations and can be difficult to manage in an environment which can inherently exacerbate trauma-related symptomology. Little is known about the effectiveness of trauma-focused interventions in prison and less is known about factors that moderate the effectiveness of these interventions.

AIM/METHODS

We examined the effectiveness of trauma-focused interventions in prison relative to prison controls using meta-analytic techniques. We further used meta-regression analysis to examine treatment, methodological and participant-level moderators to determine factors that increased the effectiveness of these interventions.

RESULTS

From 16 studies eligible for the meta-analysis, we found a small but significant effect size for trauma-focused interventions. Phase 2 trauma processing interventions and interventions delivered individually led to greater reductions in PTSD symptoms. Studies utilizing an active treatment control resulted in smaller effect sizes than those using waitlist or no contact controls. Treatment length, study quality, outcome type, and gender were not significant moderators of treatment effectiveness.

CONCLUSION

Findings from this review are encouraging but should be interpreted with caution. Results suggest that trauma processing therapies, and individual modality trauma-focused interventions can be effective and delivered successfully in prison. However, inadequate comparison groups do not allow a firm conclusion to be drawn. There is a need for high quality Randomized Controlled Trial's that additionally measure Complex PTSD, utilize a modular treatment approach, and include treatments recommended in the National Institute for health and Care Excellence (NICE) guidelines such as Trauma-focused CBT and Eye Movement Desensitization Reprocessing (EMDR).

Evaluation of a complex intervention for prisoners with common mental health problems, near to and after release: the Engager randomised controlled trial

BACKGROUND

Many male prisoners have significant mental health problems, including anxiety and depression. High proportions struggle with homelessness and substance misuse.

AIMS

This study aims to evaluate whether the Engager intervention improves mental health outcomes following release.

METHOD

The design is a parallel randomised superiority trial that was conducted in the North West and South West of England (ISRCTN11707331). Men serving a prison sentence of 2 years or less were individually allocated 1:1 to either the intervention (Engager plus usual care) or usual care alone. Engager included psychological and practical support in prison, on release and for 3-5 months in the community. The primary outcome was the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM), 6 months after release. Primary analysis compared groups based on intention-to-treat (ITT).

RESULTS

In total, 280 men were randomised out of the 396 who were potentially eligible and agreed to participate; 105 did not meet the mental health inclusion criteria. There was no mean difference in the ITT complete case analysis between groups (92 in each arm) for change in the CORE-OM score (1.1, 95% CI -1.1 to 3.2, P = 0.325) or secondary analyses. There were no consistent clinically significant between-group differences for secondary outcomes. Full delivery was not achieved, with 77% (108/140) receiving community-based contact.

CONCLUSIONS

Engager is the first trial of a collaborative care intervention adapted for prison leavers. The intervention was not shown to be effective using standard outcome measures. Further testing of different support strategies for prison with mental health problems is needed.

Interrogating intervention delivery and participants' emotional states to improve engagement and implementation: A realist informed multiple case study evaluation of Engager

Background

‘Engager’ is an innovative ‘through-the-gate’ complex care intervention for male prison-leavers with common mental health problems. In parallel to the randomised-controlled trial of Engager (Trial registration number: ISRCTN11707331), a set of process evaluation analyses were undertaken. This paper reports on the depth multiple case study analysis part of the process evaluation, exploring how a sub-sample of prison-leavers engaged and responded to the intervention offer of one-to-one support during their re-integration into the community.

Methods

To understand intervention delivery and what response it elicited in individuals, we used a realist-informed qualitative multiple ‘case’ studies approach. We scrutinised how intervention component delivery lead to outcomes by examining underlying causal pathways or ‘mechanisms’ that promoted or hindered progress towards personal outcomes. ‘Cases’ (n = 24) were prison-leavers from the intervention arm of the trial. We collected practitioner activity logs and conducted semi-structured interviews with prison-leavers and Engager/other service practitioners. We mapped data for each case against the intervention logic model and then used Bhaskar’s (2016) ‘DREIC’ analytic process to categorise cases according to extent of intervention delivery, outcomes evidenced, and contributing factors behind engagement or disengagement and progress achieved.

Results

There were variations in the dose and session focus of the intervention delivery, and how different participants responded. Participants sustaining long-term engagement and sustained change reached a state of ‘crises but coping’. We found evidence that several components of the intervention were key to achieving this: trusting relationships, therapeutic work delivered well and over time; and an in-depth shared understanding of needs, concerns, and goals between the practitioner and participants. Those who disengaged were in one of the following states: ‘Crises and chaos’, ‘Resigned acceptance’, ‘Honeymoon’ or ‘Wilful withdrawal’.

Conclusions

We demonstrate that the ‘implementability’ of an intervention can be explained by examining the delivery of core intervention components in relation to the responses elicited in the participants. Core delivery mechanisms often had to be ‘triggered’ numerous times to produce sustained change. The improvements achieved, sustained, and valued by participants were not always reflected in the quantitative measures recorded in the RCT. The compatibility between the practitioner, participant and setting were continually at risk of being undermined by implementation failure as well as changing external circumstances and participants’ own weaknesses.

Trial registration number

ISRCTN11707331, Wales Research Ethics Committee, Registered 02-04-2016—Retrospectively registered https://doi.org/10.1186/ISRCTN11707331.

The health of detainees and the role of primary care: Position paper of the European Forum for Primary Care

This position paper aims to increase awareness among primary care practitioners and policymakers about the specific and complex health needs of people who experience incarceration. We focus on the importance of primary care and of continuity of care between prison and community. We highlight what is known from the literature on the health of people who experience incarceration, on the organisation of prison health care, and on the role of primary care both during and after detention. We present three case descriptions of detainees' encounters with the organisation of prison health care in three European countries. Finally, we describe the position that the European Forum for Primary Care takes. Prisoners and ex-prisoners have a worse physical and mental health compared with a cross-section of the population. However, access to good quality treatment and care is often worse than in the outside situation. In particular, well-organised primary care in the prison context could benefit prisoners and, indirectly, society at large. Moreover, continuity of care between the community and the prison situation needs improvement.

Compounding Trauma: the Intersections of Racism, Law Enforcement, and Injury

Purpose of Review

Traumatic injury sits at the nexus of law enforcement and structural racism. This narrative review aims to explore the major impacts of law enforcement on health, its intersections with US structural racism, and their joint impacts on traumatic injury and injury care.

