The health care utilization of people in prison and after prison release: A population-based cohort study in Ontario, Canada

The Value of Screening for a History of Incarceration in the Palliative Care Setting

The United States (US) has one of the highest rates of incarceration in the world. Due to the aging of the US population as a whole and limited opportunities for early release, the proportion of older people in prison continues to rise. Some correctional health systems have adopted geriatric and palliative care principles to better care for this aging population, many of whom die in prison. However, not everyone who grows old in prison will die behind bars. In this article, we explore existing literature that highlights the unique physical, cognitive, and psychosocial challenges that formerly incarcerated patients face. We proceed to argue that palliative care providers should screen for a history of incarceration to identify and address the needs of this patient population. We also offer strategies to create a safe, welcoming environment to discuss past traumas related to these patients' time in prison.

Chronic Psychotic Disorders and Correctional Involvement: A Population-Based Matched Case-Control Study in Ontario, Canada

OBJECTIVE

Individuals with chronic psychotic disorders are overrepresented in correctional facilities, but little is known about factors that increase the risk of correctional involvement. The objective of this study was to compare individuals with chronic psychotic disorders who were released from correctional facilities in Ontario to individuals with chronic psychotic disorders but no correctional involvement on sociodemographic, clinical, and prior mental health-related health service utilization characteristics.

METHOD

All individuals with chronic psychotic disorders who were released from a provincial correctional facility in Ontario in 2010 were matched (1:2) by age and sex to Ontario residents with chronic psychotic disorders and no correctional involvement. Covariates included sociodemographic (rural residence, marginalization such as residential instability quintile, material deprivation quintile, dependency quintile, and ethnic concentration quintile) and clinical (duration of chronic psychotic disorder and comorbidities) characteristics, and mental health-related health service utilization characteristics (primary care physician, psychiatrist and emergency department visits, and hospitalizations) 1 and 3 years prior to correctional involvement. The association between correctional involvement and prior health service utilization was measured by estimating incidence rate ratios using Poisson and negative-binomial regressions.

RESULTS

Individuals with correctional involvement (N = 3,197) lived in neighbourhoods with higher material deprivation and residential instability, and had a shorter duration of illness, and more psychosocial comorbidities (e.g., behavioural issues and depression) than individuals without correctional involvement (N = 6,393). Adjusting for sociodemographic and clinical variables, individuals with correctional involvement had a higher rate of mental health-related primary care physician visits, emergency department visits, and hospitalizations but a lower rate of psychiatrist visits prior to correctional involvement, compared to individuals without correctional involvement.

CONCLUSIONS

Despite higher mental health-related comorbidities and higher rates of accessing acute mental health services among individuals with chronic psychotic disorders and correctional involvement, visits to psychiatrists prior to involvement were low.

The State of Mental Health Services for Incarcerated Adults in Ontario: A Scoping Review

Individuals with mental illness are significantly overrepresented in the Canadian justice system. Given the high rate of mental illness among individuals who are incarcerated, correctional facilities must implement accessible and effective mental health resources. This not only improves their health and well-being but also contributes to their rehabilitation efforts. However, evidence suggests that the care provided in prisons is inadequate. This scoping review asks, "What is known about the access and quality of mental health care services for adults who are incarcerated in Ontario?" Mental health care services included non-acute interventions and care that is provided in the institution. This scoping review followed the PRISMA Extension for Scoping Reviews methodology. Databases searched include MedLINE, EMBASE, CINAHL, PsycINFO, Criminal Justice Abstracts, JSTOR, Google Scholar, and the grey literature. The search yielded 354 titles and abstracts of which 16 met the inclusion criteria. Conducted from 2010-2022, the 16 studies included qualitative, quantitative, and mixed methods. Common themes that were identified related to segregation, mental health assessments, medication prescribing and access, opioid agonist therapy, psychiatric service access, systemic and institutional barriers, mental health perception, and the need for collaboration. Despite the significant demand for mental health care in Ontario correctional facilities, limitations to quality care are evident. Such limitations intersect and are then exacerbated, resulting in poor mental health care provision among the incarcerated population. More research is warranted regarding the access, quality, and efficiency of mental health care in Ontario prisons, and how factors including ethnicity, gender, and prison classification (provincial vs. federal) may influence mental health care and its outcomes.

