Supporting women leaving prison through peer health mentoring: a participatory health research study

"They Give you a bus Ticket and They Kick you Loose": A Qualitative Analysis of Post-Release Experiences among Recently Incarcerated Women Living with HIV in Metro Vancouver, Canada

To explore the transition from correctional facilities to community among women living with HIV in Vancouver, Canada, we interviewed 19 recently incarcerated women and 6 service providers. Findings highlighted heightened risk of violence at release, a lack of immediate supports, challenges accessing safe housing and addictions treatment, and interruptions in HIV treatment and care. In the face of structural barriers, women blamed themselves for not being able to break the cycle of incarceration. There is a critical need for enhanced pre-release planning with a priority on housing and substance use services, alongside supports that are trauma-and violence-informed and culturally safe.

Identifying structural risk factors for overdose following incarceration: a concept mapping study

BACKGROUND

Currently, there are more than two million people in prisons or jails, with nearly two-thirds meeting the criteria for a substance use disorder. Following these patterns, overdose is the leading cause of death following release from prison and the third leading cause of death during periods of incarceration in jails. Traditional quantitative methods analyzing the factors associated with overdose following incarceration may fail to capture structural and environmental factors present in specific communities. People with lived experiences in the criminal legal system and with substance use disorder hold unique perspectives and must be involved in the research process.

OBJECTIVE

To identify perceived factors that impact overdose following release from incarceration among people with direct criminal legal involvement and experience with substance use.

METHODS

Within a community-engaged approach to research, we used concept mapping to center the perspectives of people with personal experience with the carceral system. The following prompt guided our study: "What do you think are some of the main things that make people who have been in jail or prison more and less likely to overdose?" Individuals participated in three rounds of focus groups, which included brainstorming, sorting and rating, and community interpretation. We used the Concept Systems Inc. platform groupwisdom for our analyses and constructed cluster maps.

RESULTS

Eight individuals (ages 33 to 53) from four states participated. The brainstorming process resulted in 83 unique factors that impact overdose. The concept mapping process resulted in five clusters: (1) Community-Based Prevention, (2) Drug Use and Incarceration, (3) Resources for Treatment for Substance Use, (4) Carceral Factors, and (5) Stigma and Structural Barriers.

CONCLUSIONS

Our study provides critical insight into community-identified factors associated with overdose following incarceration. These factors should be accounted for during resource planning and decision-making.

A systematic scoping review exploring how people with lived experience have been involved in prison and forensic mental health research

BACKGROUND

Introduction of guidance by the National Institute for Health Research has led to an increase in participation by people with 'lived experience' of mental health problems. However, some researchers have questioned the extent to which involvement has been meaningful, expressing concerns that involvement is impeded by the structure and culture of academia. A prior review of literature to 2016 provided little evidence of active engagement.

AIMS

To find out from published literature how patient and public involvement in designing and or conducting research has been used in forensic mental health settings, prisons or probation since the last review period.

METHODS

A systematic scoping review of research published in academic journals between 2016 and February 2023 was completed using terms for research activity, involvement of people with experience of receiving services and health or justice systems to search three databases: MEDLINE, EMBASE and PsycINFO. We used the Guidance for Reporting Patient and Public Involvement in Research Tool to support data extraction and to summarise our own service user involvement in this study.

RESULTS

From 675 unique titles retrieved, 17 were eligible for inclusion, covering 16 unique studies. Most of the included research was by/with people who had prison experience. Only two studies had been conducted by/with people who had experience of secure hospital wards/forensic mental health services. Details of how people with lived experience had contributed to the research were scarce, but in 8 studies they had been involved throughout and included in the authorship group.

CONCLUSION

Whilst this review identifies pockets of good practice, meaningful engagement in forensic mental health research seems to remain rare, at least as reported in papers published in academic journals. Further research is required into whether this reflects real limits on inclusion, as we suspect, or such full integration that such reporting is not regarded as necessary or desirable, which we doubt. We urge journal editors to routinely ask authors to include information about how people with lived experience have been involved in any published research and the nature and extent of the influence they had. This may help to develop the evidence base and guard against tokenistic involvement.