Recent Findings

Many of the same forces of systemic disadvantage that put Black people, other people of color, and other marginalized groups at risk for violent injury also expose these same individuals and communities to intensive policing. Recent evidence speaks to the broad impact of police exposure and police violence on individual and community physical and mental health. Moreover, injured patients who are exposed to law enforcement during their care are at risk for erosion of trust in and relationships with their healthcare providers. To optimize the role of law enforcement agencies in injury prevention, collaboration across sectors and with communities is essential.

Summary

A broad approach to the prevention of injury and violence must incorporate an understanding of the intersecting impacts of law enforcement and structural racism on health and traumatic injury. Clinicians who seek to provide trauma-informed injury care should incorporate an understanding of the role of law enforcement in individual and community health.

Cost savings of a primary care program for individuals recently released from prison: a propensity-matched study

Background

Criminal justice system costs in the United States have exponentially increased over the last decades, and providing health care to individuals released from incarceration is costly. To better understand how to manage costs to state budgets for those who have been incarcerated, we aimed to assess state-level costs of an enhanced primary care program, Transitions Clinic Network (TCN), for chronically-ill and older individuals recently released from prison.

Methods

We linked administrative data from Connecticut Department of Correction, Medicaid, and Department of Mental Health and Addiction Services to identify a propensity matched comparison group and estimate costs of a primary care program serving chronically-ill and older individuals released from incarceration between 2013 and 2016. We matched 94 people released from incarceration who received care at a TCN program to 94 people released from incarceration who did not receive care at TCN program on numerous characteristics. People eligible for TCN program participation were released from incarceration within the prior 6 months and had a chronic health condition or were over the age of 50. We estimated 1) costs associated with the TCN program and 2) costs accrued by Medicaid and the criminal justice system. We evaluated associations between program participation and Medicaid and criminal justice system costs over a 12-month period using bivariate analyses with nonparametric bootstrapping method.

Results

The 12-month TCN program operating cost was estimated at $54,394 ($146 per participant per month). Average monthly Medicaid costs per participant were not statistically different between the TCN ($1737 ± $3449) and comparison ($1356 ± $2530) groups. Average monthly criminal justice system costs per participant were significantly lower among TCN group ($733 ± $1130) compared with the matched group ($1276 ± $1738, p < 0.05). We estimate every dollar invested in the TCN program yielded a 12-month return of $2.55 to the state.

Conclusions

Medicaid investments in an enhanced primary care program for individuals returning from incarceration are cost neutral and positively impact state budgets by reducing criminal justice system costs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07985-5.

Assessing incarcerated women's physical and mental health status and needs in a Swiss prison: a cross-sectional study

BACKGROUND

Women make up 5% of the European prison population on average. Almost invisible in prison and health research, and suffering the stigma associated with female offending, incarcerated women are often forgotten, and their specific healthcare needs remain much ignored. Combining face-to-face survey interviews and medical chart data, we aim to assess the health status, healthcare needs, and access to preventive medicine of women incarcerated in Switzerland.

RESULTS

Sixty incarcerated adult women participated in a cross-sectional study to assess their life and incarceration histories, physical and mental health problems, medication, and use of medical services. Eligibility criteria were (a) an incarceration of at least four weeks and (b) the ability to provide written informed consent. Exclusion criteria were psychiatric instability and insufficient language competence. Women's average age was 34.3 years old (SD = 9.8); 45.0% of them were born in Switzerland, 33.3% in Europe and 15.0% on the African continent. Overall, 61.7% of women self-reported physical or mental health problems and 13.3% indicated they were once diagnosed with a sexually transmitted infection. Further, 78.3% of women were active cigarette smokers; more than one in three women reported alcohol use problems and almost one in two women had used at least one illicit drug in the year before incarceration. Depression and perceived stress scores were above clinical cut-off points for more than half of interviewed women. When asked how they rated their health, 68.3% of women felt it had worsened since incarceration. All but four women had accessed prison medical services; however, our study does not indicate whether women's use of healthcare was indeed adequate to their needs.

CONCLUSIONS

This study demonstrated incarcerated women's poor health and health-risk behaviours. Structural changes and gender-responsive health promotion interventions have the potential to improve the health of incarcerated women and help them return to the community in better health.

Prisoner knowledge about head injury is Improved by brief psychoeducation

INTRODUCTION

The high prevalence of head injury (HI) in prisoners and its association with offending indicates a need for interventions. However, there is little evidence and none for the effectiveness of psychoeducation in improving prisoner knowledge about HI and its effects.

METHODS

Small groups of males in two Scottish prisons underwent a 1 hour psychoeducation session delivered by PowerPoint and combined with question and answer, video clips and a booklet about HI. A pre-post intervention design was used to assess knowledge about HI from vignettes. Participants indicated effects of HI using unprompted free recall and then with a questionnaire (the Symptom Checklist; SCL), pre-education (n = 34), post-education (n = 19) and at 4-week follow-up (n = 11). Free recall was scored using symptom lists from national guidelines (FR-SIGN) or the SCL (FR-SCL). Within-subject comparisons were made between pre-intervention, post-intervention and follow-up scores.

RESULTS

Knowledge about HI significantly increased pre- to post-education for FR-SIGN (d = 0.91; 95% CI 0.62, 2.53) and FR-SCL (d = 0.99; 95% CI 0.95, 4.00) without decrement at follow-up (FR-SIGN d = 1.27; 95% CI 0.53, 2.56; FR-SCL r = 0.60). Scores on the SCL did not change over time (p > .05).

CONCLUSION

Prisoner knowledge about HI was improved by brief psychoeducation suitable for delivery in prisons.

Interventions to reduce suicidal thoughts and behaviours among people in contact with the criminal justice system: A global systematic review

BACKGROUND

People who experience incarceration die by suicide at a higher rate than those who have no prior criminal justice system contact, but little is known about the effectiveness of interventions in other criminal justice settings. We aimed to synthesise evidence regarding the effectiveness of interventions to reduce suicide and suicide-related behaviours among people in contact with the criminal justice system.

METHODS

We searched Embase, PsycINFO, MEDLINE, and grey literature databases for articles published between 1 January 2000 and 1 June 2021. The protocol was registered with PROSPERO (CRD42020185989).