Factors associated with obtaining prescribed safer supply among people accessing harm reduction services: findings from a cross-sectional survey

BACKGROUND

With growing rates of unregulated drug toxicity death and concerns regarding COVID-19 transmission among people who use drugs, in March 2020, prescribed safer supply guidance was released in British Columbia. This study describes demographic and substance use characteristics associated with obtaining prescribed safer supply and examines the association between last 6-month harm reduction service access and obtaining prescribed safer supply.

METHODS

Data come from the 2021 Harm Reduction Client Survey administered at 17 harm reduction sites across British Columbia. The sample included all who self-reported use of opioids, stimulants, or benzodiazepines in the prior 3 days (N = 491), given active use of these drugs was a requirement for eligibility for prescribed safer supply. The dependent variable was obtaining a prescribed safer supply prescription (Yes vs. No). The primary independent variables were access to drug checking services and access to overdose prevention services in the last 6 months (Yes vs. No). Descriptive statistics (Chi-square tests) were used to compare the characteristics of people who did and did not obtain a prescribed safer supply prescription. Multivariable logistic regression models were run to examine the association of drug checking services and overdose prevention services access with obtaining prescribed safer supply.

RESULTS

A small proportion (n = 81(16.5%)) of the sample obtained prescribed safer supply. After adjusting for gender, age, and urbanicity, people who reported drug checking services access in the last 6 months had 1.67 (95% CI 1.00-2.79) times the odds of obtaining prescribed safer supply compared to people who had not contacted these services, and people who reported last 6 months of overdose prevention services access had more than twice the odds (OR 2.08 (95% CI 1.20-3.60)) of prescribed safer supply access, compared to people who did not access these services.

CONCLUSIONS

Overall, the proportion of respondents who received prescribed safer supply was low, suggesting that this intervention is not reaching all those in need. Harm reduction services may serve as a point of contact for referral to prescribed safer supply. Additional outreach strategies and service models are needed to improve the accessibility of harm reduction services and of prescribed safer supply in British Columbia.

"A prison is no place for a pandemic": Canadian prisoners' collective action in the time of COVID-19

Since the onset of COVID-19, social protest has expanded significantly. Little, however, has been written on prison-led and prison justice organizing in the wake of the pandemic-particularly in the Canadian context. This article is a case study of prisoner organizing in Canada throughout the first 18 months of COVID-19, which draws on qualitative interviews, media, and documentary analysis. We argue that the pandemic generated conditions under which the grievances raised by prisoners, and the strategies through which they were articulated, made possible a discursive bridge to the anxieties and grievances experienced by those in the community, thinning the walls of state-imposed societal exclusion. We demonstrate that prisons are sites of fierce contestation and are deeply embedded in, rather than separate from, our society. An important lesson learned from this case study is the need for prison organizing campaigns to strategically embrace multi-issue framing and engage in sustained coalition building.

The role of co-occurring disorders in criminal recidivism and psychiatric recovery among adults with opioid use disorder and criminal-legal involvement: A statewide retrospective cohort study

INTRODUCTION

Individuals with opioid use disorder (OUD) in the criminal-legal system commonly present co-occurring mental health disorders. However, evidence-based treatment for high-risk populations such as those with co-occurring disorders is often unavailable within jails and prisons. Coordination of timely and affordable access to behavioral health treatment following incarceration is critical to address the multidimensional needs of people with co-occurring needs. However, the role of co-occurring disorders among adults with OUD and criminal-legal involvement who are accessing community-based treatment is understudied.

METHODS

This retrospective cohort study investigated community and recovery outcomes among 2039 adults with OUD and criminal-legal involvement enrolled in a statewide forensic treatment initiative between October 2015 to March 2018. Using court records and clinical data, we assessed the impact of co-occurring OUD and mental health disorders on criminal recidivism and psychiatric recovery and the moderating role of co-occurring disorders on the relationship between community-based treatment and these outcomes.