"These Issues Aren't Separate": The Relationship Among Being Indigenous, Motherhood, and the Criminal Justice System

In using an approach encompassing intersectionality and interconnectedness, we highlight how the experiences of Indigenous mothers and mother figures in contact with the law are a result of various historical and contemporary events. We highlight a need for a wholistic approach to eliminate the overrepresentation of Indigenous Peoples, including parents, in the criminal justice system. There is a lack of research and discussion on Indigenous women and their experience with the justice system and by using an Indigenous lens, we can explore the establishment of culturally safe resources and care wherein gender inclusivity is prioritized. Our team of researchers and advocates intends for this article to contribute and spark dialogue on Indigenous Peoples, particularly mothers and mother figures and their interactions with the justice system. Although this article mainly focuses on federal programs and policies in Canada, insights on the barriers to care can be applied into policy and practice across multiple settler states.

Supporting pregnant and parenting women who use alcohol during pregnancy: A scoping review of trauma-informed approaches

Alcohol is legalized and used for a variety of reasons, including socially or as self-medication for trauma in the absence of accessible and safe supports. Trauma-informed approaches can help address the root causes of alcohol use, as well as the stigma around women's alcohol use during pregnancy. However, it is unclear how these approaches are used in contexts where pregnant and/or parenting women access care. Our objective was to synthesize existing literature and identify promising trauma-informed approaches to working with pregnant and/or parenting women who use alcohol. A multidisciplinary team of scholars with complementary expertise worked collaboratively to conduct a rigorous scoping review. All screening, extraction, and analysis was independently conducted by at least two authors before any differences were discussed and resolved through team consensus. The Joanna Briggs Institute method was used to map existing evidence from peer-reviewed articles found in PubMed, CINAHL, PsycINFO, Social Work Abstracts, and Web of Science. Data were extracted to describe study demographics, articulate trauma-informed principles in practice, and gather practice recommendations. Thirty-six studies, mostly from the United States and Canada, were included for analysis. Studies reported on findings of trauma-informed practice in different models of care, including live-in treatment centers, case coordination/management, integrated and wraparound supports, and outreach-for pregnant women, mothers, or both. We report on how the following four principles of trauma-informed practices were applied and articulated in the included studies: (1) trauma awareness; (2) safety and trustworthiness; (3) choice, collaboration, and connection; and (4) strengths-based approach and skill building. This review advances and highlights the importance of understanding trauma and applying trauma-informed practice and principles to better support women who use alcohol to reduce the risk of alcohol-exposed pregnancies. Relationships and trust are central to trauma-informed care. Moreover, when applying trauma-informed practices with pregnant and parenting women who use alcohol, we must consider the unique stigma attached to alcohol use.

Association of Mental Health Services Access and Reincarceration Among Adults Released From Prison in British Columbia, Canada

IMPORTANCE

Diagnosis of mental disorder is prevalent among people who have been incarcerated. Nevertheless, community mental health services are often limited following release from prison, and reincarceration rates are high. The prevalence of mental disorders is growing among people who are incarcerated in British Columbia (BC), Canada, increasing the urgency of timely and accessible mental health services after release.

OBJECTIVE

To examine the association of mental health services access and timeliness of services access with reincarceration risk among people released from prison.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, mental disorder diagnoses were derived from International Classification of Diseases, Ninth Revision or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes in administrative health records. Data on prison release and reincarceration were retrieved from corrections records. Population-based health and corrections data were retrieved from the BC Provincial Overdose Cohort, which contains a 20% general population random sample of 1 089 677 BC residents. This study examined releases from provincial prisons between January 1, 2015, and December 31, 2018, among people in the 20% random sample who had a mental disorder diagnosis in the year before their release. Analyses were performed from January to June 2022.