FINDINGS

Thirty-eight studies (36 primary research articles, two grey literature reports) met our inclusion criteria, 23 of which were conducted in adult custodial settings in high-income, Western countries. Four studies were randomised controlled trials. Two-thirds of studies (n=26, 68%) were assessed as medium quality, 11 (29%) were assessed as high quality, and one (3%) was assessed as low quality. Most had considerable methodological limitations and very few interventions had been rigorously evaluated; as such, drawing robust conclusions about the efficacy of interventions was difficult.

INTERPRETATION

More high-quality evidence from criminal justice settings other than adult prisons, particularly from low- and middle-income countries, should be considered a priority for future research.

FUNDING

This work was funded by the Australian government's National Suicide Prevention Taskforce. RB is supported by a National Health and Medical Research Council (NHMRC) Emerging Leader Investigator Grant (EL2; GNT2008073). MW is supported by a NHMRC Postgraduate Scholarship (GNT1151103). SF was funded by the NIHR HTA Programme (HTA Project:16/159/09).

Conducting Randomized Controlled Trials of Complex Interventions in Prisons: A Sisyphean Task?

Randomized Controlled Trials (RCT) are the "gold standard" for measuring the effectiveness of an intervention. However, they have their limitations and are especially complex in prison settings. Several systematic reviews have highlighted some of the issues, including, institutional constraints e.g., "lock-downs," follow-ups, contamination of allocation conditions and a reliance on self-report measures. In this article, we reflect on our experiences and will describe two RCTs. People in prison are a significantly disadvantaged and vulnerable group, ensuring equitable and effective interventions is key to reducing inequality and promoting positive outcomes. We ask are RCTs of complex interventions in prisons a sisyphean task? We certainly don't think so, but we propose that current accepted practice and research designs may be limiting our understanding and ability to test complex interventions in the real-world context of prisons. RCTs will always have their place, but designs need to be flexible and adaptive, with the development of other rigorous methods for evaluating impact of interventions e.g., non-randomized studies, including pre-post implementation studies. With robust research we can deliver quality evidence-based healthcare in prisons - after all the degree of civilization in a society is revealed by entering its prisons.

Predicting Violent Reoffending in Individuals Released From Prison in a Lower-Middle-Income Country: A Validation of OxRec in Tajikistan

BACKGROUND

Although around 70% of the world's prison population live in low- and middle-income countries (LMICs), risk assessment tools for criminal recidivism have been developed and validated in high-income countries (HICs). Validating such tools in LMIC settings is important for the risk management of people released from prison, development of evidence-based intervention programmes, and effective allocation of limited resources.

METHODS

We aimed to externally validate a scalable risk assessment tool, the Oxford Risk of Recidivism (OxRec) tool, which was developed in Sweden, using data from a cohort of people released from prisons in Tajikistan. Data were collected from interviews (for predictors) and criminal records (for some predictors and main outcomes). Individuals were first interviewed in prison and then followed up over a 1-year period for post-release violent reoffending outcomes. We assessed the predictive performance of OxRec by testing discrimination (area under the receiver operating characteristic curve; AUC) and calibration (calibration statistics and plots). In addition, we calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for different predetermined risk thresholds.

RESULTS

The cohort included 970 individuals released from prison. During the 12-month follow-up, 144 (15%) were reincarcerated for violent crimes. The original model performed well. The discriminative ability of OxRec Tajikistan was good (AUC = 0.70; 95% CI 0.66-0.75). The calibration plot suggested an underestimation of observed risk probabilities. However, after recalibration, model performance was improved (Brier score = 0.12; calibration in the large was 1.09). At a selected risk threshold of 15%, the tool had a sensitivity of 60%, specificity of 65%, PPV 23% and NPV 90%. In addition, OxRec was feasible to use, despite challenges to risk prediction in LMICs.

CONCLUSION

In an external validation in a LMIC, the OxRec tool demonstrated good performance in multiple measures. OxRec could be used in Tajikistan to help prioritize interventions for people who are at high-risk of violent reoffending after incarceration and screen out others who are at lower risk of violent reoffending. The use of validated risk assessment tools in LMICs could improve risk stratification and inform the development of future interventions tailored at modifiable risk factors for recidivism, such as substance use and mental health problems.

Challenges in providing ethically competent health care to incarcerated older adults with mental illness: a qualitative study exploring mental health professionals' perspectives in Canada

BACKGROUND

The population of incarcerated older adults is the fastest growing demographic in prisons. Older persons in custody have poorer health as compared with those in the community. The unmet and complex health care needs of incarcerated older adults with mental illness raise justice, safety, dignity and fairness in care as ethical concerns. As there exists research gap to better understand these concerns, the current study aimed at exploring the perspectives of mental health professionals on challenges in delivering ethically competent care to mentally ill incarcerated older adults in Canada.

METHODS

Thirty-four semi-structured interviews were conducted between August 2017 and November 2018 with prison mental health professionals in Canada who were selected using purposive and convenience sampling techniques. The audio recorded interviews were transcribed verbatim and analysed inductively to generate themes.

RESULTS

The results were distilled into three main categories and seven subcategories that related to ethical issues in the provision of health care for mentally ill incarcerated older adults. The main categories included imprisoned older persons with special care needs, lack of resources, and the peer-support program.

CONCLUSIONS

Results of this study showed that existing practices of care of mentally ill incarcerated older adults are characterised by challenges that increase their vulnerability to worse health conditions. It is imperative for local authorities, policy makers and representatives to prepare for and respond to the challenges that compromise ethically competent health care for, and healthy ageing of, mentally ill incarcerated older adults.

Use of community healthcare and overdose in the 30 days following release from provincial correctional facilities in British Columbia

BACKGROUND

Interruptions in healthcare services contribute to an elevated risk of overdose in the weeks following release from incarceration. This study examined the association of use of community healthcare with nonfatal and fatal overdose in the 30 days following release.

METHODS

We conducted a retrospective cohort study using linked administrative data from a random sample of 20% of the population of British Columbia. We examined releases from provincial correctional facilities between January 1, 2015-December 1, 2018. We fit multivariate Andersen-Gill models to examine nonfatal overdoses after release from incarceration and applied Standard Cox regression for analyses of fatal overdoses.