RESULTS

We found that 47 % of those with OUD also had an underlying mental health disorder. Co-occurring OUD and mental health disorders predicted higher rates of recidivism during the early stages of treatment. Furthermore, group and individual therapy services were associated with lower odds of recidivism. A co-occurring disorder was an important predictor of more severe behavioral health needs when exiting community-based services and did moderate the relationship between service utilization-specifically group therapy and substance use outpatient services-and psychiatric recovery (i.e., behavioral health needs at exit).

CONCLUSIONS

Co-occurring mental health disorders are highly prevalent among adults with OUD who have criminal-legal involvement, but it appears that they can benefit from social support services in the community. Given the multidimensional needs of this high-risk population, criminal-legal stakeholders and community-based clinicians must work in tandem to develop tailored treatment plans that give individuals with co-occurring OUD and mental health disorders the best chance for success post-incarceration rather than a siloed approach to overlapping disorders.

The Association Between Prior Mental Health Service Utilization and Risk of Recidivism among Incarcerated Ontario Residents

BACKGROUND

There is mixed evidence on the link between mental health and addiction (MHA) history and recidivism. Few studies have examined post-release MHA care. Our objective was to examine the association between prior (pre-incarceration) MHA service use and post-release recidivism and service use.

METHODS

We conducted a population-based cohort study linking individuals held in provincial correctional institutions in 2010 to health administrative databases. Prior MHA service use was assigned hierarchically in order of hospitalization, emergency department visit and outpatient visit. We followed up individuals post-release for up to 5 years for the first occurrence of recidivism and MHA hospitalization, emergency department visit and outpatient visit. We use Cox-proportional hazards models to examine the association between prior MHA service use and each outcome adjusting for prior correctional involvement and demographic characteristics.

RESULTS

Among a sample consisting of 45,890 individuals, we found that prior MHA service use was moderately associated with recidivism (hazard ratio (HR): 1.20-1.50, all P < 0.001), with secondary analyses finding larger associations for addiction service use (HR range: 1.34-1.54, all P < 0.001) than for mental health service use (HR range: 1.09-1.18, all P < 0.001). We found high levels of post-release MHA hospitalization and low levels of outpatient MHA care relative to need even among individuals with prior MHA hospitalization.

DISCUSSION

Despite a high risk of recidivism and acute MHA utilization post-release, we found low access to MHA outpatient care, highlighting the necessity for greater efforts to facilitate access to care and care integration for individuals with mental health needs in correctional facilities.

Factors Associated With Visual Impairment Among Adults With a History of Criminal Justice Involvement

The purpose of this study was to investigate the prevalence of and factors associated with visual impairment among adults with a history of criminal justice involvement (CJI). This retrospective, cross-sectional study reviewed adult respondents from the 2015-2018 National Survey on Drug Use and Health. We analyzed sociodemographic and health characteristics to determine factors associated with visual impairment among adults with and without a history of CJI. In this national, population-based study, we found similar rates of visual impairment among adults with and without CJI (5.7% vs. 4.2%, p < .001). However, adults with CJI were more likely to report visual impairment at a younger age. Among adults with CJI, visual impairment was associated with female sex, older age, Black/African American race, less education, lower income, and chronic health conditions (including diabetes, heart disease, respiratory illness, mental health symptoms, and hearing impairment). CJI in the past year (probation [adjusted odds ratio, AOR, 0.70; 95% confidence interval, CI, 0.53-0.93]; one arrest [AOR, 1.47; 95% CI, 1.14-1.89]; two or more arrests [AOR, 1.73; 95% CI, 1.29-2.33]) was uniquely associated with visual impairment among adults with a CJI history (p < .05 for all relationships). Research, screening, and treatment for visual impairment should include those with justice involvement to improve health equity.