EXPOSURES

Mental health services access (primary care, emergency department visits, or hospitalization) and sociodemographic, health, and incarceration characteristics.

MAIN OUTCOMES AND MEASURES

A multistate modeling approach was taken. Cox proportional hazards models were stratified by transition, from release to reincarceration, with and without mental health services access. A state arrival extended model examined the influence of timeliness of mental health services access on subsequent hazard of reincarceration.

RESULTS

A total of 4171 releases among 1664 people (3565 releases among male individuals [84.6%]; 2948 releases [70.7%] among people <40 years old; 2939 releases [70.5%] among people with concurrent substance use disorder diagnosis) were identified. The total study follow-up time was 2834.53 person-years, with a mean (SD) of 0.68 (0.93) years and median (IQR) of 0.25 (0.07-0.84) years per release. Mental health services access was associated with a reduction in the hazard of reincarceration (hazard ratio, 0.61; 95% CI, 0.39-0.94). For each additional month between release and mental health services access, the hazard of reincarceration was increased by 4% (hazard ratio, 1.04; 95% CI, 1.01-1.07).

CONCLUSIONS AND RELEVANCE

In this cohort study of people with mental disorder diagnoses released from prison in BC, mental health services access was associated with reduced reincarceration risk. These findings suggest that these services may have the greatest impact on reducing reincarceration risk when they are available in a timely manner in the days and weeks immediately following release.

Stimulant use disorder diagnosis and opioid agonist treatment dispensation following release from prison: a cohort study

BACKGROUND

Concurrent opioid and stimulant use is on the rise in North America. This increasing trend of use has been observed in the general population, and among people released from prison in British Columbia (BC), who face an elevated risk of overdose post-release. Opioid agonist treatment is an effective treatment for opioid use disorder and reduces risk of overdose mortality. In the context of rising concurrent stimulant use among people with opioid use disorder, this study aims to investigate the impact of stimulant use disorder on opioid agonist treatment dispensation following release from prison in BC.

METHODS

Linked health and corrections records were retrieved for releases between January 1^st 2015 and December 29^th 2018 (N = 13,380). Hospital and primary-care administrative health records were used to identify opioid and stimulant use disorder and mental illness. Age, sex, and health region were derived from BC's Client Roster. Incarceration data were retrieved from provincial prison records. Opioid agonist treatment data was retrieved from BC's provincial drug dispensation database. A generalized estimating equation produced estimates for the relationship of stimulant use disorder and opioid agonist treatment dispensation within two days post-release.

RESULTS

Cases of release among people with an opioid use disorder were identified (N = 13,380). Approximately 25% (N = 3,328) of releases ended in opioid agonist treatment dispensation within two days post-release. A statistically significant interaction of stimulant use disorder and mental illness was identified. Stratified odds ratios (ORs) found that in the presence of mental illness, stimulant use disorder was associated with lower odds of obtaining OAT [(OR) = 0.73, 95% confidence interval (CI) = 0.64-0.84)] while in the absence of mental illness, this relationship did not hold [OR = 0.89, 95% CI = 0.70-1.13].

CONCLUSIONS

People with mental illness and stimulant use disorder diagnoses have a lower odds of being dispensed agonist treatment post-release compared to people with mental illness alone. There is a critical need to scale up and adapt opioid agonist treatment and ancillary harm reduction, and treatment services to reach people released from prison who have concurrent stimulant use disorder and mental illness diagnoses.

Association of Opioid and Stimulant Use Disorder Diagnoses With Fatal and Nonfatal Overdose Among People With a History of Incarceration

IMPORTANCE

Studies have suggested a rise in opioid- and stimulant-involved overdoses in recent years in North America. This risk may be acute for individuals who have had contact with the criminal justice system, who are particularly vulnerable to overdose risk.