RESULTS

There were a combined 16,809 releases of 6721 people in this study. At least one overdose occurred in 2.8% of releases. A community healthcare visit preceded the first nonfatal overdose in 86.4% of releases with a nonfatal overdose event. Only 48.4% of people who had a fatal overdose used community healthcare. In adjusted analysis, people who had used community healthcare had a higher hazard of healthcare-attended nonfatal overdose (aHR 2.83 95% CI 2.13, 3.78) and lower hazard of fatal overdose (aHR 0.58, 95%CI 0.28, 1.19).

CONCLUSIONS

Community healthcare visits after release from custody may be an important opportunity to provide overdose prevention and harm reduction supports. Policies and resourcing are needed to facilitate better connection to primary healthcare during the transition to community. Providers in community should be equipped to offer care to people who have recently experienced incarceration in a way that is accessible, acceptable and trauma-informed.

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.

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.

Implementing a Culture of Health Among Probationers

Justice-involved individuals struggle with a multitude of health issues, and addressing the needs of these individuals requires the efforts of multiple agencies working across traditionally siloed systems. This study provides evidence on the implementation of a one-stop health services delivery model, Culture of Health, piloted in an urban probation office. This model uses a change team approach to focus the efforts of multiple agencies toward improving the alignment, collaboration, and synergy of health and other social service delivery to this underserved population. This article reports on the development and application issues involved in instituting such a novel design. The study demonstrates that the health culture within probation, buy-in from probation officers, and dwindling support from change team members all posed noteworthy issues for program implementation.

Older Adults Post-Incarceration: Restructuring Long-term Services and Supports in the Time of COVID-19

OBJECTIVES

To describe long-term care services and supports (LTSS) in the United States, note their limitations in serving older adults post-incarceration, and offer potential solutions, with special consideration for the Coronavirus Disease 2019 pandemic.

DESIGN

Narrative review.

SETTING AND PARTICIPANTS

LTSS for older adults post-incarceration.

METHODS

Literature review and policy analysis.

RESULTS

Skilled nursing facilities, nursing homes, assisted living, adult foster homes, and informal care from family and friends compose LTSS for older adults, but their utilization suffers from access and payment complexities, especially for older adults post-incarceration. A combination of public-private partnerships, utilization of health professional trainees, and unique approaches to informal caregiver support, including direct compensation to caregivers, could help older adults reentering our communities following prison.

CONCLUSIONS AND IMPLICATIONS

Long-standing gaps in US LTSS are revealed by the coronavirus (severe acute respiratory syndrome coronavirus 2) pandemic. Older adults entering our communities from prison are particularly vulnerable and need unique solutions to aging care as they face stigma and access challenges not typically encountered by the general population. Our review and discussion offer guidance to systems, practitioners, and policy makers on how to improve the care of older adults after incarceration.

Interventions to Improve HIV Care Continuum Outcomes Among Individuals Released From Prison or Jail: Systematic Literature Review

BACKGROUND

HIV care continuum outcomes deteriorate among people returning from incarceration. Interventions to improve care outcomes postincarceration have been characterized by substantial heterogeneity in approach, outcome metrics, and results. A large number of recently published interventions have not been systematically reviewed.

METHODS

We searched peer reviewed and scholarly databases for published and gray literature describing interventions to improve HIV care continuum outcomes among individuals released from prison or jail. We systematically screened quantitative and qualitative intervention reports published through 2018, then extracted and analyzed study data using a classification scheme that we developed for categorizing intervention levels and strategies.

RESULTS

We included 23 reports from the peer-reviewed literature, 2 from gray literature, and 2 from conference abstracts (27 total). Seventeen studies were classified as individual level, 3 as biomedical level, 2 as organizational level, and 5 as multilevel. Nine studies were randomized controlled trials, 4 of which reported power calculations. Fifteen studies were quasiexperimental; one was a case study. Eleven studies were conducted in prisons, 7 in jails, and 9 in both prisons and jails. Of 11 studies reporting hypothesis tests, 5 found statistically significant effect sizes on primary outcomes.

CONCLUSIONS

Interventions that demonstrate postrelease improvements in clinic attendance and viral suppression include patient navigation strategies, especially involving peer support, and substance use treatment strategies.

Promoting adherence to psychopharmacological treatment among prisoners with mental health problems: Follow-up of a randomized controlled trial

This study presents follow-up results regarding a treatment adherence programme (TAP) for prisoners, the initial effectiveness of which we previously evaluated in a randomized controlled trial. Here we used an experimental design with two randomized groups and assessment at four time points: baseline (pre-intervention), at 3 months (post-intervention), and at 6 and 9 months after baseline. Participants were 151 prisoners with mental health problems (M_age = 41.85, SD = 10.31) who were randomly assigned to either the TAP or treatment as usual (TAU). Prisoners who completed the TAP showed a greater improvement in treatment adherence at 3 and 9 months, compared with those who received TAU. There were no significant differences between the groups in subjective well-being under medication. The availability of an easy-to-apply, universal programme that is able to promote treatment adherence in the prison context could make a positive contribution to the general health of inmates.

Community stakeholders' perspectives regarding acceptability of a life skills building intervention to empower women in Pakistan

Violence against women (VAW) is a major determinant in the assessment of a women's mental health. Many interventions have addressed strategies to reduce VAW, however, little information is available regarding effectiveness in the local context, particularly the role of men in women's empowerment. In Pakistan, a qualitative approach was undertaken in all four of its provinces to describe the community residents', both men and women, perceptions regarding the acceptability of a proposed life skills building (LSB) intervention involving men's engagement with regards to women's empowerment and VAW. Eighteen focus group discussions were conducted with men and women from locales within each province of Pakistan, averaging 6-10 participants per group. Fourteen key informant interviews were conducted with community stakeholders. The analysis identified three major themes: family life and male engagement, LSB training as an empowerment tool, and operationalization of the proposed LSB intervention. The proposed LSB intervention was well accepted by the participants with a strong urge to engage men in receiving the LSB training sessions. Men's engagement has been identified as an important element to facilitate women's empowerment. Participants suggested that these sessions should be held for two and a half hours per week within the community public spaces. In addition, these sessions should be based on an interactive approach. The focus of these sessions should include ideas surrounding positive relationships and economic skills building. Moreover, men's engagement will help to reduce VAW and improve the mental health of women in a patriarchal country like Pakistan.