Health status and health-care utilization among men recently released from a superjail: a matched prospective cohort study

PURPOSE

Continuity of care and access to primary care have been identified as important contributors to improved health outcomes and reduced reincarceration among people who are justice-involved. While the disproportionate burden of health concerns among incarcerated populations is well documented, less is known about their health service utilization, limiting the potential for effective improvements to current policy and practice. This study aims to examine health status and health care utilization among men recently released from a superjail in a large metropolitan area to better understand patterns of use, risk factors and facilitators.

DESIGN/METHODOLOGY/APPROACH

Participants included adult men (n = 106) matched to a general population group (n = 530) in Ontario, Canada, linked to medical records (88.5% linkage) to examine baseline health status and health utilization three-months post-release. The authors compared differences between the groups in baseline health conditions and estimated the risk of emergency department, primary care, inpatient hospitalization and specialist ambulatory care visits.

FINDINGS

Superjail participants had a significantly higher prevalence of respiratory conditions, mental illness, substance use and injuries. Substance use was a significant risk factor for all types of visits and emergency department visits were over three times higher among superjail participants.

ORIGINALITY/VALUE

This empirical case is illustrative of an emerging phenomenon in some regions of the world where emergency departments serve as de facto "walk-in clinics" for those with criminal justice involvement. Strategic approaches to health services are required to meet the complex social and health needs and disparities in access to care experienced by men released from custody.

Sex differences in pre-incarceration mental illness, substance use, injury and sexually transmitted infections and health service utilization: a longitudinal linkage study of people serving federal sentences in Ontario

BACKGROUND

People who experience incarceration have poorer health than the general population. Yet, we know little about the health and health service utilization of people during the critical period prior to their incarceration, relative to during incarceration and post-release. In this study, we conducted a longitudinal cohort study of 39,498 adults in Ontario, Canada between January 1, 2002, and December 31, 2011 using linked administrative health and correctional data to describe mental illness, substance use, injury, sexually transmitted infections and health service utilization of men and women in federal prisons in the 3 years prior to their incarceration, compared to a matched group.

RESULTS

We found that, in the 3-year period prior to their incarceration, men (n = 6,134) and women (n = 449) experiencing their first federal sentence had poorer health across all indicators examined (e.g., psychosis, drug/alcohol use, and self-harm) and higher outpatient psychiatric and emergency department visits, compared with the matched group. Women in the pre-incarceration group exhibited a higher prevalence of self-harm and substance use, relative to women in the matched comparison group and higher relative prevalence to that of men in the pre-incarceration group, compared to their matched counterparts.

CONCLUSIONS

Disparities in health and health service utilization are gendered and exist prior to incarceration. The gendered nature of these findings, specifically the significantly higher prevalence of poor health among women across several indicators, necessitates a focus on the social and systemic factors that contribute to these disparities. Gender-responsive and trauma-informed primary, secondary, and tertiary prevention strategies, alongside transformative approaches to justice should be considered in addressing the health needs of men and women who experience incarceration.

Healthcare utilization and psychiatric morbidity in violent offenders: findings from a prospective cohort study

PURPOSE

Although persistent offenders with histories of imprisonment and violence have disproportionate high rates of psychiatric disorders, little is known of their psychiatric healthcare utilization (HCU) and HCU-associated factors. This study aimed to explore psychiatric HCU, psychiatric morbidity, and psychotropic prescription drugs in violent offenders with a history of incarceration.

METHODS

Male offenders aged 18-25 (n = 266) imprisoned for violent and/or physical sexual offenses were clinically assessed in 2010-2012 and prospectively followed in Swedish national registries through 2017. Register-based information regarding HCU, psychiatric morbidity, and psychotropic drugs was tracked and compared with a general population group (n = 10,000) and across offending trajectory groups. Baseline risk factors were used to explain prospective psychiatric HCU in violent offenders.

RESULTS

Violent offenders used less general healthcare and psychiatric outpatient care, but more psychiatric inpatient care and were more often given psychiatric diagnoses and psychotropic drugs than the general population. Participants previously assigned to persisting offending trajectory groups had higher rates of psychiatric HCU than those assigned to a desisting trajectory. In multivariable regression models, psychiatric HCU was associated with anxiety disorders, prior psychiatric contact, placement in a foster home, psychopathic traits, low intellectual functioning, and persistent offending.

