The Impact of Homelessness and Incarceration on Women's Health

Implementing Interventions for Women and Youth with Traumatic Brain Injury at Transition from Custodial Settings: A Call to Action

Traumatic brain injury (TBI) is a serious public health concern and overrepresented among justice-involved populations. An emerging area of research focuses on the complex, interrelated and unmet health and social needs of justice-involved women and youth with TBI. Evidence of these needs continues to grow, yet the health and justice systems continue to underperform in supporting the health and social care of justice-involved women and youth. This commentary is a call to action to begin to redress these gaps. We first provide an overview of the needs of women and youth with TBI that affect their transition from custody to community, including those related to victimization, trauma, mental health, substance use, and homelessness. We then highlight the current gaps in knowledge and practice with respect to interventions for women and youth with TBI at transition from custody. The available evidence for the impact of interventions on people with head injury who are justice-involved is sparse, especially studies of interventions focused on women and youth. We conclude with a call for implementation science studies to support translation from research to practice, emphasizing that researchers, practitioners, policy makers, and women and youth at transition should collaborate to develop, implement, and evaluate accommodations and interventions for TBI. To have meaningful, positive impacts on the systems that serve these women and youth, interdisciplinary service delivery approaches should aim to prevent, raise awareness, identify, and provide timely support and services for the varied needs of women and youth with TBI in transition.

Mental health needs of homeless and recently housed individuals in Canada: A meta-ethnography

Homeless individuals are disproportionately likely to experience mental health conditions, and typically face many systemic barriers to access mental health services. This study sought to determine the mental health needs of homeless and recently housed individuals in Canada. A meta-ethnography was conducted to synthesise existing qualitative data and translate themes across a broader context. Thirty-five studies on the experiences of 1511 individuals with a history of homelessness were included. Themes were interpreted by comparing and contrasting findings across multiple contexts. Distinct, yet highly interrelated, unmet mental health needs were revealed through personal narratives of trauma, stigmatisation, victimisation, and a lack of basic necessities. Six themes that characterised this population's mental health needs were ontological security, autonomy, hope and purpose, empowerment, social connection and belonging, and access to services. This study revealed homeless individuals' unmet mental health needs to inform social and policy change and improve psychological well-being.

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.

Application of the Frailty Framework among Vulnerable Populations to Hospitalization Outcomes of Individuals Experiencing Homelessness in Long Beach, California

BACKGROUND

Individuals experiencing homelessness have a high prevalence of infectious diseases that may result in hospitalization. However, low ability to navigate the healthcare system and lack of health insurance may mean that those who are experiencing homelessness may not receive the healthcare that they need.

OBJECTIVES

This study uses risk factors at baseline to predict hospitalization at follow-up. This paper also presents the associations between reporting homelessness and selected infectious diseases.

RESEARCH DESIGN

Longitudinal study of baseline and follow-up conducted August 2000 through July 2014.

SUBJECTS

4916 Not experiencing homelessness mean age 37.9 years, 29% female, and 2692 experiencing homelessness age 42.1 years, 29% female received services from a research/service center in a low-income, high-crime area of Long Beach, CA.

MEASURES

Risk Behavior Assessment, Risk Behavior Follow-up Assessment, laboratory testing for hepatitis A, hepatitis B, hepatitis C, syphilis, chlamydia, and gonorrhea.

RESULTS

Predictors of hospitalization at follow-up were ever use of crack cocaine, income from Social Security or disability, reporting homelessness, female, and those who identify as Black compared to White race/ethnicity.

CONCLUSIONS

Income from the safety net of Social Security or disability appears to provide the participant with experience that transfers to being able to obtain healthcare. A higher proportion of those experiencing homelessness, compared to those not experiencing homelessness, appear to be hospitalized at follow-up. Women, those who identified as Black, and those who used crack at baseline are more likely to be hospitalized at follow-up whether or not they were experiencing homelessness. We recommend coordination with substance abuse treatment programs for discharge planning for homeless patients. Our findings support use of the Frailty Framework when working with individuals experiencing both homelessness and hospitalization.