Exploring the acceptability of HIV partner notification in prisons: Findings from a survey of incarcerated people living with HIV in Indonesia

Assisted HIV partner notification services provide a safe and effective way for people living with HIV (PLHIV) to inform their partners about the possibility of exposure and to offer them testing, treatment, and support. This study examined whether or not PLHIV in prison might be willing to participate in assisted HIV partner notification services and their reasons for and against disclosing their HIV-positive status to their partners. PLHIV (n = 150) recruited from Jakarta's two largest all-male prisons completed an interviewer-administered questionnaire collecting demographic and risk behavior data, and attitudes toward HIV disclosure and partner services. Among those who were sexually active and/or injecting drugs before incarceration, two-thirds (66.4%, 91/137) endorsed provider referral as an acceptable way to notify their sex partners, and nearly three quarters (72.4%, 89/123) endorsed provider referral to notify their drug-injecting partners. Only a quarter (25.1%) of participants reported that their main sex partner had ever received an HIV test. Participants with anticipated stigma were less likely to endorse provider referral for sex partners (adjusted odds ratio [aOR] = 0.58, 95% CI: 0.35, 0.96) and drug-injecting partners (aOR = 0.54, 95% CI: 0.29, 1.00). Relationship closeness was associated with higher odds of endorsing provider referral for drug-injecting partners (aOR = 2.08, 95% CI: 1.25, 3.45). Protecting partners from infection and a moral duty to inform were main reasons to disclose, while stigma and privacy concerns were main reasons not to disclose. Most incarcerated PLHIV have at-risk partners in the community who they would be willing to notify if provided with assistance. Assisted partner notification for prison populations offers a promising public health approach to accelerate diagnosis, treatment, and prevention of HIV infection in the community, particularly among women.

Leveraging best practices: protecting sub-Saharan African prison detainees amid COVID-19

The risk of infection and death from COVID-19 is higher among older prisoners with pre-existing health conditions especially in sub-Saharan African. Hawks L et al. raise four concerns that need to be considered when developing public health and clinical responses to COVID-19 to protect prisoners. This paper applies these concerns to the sub-Saharan African context. These focus areas include 1) challenges of social distancing; 2) higher risk of severe infection and death; 3) difficulties health care systems may face in the case of COVID-19 surge; and 4) recommended solutions to prevent harm and preventing a public health catastrophe. Prisoners are more vulnerable and the time to take immediate actions to minimize an imminent COVID-19 outbreak and its impacts is now.

Longitudinal associations between the disruption of incarceration and community re-entry on substance use risk escalation among Black men who have sex with men; A causal analysis

BACKGROUND AND AIMS

While substance use can lead to incarceration, the disruptive effects of incarceration may lead to, or increase psychosocial vulnerability and substance use. Using causal inference methods, we measured longitudinal associations between incarceration and post-release substance use among Black men who have sex with men (BMSM), populations facing disproportionate risk of incarceration and substance use.

METHODS

Using data from the HIV Prevention Trials Network (HPTN 061) study (N = 1553) we estimated associations between past 6-month incarceration and binge drinking, marijuana use, and stimulant use post release (at 12-month follow-up visit). Adjusted models used inverse probability weighting (IPW) to control for baseline (pre-incarceration) substance use and additional risk factors.

RESULTS

There were 1133 participants present at the twelve-month follow-up visit. Participants were predominately non-Hispanic Blacks and unemployed. At baseline, 60.1 % reported a lifetime history of incarceration, 22.9 % were HIV positive and 13.7 % had a history of an STI infection. A total of 43 % reported a history of depression. In adjusted analyses with IPW, recent incarceration was associated with crack-cocaine (adjusted odds ratio (AOR): 1.53, 95 % confidence interval (CI): 1.03, 2.23) and methamphetamine use (AOR: 1.52, 95 % CI: 0.94-2.45). Controlling for pre-incarceration binge drinking, incarceration was associated with post-release binge drinking (AOR: 1.47, 95 % CI: 1.05, 2.04); in fully adjusted models the AOR was 1.14 (95 % CI: 0.81, 1.62). Incarceration was not associated with marijuana use.

CONCLUSION

Findings underscore the need to provide substance use treatment in custody and post-release, and to consider alternatives to incarceration for substance using populations.

Social Determinants of Health and Retention in HIV Care Among Recently Incarcerated Women Living with HIV in Canada

Women living with HIV (WLWH) are over-represented in corrections in Canada, yet little is known about women's experiences post-release. We used CHIWOS cross-sectional data from WLWH to estimate associations between social determinants of health and HIV-related care outcomes among WLWH with recent (within past year) or ever (before past year) incarceration experience. Lifetime incarceration prevalence was 36.9% (6.5% recent; 30.4% ever), with significant differences by province of residence (British Columbia: 10% recent; 52% ever; Ontario: 5%; 24%; Quebec: 6%; 22%; p < 0.001). In adjusted multinomial logistic regression analyses, compared with never incarcerated, recent incarceration was associated with Indigenous ancestry, lower annual income (< $20,000 CAD), unstable housing, current sex work, injection drug use (IDU), and sub-optimal antiretroviral therapy (ART) adherence, while ever incarceration was associated with current sex work, IDU, and experiencing adulthood violence. Our findings have implications regarding supports needed by WLWH in the post-release period, including ART adherence and achieving health and social goals.