CONCLUSIONS

Violent offenders are burdened by extensive and serious psychiatric morbidity and typically interact with psychiatric healthcare as inpatients rather than outpatients. Knowledge about their backgrounds, criminal behaviors, and psychiatric statuses can aid the planning of psychiatric services for this troublesome group.

Equivalence of care, confidentiality, and professional independence must underpin the hospital care of individuals experiencing incarceration

We present the reflections of three clinical practitioners on ethical considerations when caring for individuals experiencing incarceration needing in-patient hospital services. We examine the challenges and critical importance of adhering to core principles of medical ethics in such settings. These principles encompass access to a physician, equivalence of care, patient's consent and confidentiality, preventive healthcare, humanitarian assistance, professional independence, and professional competence. We strongly believe that detained persons have a right to access healthcare services that are equivalent to those available in the general population, including in-patient services. All the other established standards to uphold the health and dignity of people experiencing incarceration should also apply to in-patient care, whether this takes place outside or inside the prison boundaries. Our reflection focuses on the principles of confidentiality, professional independence, and equivalence of care. We argue that the respect for these three principles, although they present specific implementation challenges, is foundational for implementing the other principles. Critically important are respect for the distinct roles and responsibilities of healthcare and security staff as well as transparent and non-hierarchical dialogue between them to ensure optimal health outcomes and functioning of hospital wards while balancing the ongoing tensions between care and control.

Finding help and hope in a peer-led reentry service hub near a detention centre: A process evaluation

When people leave correctional institutions, they face myriad personal, social and structural barriers to reentry, including significant challenges with mental health, substance use, and homelessness. However, there are few reentry programs designed to support people's health, wellbeing, and social integration, and there are even fewer evaluations of such programs. The purpose of this article is to report the qualitative findings from an early process evaluation of the Reintegration Centre-a peer-led service hub designed to support men on the day they are released from custody. We conducted semi-structured qualitative interviews and examined quantitative service intake data with 21 men who accessed the Reintegration Centre immediately upon release. Participants encountered significant reentry challenges and barriers to service access and utilization. The data suggest that the peer-led service hub model enhanced the service encounter experience and efficiently and effectively addressed reentry needs through the provision of basic supports and individualized service referrals. Notably, the Reintegration Centre's proximity to the detention centre facilitated rapid access to essential services upon release, and the peer-support workers affirmed client autonomy and moral worth in the service encounter, fostering mutual respect and trust. Locating reentry programs near bail courts and detention centres may reduce barriers to service access. A peer-led service hub that provides immediate support for basic needs along with individualized service referrals is a promising approach to reentry programs that aim to support post-release health, wellbeing, and social integration. A social system that fosters cross-sectoral collaboration and continuity of care through innovative funding initiatives is vital to the effectiveness and sustainability of such reentry programs.

Criminality labelling influences reactions to others' pain

Disparities in healthcare for underrepresented and stigmatized groups are well documented. Current understanding is that these inequalities arise, at least in part, from psychosocial factors such as stereotypes and in-group/out-group categorization. Pain management, perhaps because of the subjective nature of pain, is one area of research that has spearheaded these efforts. We investigated how observers react to the pain of individuals labelled as criminals. Face models expressing pain of different levels of intensity were portrayed as having committed a crime or not (control group). A sample of n = 327 college students were asked to estimate the intensity of the pain expressed by face models as well as their willingness to help them. Trait empathy was also measured. Data was analyzed using regression, mediation and moderation analyses. We show for the first time that observers were less willing to help individuals with a criminal history. Moreover, a moderation effect was observed whereby empathic participants were more willing to help control face models compared to less empathic participants. However, criminality history did not influence participant's pain estimation. We conclude that negative stereotypes associated with criminality can reduce willingness to help individuals in pain even when pain signals are accurately perceived.