Health Status of Females Who Experience Incarceration: A Population-Based Retrospective Cohort Study

Background: People who experience incarceration have poor health across a variety of indicators, but we lack population-level data on the health of females in particular. We examined the health status of females released from provincial prison, and compared their data with data for males released from provincial prison and females in the general population in Ontario, Canada in 2010. Methods: We conducted a retrospective cohort study using linked correctional and health administrative data. We compared sociodemographic data, morbidity, mortality, and use of health care for (1) females released from provincial prison in 2010, (2) males released from provincial prison in 2010, and (3) age-matched females in the general population. Results: Females in the incarceration group (N = 6,107) were more likely to have higher morbidity and specific psychiatric conditions compared with the male incarceration group (N = 42,754) and the female general population group (N = 24,428). Their mortality rate postrelease was several times higher than that for the female general population group. They used primary care more often than both comparator groups across all time periods, and they used emergency departments more often compared with the female general population group and in most periods postrelease compared with the male incarceration group. They also tended to have higher rates of medical-surgical and psychiatric hospitalization. Conclusion: Females who experience incarceration have worse health overall than males who experience incarceration and females in the general population. Efforts should be made to reform programs and policies in the criminal justice and health care systems to support and promote health for females who experience incarceration.

Menopausal Symptoms in Underserved and Homeless Women Living in Extreme Temperatures in the Southwest

Background: Little is known about menopausal symptoms in underserved women. Aim: To better understand self-reported menopausal symptoms in underserved and homeless women living in extreme heat during different seasons. Methods: A cross-sectional study, including the Greene Climacteric Scale (GCS), climate-related questions, and demographics was administered June to August of 2017 and December to February 2018 to women 40-65 years of age. Results: In 104 predominantly Hispanic (56%), uninsured (53%), menopausal (56%), and mid-aged (50 ± 9.5) women, 57% reported any bother, while 20% of these women reported "quite a bit" or "extreme" bother from hot flushes. The total GCS score was a mean of 41 ± 15.0; out of 63 indicating significant symptoms, the psychological and somatic clusters were highest. Women did not think temperature outside influenced their menopausal symptoms at either time point (69% in winter vs. 57% in summer, p = 0.23). In multivariable analyses after adjusting for race, body mass index, and living situation neither season nor temperature was associated with self-reported hot flush bother. While one-third of women reported becoming ill from the heat, 90% of women reported not seeking care from a doctor for their illness. Conclusion: Menopausal, underserved, homeless women living in Arizona reported few vasomotor symptoms regardless of season, and endorsed psychological and somatic complaints. Socioeconomic factors may influence types of bothersome menopausal symptoms in this population of women.

Health Access of Women in Provincial Correctional Institutions

Historically, there has been a disparity between men and women rates of incarceration, even though there has been a significant increase in the number of women imprisoned over the past 20 years, globally. Women have unique health care needs that are often not adequately addressed within the correctional institutions in which they are held. The focus of this study was to explore women's experiences when accessing health services within Canadian provincial correctional institutions. Narrative inquiry was used to investigate the life stories of five women who accessed health care in provincial correctional institutions. A total of two storylines and five sub-storylines resulted from the analysis of interviews conducted with the participants. The findings suggest that during incarceration, participants experienced compromising conditions that contributed to the worsening of their health, and faced difficulties accessing their prescribed treatments and medications. Consequently, this contributed to the worsening of their physical and mental wellbeing.