Reentry interventions that address substance use: A systematic review

Justice-involved individuals with substance use problems have heightened risk of relapse and recidivism after release from incarceration, making reentry a critical time to provide evidence-based treatments (EBTs) for substance use; however, the extent to which reentry interventions incorporate EBTs for substance use is unclear. This systematic review identified studies of reentry interventions in the past 10 years that address substance use, assessed whether EBTs were used, and explored which interventions were effective in reducing substance use and recidivism postrelease. Eligible studies included interventions that began during incarceration and continued postrelease or began within 3 months of release and addressed substance use in some capacity. One hundred twelve full text articles were reviewed and 38 met inclusion criteria, representing 34 unique interventions. Of the 34 interventions, 21 provided substance use treatment whereas 13 facilitated connections to treatment. Of the 21 interventions providing treatment, the primary modalities were cognitive-behavioral therapy (n = 6), motivational interviewing (n = 2), medication assisted treatment (n = 2), therapeutic community (n = 2), psychoeducation or 12-step (n = 5), and four did not specify the modality. Of the 31 studies that assessed recidivism outcomes, 18 found reduced recidivism for the treatment group on at least one indicator (e.g., rearrest, reincarceration). Of the 13 studies that assessed substance use outcomes, 7 found reduced substance use for the treatment group on at least one indicator. Results were not consistent for any particular treatment approach or modality and highlight the need for consistent integration of EBTs for substance use into reentry interventions. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Challenges and Opportunities to Meet the Mental Health Needs of Underserved and Disenfranchised Populations in the United States

This article investigates the gap in access to and quality of mental health care in the United States. This work first discusses how minority populations are most affected by the treatment gap. It summarizes recent literature on the topic for better understanding the needs of psychiatrically underserved and disenfranchised populations and the causes of mental health disparities. It reviews some of the barriers to behavioral health care, including lack of insurance coverage, lack of community-based interventions, unequal access to evidence-based practices, stigma, mental health workforce shortages, and geographical maldistribution of providers. Second, it reviews opportunities to address these disparities. The article provides examples of effective interventions that researchers worldwide have already implemented to address the gap of mental health services within the collaborative care model and global mental health initiatives. Telepsychiatry and improvements in training of the mental health workforce are also listed as useful implementations to overcome the treatment gap for patients seeking mental health care.

Individual health trainers to support health and well-being for people under community supervision in the criminal justice system: the STRENGTHEN pilot RCT

Background

Little is known about the effectiveness or cost-effectiveness of interventions, such as health trainer support, to improve the health and well-being of people recently released from prison or serving a community sentence, because of the challenges in recruiting participants and following them up.

Objectives

This pilot trial aimed to assess the acceptability and feasibility of the trial methods and intervention (and associated costs) for a randomised trial to assess the effectiveness and cost-effectiveness of health trainer support versus usual care.

Design

This trial involved a pilot multicentre, parallel, two-group randomised controlled trial recruiting 120 participants with 1 : 1 individual allocation to receive support from a health trainer and usual care or usual care alone, with a mixed-methods process evaluation, in 2017–18.

Setting

Participants were identified, screened and recruited in Community Rehabilitation Companies in Plymouth and Manchester or the National Probation Service in Plymouth. The intervention was delivered in the community.

Participants

Those who had been out of prison for at least 2 months (to allow community stabilisation), with at least 7 months of a community sentence remaining, were invited to participate; those who may have posed an unacceptable risk to the researchers and health trainers and those who were not interested in the trial or intervention support were excluded.

Interventions

The intervention group received, in addition to usual care, our person-centred health trainer support in one-to-one sessions for up to 14 weeks, either in person or via telephone. Health trainers aimed to empower participants to make healthy lifestyle changes (particularly in alcohol use, smoking, diet and physical activity) and take on the Five Ways to Well-being [Foresight Projects. Mental Capital and Wellbeing: Final Project Report. 2008. URL: www.gov.uk/government/publications/mental-capital-and-wellbeing-making-the-most-of-ourselves-in-the-21st-century (accessed 24 January 2019).], and also signposted to other options for support. The control group received treatment as usual, defined by available community and public service options for improving health and well-being.

Main outcome measures

The main outcomes included the Warwick–Edinburgh Mental Well-being Scale scores, alcohol use, smoking behaviour, dietary behaviour, physical activity, substance use, resource use, quality of life, intervention costs, intervention engagement and feasibility and acceptability of trial methods and the intervention.

Results

A great deal about recruitment was learned and the target of 120 participants was achieved. The minimum trial retention target at 6 months (60%) was met. Among those offered health trainer support, 62% had at least two sessions. The mixed-methods process evaluation generally supported the trial methods and intervention acceptability and feasibility. The proposed primary outcome, the Warwick–Edinburgh Mental Well-being Scale scores, provided us with valuable data to estimate the sample size for a full trial in which to test the effectiveness and cost-effectiveness of the intervention.

Conclusions

Based on the findings from this pilot trial, a full trial (with some modifications) seems justified, with a sample size of around 900 participants to detect between-group differences in the Warwick-Edinburgh Mental Well-being Scale scores at a 6-month follow-up.

Future work

A number of recruitment, trial retention, intervention engagement and blinding issues were identified in this pilot and recommendations are made in preparation of and within a full trial.

Trial registration

Current Controlled Trials ISRCTN80475744.

Funding

This project was funded by the National Institute for Health Research Public Health Research programme and will be published in full in Public Health Research; Vol. 7, No. 20. See the National Institute for Health Research Journals Library website for further project information.

Opioid-related treatment, interventions, and outcomes among incarcerated persons: A systematic review

BACKGROUND

Worldwide opioid-related overdose has become a major public health crisis. People with opioid use disorder (OUD) are overrepresented in the criminal justice system and at higher risk for opioid-related mortality. However, correctional facilities frequently adopt an abstinence-only approach, seldom offering the gold standard opioid agonist treatment (OAT) to incarcerated persons with OUD. In an attempt to inform adequate management of OUD among incarcerated persons, we conducted a systematic review of opioid-related interventions delivered before, during, and after incarceration.

METHODS AND FINDINGS

We systematically reviewed 8 electronic databases for original, peer-reviewed literature published between January 2008 and October 2019. Our review included studies conducted among adult participants with OUD who were incarcerated or recently released into the community (≤90 days post-incarceration). The search identified 2,356 articles, 46 of which met the inclusion criteria based on assessments by 2 independent reviewers. Thirty studies were conducted in North America, 9 in Europe, and 7 in Asia/Oceania. The systematic review included 22 randomized control trials (RCTs), 3 non-randomized clinical trials, and 21 observational studies. Eight observational studies utilized administrative data and included large sample sizes (median of 10,419 [range 2273-131,472] participants), and 13 observational studies utilized primary data, with a median of 140 (range 27-960) participants. RCTs and non-randomized clinical trials included a median of 198 (range 15-1,557) and 44 (range 27-382) participants, respectively. Twelve studies included only men, 1 study included only women, and in the remaining 33 studies, the percentage of women was below 30%. The majority of study participants were middle-aged adults (36-55 years). Participants treated at a correctional facility with methadone maintenance treatment (MMT) or buprenorphine (BPN)/naloxone (NLX) had lower rates of illicit opioid use, had higher adherence to OUD treatment, were less likely to be re-incarcerated, and were more likely to be working 1 year post-incarceration. Participants who received MMT or BPN/NLX while incarcerated had fewer nonfatal overdoses and lower mortality. The main limitation of our systematic review is the high heterogeneity of studies (different designs, settings, populations, treatments, and outcomes), precluding a meta-analysis. Other study limitations include the insufficient data about incarcerated women with OUD, and the lack of information about incarcerated populations with OUD who are not included in published research.