Challenges, Lessons Learned, and Implications for Conducting Nutrition/Health Research in Canadian Federal Correctional Facilities

While conducting nutrition/health research into weight changes during incarceration and related determinants, it became apparent that the correctional setting in Canada was unique and required study design modifications to ensure study success. Consequently, we made many methodological adjustments during recruitment and data collection because of unforeseen challenges in the correctional context. This paper provides an illustrative example and shares insights on the challenges faced when conducting nutrition/health research in Canadian correctional facilities. Guidance on how to adapt research methods to make them more conducive to this unique environment is provided. This paper also highlights the importance of conducting nutrition/health research in this setting, especially given the lack of this type of research and the need for more evidence-based data to guide health promotion and nutritional interventions in Canadian correctional facilities.

Jail-based reentry programming to support continued treatment with medications for opioid use disorder: Qualitative perspectives and experiences among jail staff in Massachusetts

BACKGROUND

Individuals with opioid use disorder released to communities after incarceration experience an elevated risk for overdose death. Massachusetts is the first state to mandate county jails to deliver all FDA approved medications for opioid use disorder (MOUD). The present study considered perspectives around coordination of post-release care among jail staff engaged in MOUD programs focused on coordination of care to the community.

METHODS

Focus groups and semi-structured interviews were conducted with 61 jail staff involved in implementation of MOUD programs. Interview guide development, and coding and analysis of qualitative data were guided by the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Deductive and inductive approaches were used for coding and themes were organized using the EPIS.

RESULTS

Salient themes in the inner context focused on the elements of reentry planning that influence coordination of post-release care including timing of initiation, staff knowledge about availability of MOUD in community settings, and internal collaborations. Findings on bridging factors highlighted the importance of interagency communication to follow pre-scheduled release dates and use of bridge scripts to minimize the gap in treatment during the transition. Use of navigators was an additional factor that influenced MOUD initiation and engagement in community settings. Outer context findings indicated partnerships with community providers and timely reinstatement of health insurance coverage as critical factors that influence coordination of post-release care.

CONCLUSIONS

Coordination of MOUD post-release continuity of care requires training supporting staff in reentry planning as well as resources to enhance internal collaborations and bridging partnerships between in-jail MOUD programs and community MOUD providers. In addition, efforts to reduce systemic barriers related to unanticipated timing of release and reinstatement of health insurance coverage are needed to optimize seamless post-release care.

Health Research in a Jail: Methodological Challenges

Strict regulations are in place for conducting research with prisoners. Published studies are limited that focus on improving the health and well-being of incarcerated persons. Subsequently, institutional review boards established methods to guide researchers in conducting fair and ethical research in carceral settings. The authors of this paper discuss some of the methodological challenges that exist when conducting research with incarcerated persons. Unique methodological challenges were found during the process of conducting a research study inside a jail setting. The authors discuss challenges and provide guidance for future studies. Despite challenges, researchers can conduct studies that can benefit incarcerated persons.

Prevalence of Mental Health and Addiction Service use Prior to and During Incarceration in Provincial Jails in Ontario, Canada: A Retrospective Cohort Study

OBJECTIVE

Individuals with mental illness and addiction are overrepresented in prisons. Few studies have assessed mental health and addiction (MHA)-related service use among individuals experiencing incarceration using health administrative data and most focus on service use after prison release. The objective of this study was to determine the prevalence of MHA-related service use in the 5 years prior to and during incarceration.

METHODS

We used linked correctional and administrative health data for people released from Ontario provincial jails in 2010. MHA-related service use in the 5 years prior to the index incarceration was categorized hierarchically into four mutually exclusive categories based on the type of service use: psychiatric hospitalization, MHA-related emergency department (ED) visit, MHA-related outpatient visit (from psychiatrist or primary care physician), and no MHA-related service use. Demographic, diagnostic, and incarceration characteristics were compared across the four service use categories. MHA-related service use during the index incarceration was assessed by category and length of incarceration.