OBJECTIVE

To examine the association of opioid and/or stimulant use disorder diagnoses with overdose (fatal and nonfatal) among people with histories of incarceration.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, population-based health and corrections data were retrieved from the British Columbia Provincial Overdose Cohort, which contains a 20% random sample of residents of British Columbia. The analysis included all people in the 20% random sample who had a history of incarceration between January 1, 2010, and December 31, 2014. Outcomes were derived from 5-years of follow-up data (January 1, 2015, to December 31, 2019). Statistical analysis took place from January 2022 to June 2022.

EXPOSURES

Substance use disorder diagnosis type (ie, opioid use disorder, stimulant use disorder, both, or neither), sociodemographic, health, and incarceration characteristics.

MAIN OUTCOMES AND MEASURES

Hazard ratios (HRs) are reported from an Andersen-Gill model for recurrent nonfatal overdose events and from a Fine and Gray competing risk model for fatal overdose events.

RESULTS

The study identified 6816 people (5980 male [87.7%]; 2820 aged <30 years [41.4%]) with histories of incarceration. Of these, 293 (4.3%) had opioid use disorder only, 395 (6.8%) had stimulant use disorder only, and 281 (4.1%) had both diagnoses. During follow-up, 1655 people experienced 4026 overdoses including 3781 (93.9%) nonfatal overdoses, and 245 (6.1%) fatal overdoses. In adjusted analyses, the hazard of both fatal (HR, 2.39; 95% CI, 1.48-3.86) and nonfatal (HR, 2.45; 95% CI, 1.94-3.11) overdose was highest in the group with both opioid and stimulant use disorder diagnoses.

CONCLUSIONS AND RELEVANCE

This cohort study of people with a history of incarceration found an elevated hazard of fatal and nonfatal overdose among people with both opioid and stimulant use disorder diagnoses. This study suggests an urgent need to address the service needs of individuals who have had contact with the criminal justice system and who co-use opioids and stimulants.

Community-based models of health care for women, trans and nonbinary people released from prisons: An international scoping review with implications for Canada

AIMS AND OBJECTIVES

To illustrate the scope of different types of transitional, community-based health interventions for formerly incarcerated women, trans and nonbinary people, the eligibility criteria for these interventions, and associated health outcomes.

BACKGROUND

Meeting the health needs of formerly incarcerated people in community, rather than through the criminal justice system, may prevent further experiences of criminalization. Research is needed to understand what community-based health interventions have been implemented internationally to inform the design of an intervention in Canada.

DESIGN

Scoping review using the Joanna Briggs Institute scoping review methodology.

METHODS

In consultation with a medical research librarian, key databases and journals were searched for English language articles, from any country, with no specified date range. Three authors independently screened titles and abstracts to identify articles for full-text review. The study adheres to PRISMA-EQUATOR guidelines.

RESULTS

Thirty-six studies met the present criteria and were reviewed in full text. Method, setting, participants, sample, relevant outcomes and relevant findings were extracted from each study for synthesis. Included studies had varied methods and were published from 1999 to 2020. Thirty-one studies were based in the United States, one in Puerto Rico and two each in Canada and the United Kingdom. The most common health issue focus was human immunodeficiency virus and/or hepatitis c virus. The most common outcome was uptake of offered services, such as a transitional clinic.

CONCLUSIONS

Gaps in the research pertain to a lack of attention to clinical outcomes and patient experience, and a lack of consideration of sexual and reproductive health concerns. Women were the minority population in all studies that included both men and women; transgender participants were mentioned in only four of thirty-six studies. The specific needs of women, trans and nonbinary people must be taken into consideration.

RELEVANCE TO CLINICAL PRACTICE

Nurses must be conscious of the elevated health risks associated with exposure to correctional institutions and the risks associated with the period of transition.

PATIENT OR PUBLIC CONTRIBUTION

A member of the research team brings lived experience expertise with respect to the criminal justice system.