Correlates of sexually transmitted infection testing following women's release from jail

Given incarcerated women's frequent transitions between jail and community, it is important to seize opportunities to provide comprehensive health care. A potential time to provide care might be when getting tested for sexually transmitted infections (STIs). Our objective was to determine the proportion of women receiving STI testing and correlates, following jail release. This secondary analysis was of one-year follow-up data from women who participated in a jail-based cervical health literacy intervention in three Kansas City jails from 2014 to 2016. Most (82%) completed the survey in the community. The analysis included 133 women. Mean age 35 years (19-58 years). Sixty-two percent obtained STI testing within one-year post-intervention. Using logistic regression this was associated with younger age (odds ratio [OR] = 0.87; 95% confidence interval [CI] 0.80, 0.95), receiving high school education (OR = 4.33; 95% CI 1.00, 18.74), having insurance (OR = 4.32; 95% CI 1.25, 14.89), no illicit drug use (OR = 0.09; 95% CI 0.01, 0.81), and no drinking problem (OR = 0.04; 95% CI 0.00, 0.45). In this study, many women sought STI testing following jail release. Clinicians/public health practitioners may find it useful to engage these high-risk women in broader women's health services seeking STI testing.

Correlates of Posttraumatic Stress Symptoms among Formerly Incarcerated, Homeless Women

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

Outcomes among pregnant recently incarcerated women attending a reentry transitions clinic

This mixed methods retrospective case series and qualitative descriptive study describes pregnancy outcomes during the postincarceration period. A retrospective case series via electronic medical record chart review from a subset of women attending a postincarceration primary care clinic with a condition of interest (pregnancy) described demographics, substance use, diagnoses, and pregnancy outcomes. We compared 27 pregnant to 79 nonpregnant women and contextualized quantitative data with qualitative descriptive vignettes. Twenty-seven women completed 29 pregnancies (2 women with 2 deliveries each), all of which were unplanned; there were 11 live births, 8 pregnant at study closure, 7 miscarriages, and 3 terminations. Although substance use history was high, rates were higher among nonpregnant women (92% vs 74%). Among the 5 births, 4 tested positive for substance use during pregnancy. All 11 infants had pregnancy or delivery complications. Although 7 of the 10 pregnant women with live births had prior pregnancy complications, only 4 were placed in a special care obstetrics clinic. Although unplanned pregnancies were common, most births did not demonstrate maternal substance use. All live births had pregnancy or delivery complications, but few were accepted to specialist prenatal care, suggesting potential considerations for recently incarcerated women.

Women on the Institutional Circuit: A 9-Year Qualitative Study

Using a mixed-method approach of interviews and ethnographic observations, the authors followed a cohort of women postincarceration in Massachusetts for a period of 9 years. The women repeatedly cycled through health care and other institutions, yet very few moved into stable housing, jobs, and family situations. Nearly all continue to suffer multiple physical and mental health challenges despite high levels of access to health care. This article is intended to provide those who work in correctional institutions a broader view of the lives of justice-involved women outside of those institutions. In light of the short sentences and frequent breaks in continuity of care experienced by these women, the authors call for expansion of the roles of community health center providers inside jails and prisons.

Cervical Cancer Screening Access for Women Who Experience Imprisonment in Ontario, Canada

IMPORTANCE

Women who experience imprisonment have higher rates of cervical cancer. Lack of access to cervical cancer screening in the community or in prison may contribute to increased cervical cancer incidence.

OBJECTIVES

To determine cervical cancer screening rates for women in provincial prison in Ontario, Canada, and to compare these data with data for the general population.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used correctional and health administrative data from January 1, 2006, to December 31, 2013. Participants included Ontario women aged 21 to 69 years during the follow-up period with no history of cervical cancer or hysterectomy. Analyses were conducted between July 2017 and September 2018.

EXPOSURES

Women admitted to Ontario provincial prison in 2009 or 2010 and released in 2010 were considered exposed, and women in the general population of Ontario were considered unexposed.

MAIN OUTCOMES AND MEASURES

Whether women were overdue for cervical cancer screening at the time of admission to prison or on July 1, 2010, for the general population, defined as not having been screened in the previous 3 years, and whether women who were overdue were still overdue after 3 years.