CONCLUSIONS

In this carefully conducted systematic review, we found that correctional facilities should scale up OAT among incarcerated persons with OUD. The strategy is likely to decrease opioid-related overdose and mortality, reduce opioid use and other risky behaviors during and after incarceration, and improve retention in addiction treatment after prison release. Immediate OAT after prison release and additional preventive strategies such as the distribution of NLX kits to at-risk individuals upon release greatly decrease the occurrence of opioid-related overdose and mortality. In an effort to mitigate the impact of the opioid-related overdose crisis, it is crucial to scale up OAT and opioid-related overdose prevention strategies (e.g., NLX) within a continuum of treatment before, during, and after incarceration.

Adherence to Antiretroviral Therapy Among Incarcerated Persons with HIV: Associations with Methadone and Perceived Safety

With adequate support, people with HIV (PWH) may achieve high levels of adherence to antiretroviral therapy (ART) during incarceration. We examined factors associated with ART utilization and adherence among incarcerated PWH (N = 150) in Indonesia. ART utilization was positively associated with HIV status disclosure (adjusted odds ratio [aOR] = 5.5, 95% CI 1.2-24.1, p = 0.023), drug dependency (aOR = 3.9, 95% CI 1.2-12.6, p = 0.022), health service satisfaction (aOR = 3.2, 95% CI 1.7-6.2, p < 0.001), and perceived need for medical treatment (aOR = 1.6, 95% CI 1.1-2.5, p = 0.011), and negatively associated with chance locus of control (aOR = 0.3, 95% CI 0.1-0.7, p = 0.013). Most participants utilizing ART (74.5%) reported less than "perfect" ART adherence. ART adherence was independently associated with perceived personal safety (β = 0.21, 95% CI 0.01-0.40, p = 0.032) and methadone utilization (β = 0.84, 95% CI 0.10-1.67, p = 0.047). PWH receiving methadone had a sixfold higher adjusted odds of being highly-adherent to ART (aOR = 6.3, 95% CI 1.1-35.7, p = 0.036). Interventions that increase methadone utilization and personal safety may improve ART adherence among incarcerated PWH.

Interventions at the Transition from Prison to the Community for Prisoners with Mental Illness: A Systematic Review

Prisoners have high rates of mental illness and the transition from prison to the community is a problematic time for the provision of mental health services and a range of negative outcomes have been identified in this period. A systematic review was conducted to identify interventions for prisoners with diagnosed mental health conditions that targeted this transition period. Fourteen papers from 13 research studies were included. The interventions identified in this review were targeted at different stages of release from prison and their content differed, ranging from Medicaid enrolment schemes to assertive community treatment. It was found that insurance coverage, and contact with mental health and other services can be improved by interventions in this period but the impact on reoffending and reincarceration is complex and interventions may lead to increased return to prison. There is a developing evidence base that suggests targeting this period can improve contact with community mental health and other health services but further high quality evidence with comparable outcomes is needed to provide more definitive conclusions. The impact of programmes on return to prison should be evaluated further to establish the effect of interventions on clinical outcomes and to clarify the role of interventions on reincarceration.

Modifiable risk factors for external cause mortality after release from prison: a nested case-control study

AIM

People released from prison are at higher risk of mortality from potentially preventable causes than their peers in the general population. Because most studies of this phenomenon are reliant on registry data, there is little health and behavioural information available on those at risk, hampering the development of targeted, evidence-based preventive responses. Our aim was to identify modifiable risk and protective factors for external cause and cause-specific mortality after release from prison.

METHODS

We undertook a nested case-control study using data from a larger retrospective cohort study of mortality after release from prison in Queensland, Australia between 1994 and 2007. Cases were 286 individuals who had died from external causes (drug overdose, suicide, transport accidents, or violence) matched with 286 controls on sex, Indigenous status, and release date. We extracted data from detention, case-management, and prison medical records.

RESULTS

Factors associated with increased risk of external cause mortality included use of heroin and other opioids in the community [odds ratio (OR) = 2.20, 95% CI 1.41-3.43, p &lt; 0.001], a prescription for antidepressants during the current prison sentence (OR = 1.94, 95% CI 1.02-3.67, p = 0.042), a history of problematic alcohol use in the community (OR = 1.54, 95% CI 1.05-2.26, p = 0.028), and having ever served two or more custodial sentences (OR = 1.51, 95% CI 1.01-2.25, p = 0.045). Being married (OR = 0.45, 95% CI 0.29-0.70, p &lt; 0.001) was protective. Fewer predictors were associated with cause-specific mortality.

CONCLUSIONS

We identified several behavioural, psychosocial, and clinical markers associated with mortality from preventable causes in people released from prison. Emerging evidence points to interventions that could be targeted at those at increased risk of external cause mortality. These include treatment and harm reduction programmes (for substance use), improving transitional support programmes and continuity of care (for mental health), diversion and drug reform (for repeat incarceration) and nurturing stable relationships during incarceration. The period of imprisonment and shortly after release provides a unique opportunity to improve the long-term health of ex-prisoners and overcome the disadvantage associated with imprisonment.