Providing peer navigation services to women with a history of opioid misuse pre- and post-release from jail: A program description

Background:

Justice system-involved women with opioid use disorder (OUD) experience layered health risks and stigma, yet peer navigation services during reentry may support positive outcomes. This manuscript offers a program description of a women’s peer navigation intervention delivered pre- and post-release from jail to remove barriers to women’s access to OUD treatment, including medications for opioid use disorder (MOUD).

Methods:

All data were collected as part of a NIH/NIDA-funded national cooperative, the Justice Community Opioid Innovation Network (JCOIN) project. Through the larger study’s intervention, women in jail with OUD are connected via videoconference to a peer navigator, who provides an initial reentry recovery assessment and 12+ weeks of recovery support sessions post-release. Qualitative analyses examined peers’ notes from initial sessions with women (N = 50) and in-depth interviews with peers (N = 3).

Results:

Peers’ notes from initial sessions suggest that women anticipate challenges to successful recovery and community reentry. More than half of women (51.9%) chose OUD treatment as their primary goal, while others selected more basic needs (e.g. housing, transportation). In qualitative interviews, peers described women’s transitions to the community as unpredictable, creating difficulties for reentry planning, particularly for rural women. Peers also described challenges with stigma against MOUD and establishing relationships via telehealth, but ultimately believed their role was valuable in providing resource referrals, support, and hope for recovery.

Conclusions:

For women with OUD, peer navigation can offer critical linkages to services at release from jail, in addition to hope, encouragement, and solidarity. Findings provide important insights for future peer-based interventions.

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.

Patient and public involvement (PPI) in prisons: the involvement of people living in prison in the research process - a systematic scoping review

BACKGROUND

Patient and Public Involvement (PPI) in health and social care research is increasingly prevalent and is promoted in policy as a means of improving the validity of research. This also applies to people living in prison and using social care services. Whilst evidence for the effectiveness of PPI was limited and reviews of its application in prisons were not found, the infancy of the evidence base and moral and ethical reasons for involvement mean that PPI continues to be advocated in the community and in prisons.

OBJECTIVES

To conduct a review of the literature regarding the involvement of people or persons living in prison (PLiP) in health and social care research focused on: (i) aims; (ii) types of involvement; (iii) evaluations and findings; (iv) barriers and solutions; and (v) feasibility of undertaking a systematic review.

METHODS

A systematic scoping review was undertaken following Arksey and O'Malley's (International Journal of Social Research Methodology 8: 19-32, 2005) five-stage framework. A comprehensive search was conducted involving ten electronic databases up until December 2020 using patient involvement and context related search terms. A review-specific spreadsheet was created following the PICO formula, and a narrative synthesis approach was taken to answer the research questions. PRISMA guidelines were followed in reporting.

RESULTS

39 papers were selected for inclusion in the review. The majority of these took a 'participatory' approach to prisoner involvement, which occurred at most stages during the research process except for more 'higher' level research operations (funding applications and project management), and only one study was led by PLiPs. Few studies involved an evaluation of the involvement of PLiP, and this was mostly PLiP or researcher reflections without formal or independent analysis, and largely reported a positive impact. Barriers to the involvement of PLiP coalesced around power differences and prison bureaucracy.

CONCLUSION

Given the very high risk of bias arising from the available 'evaluations', it was not possible to derive firm conclusions about the effectiveness of PLiP involvement in the research process. In addition, given the state of the evidence base, it was felt that a systematic review would not be feasible until more evaluations were undertaken using a range of methodologies to develop the field further.

Knowledge of the Good Samaritan Drug Overdose Act and possession of a naloxone kit among people recently released from prison

PURPOSE

This study aims to describe knowledge of Canada's Good Samaritan Drug Overdose Act (GSDOA) and take home naloxone (THN) training and kit possession among people being released from provincial correctional facilities in British Columbia.

DESIGN/METHODOLOGY/APPROACH

The authors conducted surveys with clients of the Unlocking the Gates Peer Health Mentoring program on their release. The authors compared the characteristics of people who had and had not heard of the GSDOA and who were in possession of a THN kit.