RESULTS

There were 4553 women in the prison group and 3 647 936 women in the general population group. The median (interquartile range) age was 36 (29-43) years in the prison group and 43 (34-53) years in the general population. Women in the prison group had 2.20 times (95% CI, 2.08-2.33) the odds of being overdue for cervical cancer screening compared with women in the general population after adjusting for neighborhood income quintile, at 53.9% (95% CI, 51.8%-56.1%) compared with 32.9% (95% CI, 32.8%-33.0%) (P < .001). Women in the prison group also had nearly twice the odds of still being overdue at 3 years, with an odds ratio of 1.87 (95% CI, 1.76-1.99) after adjusting for neighborhood income quintile, and rates of still being overdue of 36.2% (95% CI, 34.5%-38.0%) compared with 21.9% (95% CI, 21.8%-21.9%) (P < .001).

CONCLUSIONS AND RELEVANCE

Women who experience imprisonment have worse cervical cancer screening access than women in the general population. Work should be done to promote cervical cancer screening awareness and to improve access to acceptable screening in prison and in the community after prison release.

Correlates of Treatment Readiness among Formerly Incarcerated Homeless Women

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

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.

Policy and Legal Protection for Breastfeeding and Incarcerated Women in Canada

Most incarcerated women in Canada are mothers. Because women are the fastest growing population in carceral facilities, protecting the rights of incarcerated women to breastfeed their children is increasingly important. There is considerable evidence that incarcerated women in Canada experience poor physical and mental health, isolation, and barriers to care. Incarcerated women and their children could benefit significantly from breastfeeding. This Insight in Policy explores policy and legal protection for breastfeeding in Canada as it relates to carceral facilities, considers key cases regarding breastfeeding rights among incarcerated women, and presents recommendations for policy development and advocacy. The Canadian Constitution and human rights legislation across Canada prohibits discrimination on the basis of gender and includes pregnancy and the possibility of becoming pregnant as a characteristic of gender. Some provinces note that breastfeeding is a characteristic of gender. Women's Wellness Within, a nonprofit organization providing volunteer perinatal support to criminalized women in Nova Scotia, conducted a scan of all provincial and territorial correctional services acts and the federal Corrections and Conditional Release Act: none mention breastfeeding. Protocols for breastfeeding during arrest and lockup by police were not available in any jurisdiction across Canada. International law, including the Convention on the Rights of the Child, the Nelson Mandela Rules, and the Bangkok Rules, have application to the rights of incarcerated breastfeeding women. The Inglis v. British Columbia (Minister of Public Safety) (2013) and Hidalgo v. New Mexico Department of Corrections (2017) decisions are pivotal examples of successful litigation brought forward by incarcerated mothers to advance breastfeeding rights. Improved application and understanding of existent law could advance breastfeeding rights.

Access to healthcare services during incarceration among female inmates

Purpose

Incarcerated women have a disproportionate burden of infectious and chronic disease, in addition to substance use disorder and mental health illness, when compared to the general population (Binswanger et al., 2009; Fazel et al., 2006; Fuentes, 2013; Kouyoumdjian et al., 2012). Women often enter the correctional system in poor health, making incarceration an opportunity to address health issues. The purpose of this paper is to explore the barriers to accessing health services that female inmates face during incarceration, the consequences to their health, and implications for correctional health services delivery.

Design/methodology/approach

Focus groups were conducted in Canadian correctional center with female inmates. Focus groups explored women’s experiences with accessing health services while incarcerated; the impact of access to health services on health during incarceration and in the community; and recommendations for improving access to health services. Thematic analysis was completed using N-vivo 10.

Findings

The women described multiple barriers to accessing health services that resulted in negative consequences to their health: treatment interruption; health disempowerment; poor mental and physical health; and recidivism into addiction and crime upon release. Women made three important recommendations for correctional health service delivery: provision of comprehensive health entry and exit assessments; improvement of health literacy; and establishment of health support networks. The recommendations were organized into an “Accessing Health Services Resource Manual” for incarcerated women.

Originality/value

There is a paucity of existing literature examining provision of health services for female inmates. These findings have relevancy for correctional and community health care providers and organizations that provide health services for this vulnerable population.