Retention in clinical trials after prison release: results from a clinical trial with incarcerated men with HIV and opioid dependence in Malaysia

Background: Study retention is a major challenge in HIV clinical trials conducted with persons recruited from correctional facilities. Objective: To examine study retention in a trial of within-prison methadone initiation and a behavioral intervention among incarcerated men with HIV and opioid dependence in Malaysia. Methods: In this 2x2 factorial trial, 296 incarcerated men with HIV and opioid dependence were allocated to (1) an HIV risk reduction intervention, the Holistic Health Recovery Program for Malaysia (HHRP-M), (2) pre-release methadone initiation, (3) both interventions, or (4) standard care (NCT02396979). Here we estimate effects of these interventions on linkage to the study after prison release and completion of post-release study visits. Results: Most participants (68.9%) completed at least one post-release study visit but few (18.6%) completed all 12. HHRP-M was associated with a 13.5% (95% confidence interval (CI): 3.8%, 23.2%) increased probability of completing at least one post-release study visit. Although not associated with initial linkage, methadone treatment was associated with an 11% (95% CI: 2.0%, 20.6%) increased probability of completing all twelve post-release study visits. Being subject to forced relocation outside Kuala Lumpur after prison release decreased retention by 43.3% (95% CI: -51.9%, -34.8%). Conclusion: Retaining study participants in HIV clinical trials following prison release is challenging and potentially related to the broader challenges that participants experience during community reentry. Researchers conducting clinical trials with this population may want to consider methadone and HHRP as means to improve post-release retention, even in clinical trials where these interventions are not being directly evaluated.

Best Practices for Pregnant Incarcerated Women With Opioid Use Disorder

Pregnant women represent a unique population for correctional facilities to care for. The incarcerated pregnant population is at an increased risk of concurrent opioid use disorder (OUD) that requires specialized care. The evidence-based best practice and standard of care for pregnant women with OUD is medication-assisted treatment (MAT) with methadone or buprenorphine pharmacotherapy. Correctional facilities that house women must be prepared to provide this care in a timely manner upon intake in order to address the serious medical needs of the pregnant woman and her fetus. Providing MAT in the incarceration setting has distinctive logistics that must be considered. This article recommends strategies to optimize the care of pregnant incarcerated women with OUD, emphasizing the importance of appropriate counseling and treatment with opioid agonist pharmacotherapy.

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.

Brief intervention on Smoking, Nutrition, Alcohol and Physical (SNAP) inactivity for smoking relapse prevention after release from smoke-free prisons: a study protocol for a multicentre, investigator-blinded, randomised controlled trial

INTRODUCTION

Smoking remains the leading risk factor for disease burden and mortality worldwide. Heavy Smoking is often associated with poor Nutrition, Alcohol abuse and Physical inactivity (known as 'SNAP'). Australia's first prison smoking ban was introduced in the Northern Territory in July 2013. However, relapse to smoking after release from prison is normative. Holistic and cost-effective interventions are needed to maintain post-release abstinence to realise the potential public health impact of smoke-free prison policies. Rigorous, large-scale trials of innovative and scalable interventions are crucial to inform tobacco control policies in correctional settings.

METHODS AND ANALYSIS

This multicentre, investigator-blinded, randomised parallel superiority trial will evaluate the effectiveness of a brief intervention on SNAP versus usual care in preventing smoking relapse among people released from smoke-free prisons in the Northern Territory, Australia. A maximum of 824 participants will be enrolled and randomly assigned to either SNAP intervention or usual care at a 1:1 ratio at baseline. The primary endpoint is self-reported continuous smoking abstinence three months after release from prison, verified by breath carbon monoxide test. Secondary endpoints include seven-day point prevalence abstinence, time to first cigarette, number of cigarettes smoked post release, Health Eating Index for Australian Adults, Alcohol Use Disorder Identification Test-Consumption and International Physical Activity Questionnaire scores. The primary endpoint will be analysed on an intention-to-treat basis using a simple log binomial regression model with multiple imputation for missing outcome data. A cost-effectiveness analysis of the brief intervention will be conducted subsequently.

ETHICS AND DISSEMINATION

This study was approved by the University of New South Wales Human Research Ethics Committee (HREC), Menzies HREC and Central Australia HREC. Primary results of the trial and each of the secondary endpoints will be submitted for publication in a peer-review journal.

TRIAL REGISTRATION NUMBER

ACTRN12617000217303; Pre-results.

A Systematic Review of Interventions to Improve Health Factors or Behaviors of the Cardiovascular Health of Prisoners During Incarceration

BACKGROUND

Prisoners are disproportionately affected by cardiovascular disease and its risk factors. However, primary prevention of cardiovascular disease in correctional settings has been widely neglected, and there is little information on interventions to improve the cardiovascular health of prisoners while incarcerated.

OBJECTIVE

The aim of this study was to systematically review published literature to identify interventions to improve the health factors or behaviors of the cardiovascular health of prisoners during incarceration.

METHODS

Selected databases were searched using terms related to prisoners and cardiovascular disease. Studies were included if they had prisoners as participants and measured outcomes of cardiovascular health. Narrative synthesis was used to organize the evidence from the studies.

RESULTS

Twelve articles detailing 11 studies were identified. Most of the studies involved only men. Interventions were classified into 4 types: structured physical activity, nutrition, mixed with physical activity and educational sessions, and smoking cessation. Most studies measured short-term outcomes relating to cardiovascular health such as changes in blood pressure and weight. Only 4 studies were of high quality. Structured physical activity interventions, nutrition interventions, and smoking cessation interventions delivered in a group setting had significant effects on at least 1 measured outcome. The effect of mixed interventions could not be determined.

CONCLUSIONS

Structured physical activity interventions, nutrition interventions, and smoking cessation interventions delivered in a group setting can improve health factors or behaviors of the cardiovascular health of prisoners during incarceration. More high-quality research is needed to increase the evidence base on the effectiveness of these interventions in the correctional setting.

Addressing Women's Unmet Health Care Needs in a Canadian Remand Center: Catalyst for Improved Health?

Incarcerated women have a disproportionate burden of infectious and chronic disease, substance disorders, and mental illness. This study explored incarcerated women's health and whether a Women's Health Clinic improved care within this vulnerable population. Retrospective chart reviews and focus groups were conducted. Poor access to care in the community due to competing social needs was described. Barriers to care during incarceration included lack of comprehensive gender-specific services, mistrust of providers, and fragmentation. Of 109 women, high rates of mental illness, partner violence, substance use, sexually transmitted infection (STI), and irregular Pap testing were observed. Pap (15% to 54%, p < .001) and STI (17% to 89%, p < .001) testing rates increased. Fragmentation of care remained at transition points, and further work is needed to improve continuity within corrections and the community.