FINDINGS

In this study, 71% people had heard of the GSDOA, and 55.6% were in possession of a THN kit. This study found that 99% of people who had heard of the GSDOA indicated that they would call 911 if they saw an overdose. Among people who perceived themselves to be at risk of overdose, 28.3% did not have a THN kit. Only half (52%) of participants had a mobile phone, but 100% of those with a phone said they would call 911 if they witnessed an overdose.

ORIGINALITY/VALUE

The authors found that people with knowledge of the GSDOA were likely to report that they would call 911 for help with an overdose. Education about the GSDOA should be a standard component of naloxone training in correctional facilities. More than one in four people at risk of overdose were released without a naloxone kit, highlighting opportunities for training and distribution. Access to a cellphone is important in enabling calls to 911 and should be included in discharge planning.

Supporting people leaving prisons during COVID-19: perspectives from peer health mentors

PURPOSE

Currently, people leaving prisons face concurrent risks from the COVID-19 pandemic and the overdose public health emergency. The closure or reduction of community services people rely on after release such as treatment centres and shelters has exacerbated the risks of poor health outcomes and harms. This paper aims to learn from peer health mentors (PHM) about changes to their work during overlapping health emergencies, as well as barriers and opportunities to support people leaving prison in this context.

DESIGN/METHODOLOGY/APPROACH

The Unlocking the Gates (UTG) Peer Health Mentoring Program supports people leaving prison in British Columbia during the first three days after release. The authors conducted two focus groups with PHM over video conference in May 2020. Focus groups were recorded and transcribed, and themes were iteratively developed using narrative thematic analysis.

FINDINGS

The findings highlighted the importance of peer health mentorship for people leaving prisons. PHM discussed increased opportunities for collaboration, ways the pandemic has changed how they are able to provide support, and how PHM are able to remain responsive and flexible to meet client needs. Additionally, PHM illuminated ways that COVID-19 has exacerbated existing barriers and identified specific actions needed to support client health, including increased housing and recovery beds, and tools for social and emotional well-being.

ORIGINALITY/VALUE

This study contributes to our understanding of peer health mentorship during the COVID-19 pandemic from the perspective of mentors. PHM expertise can support release planning, improved health and well-being of people leaving prison and facilitate policy-supported pandemic responses.

Key issues for participatory research in the design and implementation of humanitarian assistance: a scoping review

Background

Participatory approaches that engage affected populations are increasingly applied in humanitarian health programs in concert with emerging accountability frameworks and the rapid growth of research in these settings. Participatory initiatives within this domain appear to be largely adopted at an operational level and are infrequently reported as a component of research efforts. Yet the evidence of the benefits of research involving community members is growing worldwide. This is the first review of participatory research (PR) in humanitarian settings.

Objectives

This study sought to understand the extent to which PR values and practices have been adopted in humanitarian health programs and to explore key issues in applying PR in this context.

Methods

This scoping review was based on the approach developed by Arksey and O’Malley. The search for relevant peer-reviewed articles included scientific databases, a humanitarian database, targeted journals and online resources published since 2009. Eleven articles were retrieved and reviewed to identify practices and key issues related to conducting PR in humanitarian settings.

Results

Four key themes were identified: building trust with local research stakeholders and participants; the importance of contextual understanding; implications of collaborating with affected populations in PR, and neutrality of researchers and Non-Governmental Organizations (NGOs). Study teams considered PR as a valued approach where there was mistrust or a need for contextualized understanding. The studies described how adaptations made during the study optimized collaboration with affected populations and how the presence of NGOs influenced the approach and results of PR.

Conclusions

One of the most important contributions of humanitarian health programs is to develop ‘medical practices that are better adapted to the living conditions and priorities of patients who are generally ignored’. Participatory approaches, such as PR, support the development of health-related practices that are more relevant and sustainable for affected populations.