RESULTS

A total of 48,917 individuals were included. Prior to incarceration, 6,116 (12.5%) had a psychiatric hospitalization, 8,837 (18.1%) had an MHA-related ED visit, and 15,866 (32.4%) had an MHA-related outpatient visit. Of the individuals with any MHA-related service prior to incarceration, 60.4% did not receive outpatient care from a psychiatrist prior to incarceration and 65.6% did not receive MHA-related care during incarceration.

CONCLUSION

Despite a high prevalence of mental illness and addiction among people experiencing incarceration, access to and use of MHA-related care prior to and during incarceration is poor. Increasing the accessibility and use of MHA-related services throughout the criminal justice pathway is warranted.

Health Care Costs of Individuals With Chronic Psychotic Disorders Who Experience Incarceration in Ontario

OBJECTIVE

Little is known about the health care costs of individuals with chronic psychotic disorders who experience incarceration. This study sought to address this knowledge gap.

METHODS

The authors analyzed linked 2007-2010 correctional and administrative health care data on sex- and age-matched individuals with chronic psychotic disorders with and without known incarceration in prison for up to 2 years in the Ontario correctional system. Mean 1-year health care costs (overall and by sex) in the year before incarceration (when release occurred in 2010) were estimated from third-party payer data and compared between the two groups. Costs were calculated in 2018 Canadian dollars.

RESULTS

Individuals who experienced incarceration (N=3,197) had mean 1-year costs of $15,728 in the year before incarceration, whereas those who did not (N=6,393) had 1-year costs of $11,588. This difference was mostly due to costs arising from psychiatric hospitalizations, emergency department visits, and physician services. The main factors associated with the difference were incarceration in the following year (increase of $4,827, p<0.001), being age 18-29 years compared with ages 30-39 or 40-49 (increase of $4,448 and $4,218, respectively, p<0.001), and chronic psychotic disorder duration of 1-2 years compared with ≤1 year duration (increase of $6,812, p=0.004). Women who experienced incarceration had higher costs than incarcerated men ($20,648 vs. $14,763).

CONCLUSIONS

Individuals with chronic psychotic disorders who experienced incarceration had higher health care costs than comparable individuals who did not. These higher health care costs may signal the need for interventions and policies that help individuals with psychotic disorders avoid criminal justice system involvement.

The burden of alcohol, tobacco and others drugs among incarcerated population diagnosed with tuberculosis: time trends and spatial determinants in Southern Brazil

BACKGROUND

Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis and is a public health problem worldwide. It is estimated that 90% of the patients diagnosed with TB live in vulnerable environments with limited health resources, such as individuals living in correctional facilities. This study aimed to identify the consumption of alcohol, tobacco, and other drugs among prisoners diagnosed with TB and the spatial determinants and time trends of the phenomenon in southern Brazil.

METHODS

A cross-sectional study using data from the Brazilian Notifiable Diseases Information System was carried out. TB cases confirmed from 2014 to 2018 in prisons located in Paraná, Brazil, were selected. The Prais-Winsten procedure was performed to identify time trends by calculating monthly rates and the percentage of monthly variation. The Seasonal-Trend by Loess decomposition method was used to verify the time series and trends. The spatial association was verified with the Getis-Ord Gi* technique, and the risk areas were identified using spatial scan statistics.

RESULTS

A total of 1,099 TB cases were found in the studied population. The consumption of tobacco (n = 460; 41.9%), illegal drugs (n = 451; 41.0%), and alcohol (n = 179; 16.3%) stood out. An ascending trend was found for the consumption of alcohol (+ 19.4%/mo. (95%CI: 12.20-23.03)), tobacco (+ 20.2%/mo. (95%CI: 12.20-28.82)), and illegal drugs (+ 62.2%/mo. (95%CI: 44.54-81.97)). Spatial analysis revealed clusters for the use of alcohol, tobacco, and illegal drugs.

CONCLUSIONS

This study advances knowledge presenting the burden of drug use and its typology among individuals diagnosed with TB in the prison system. There is a growing trend among patients to use drugs, especially illegal drugs. The clusters show differences between the places where the prisons are located.

Intellectual/developmental disabilities among people incarcerated in federal correctional facilities in Ontario, Canada: Examining prevalence, health and correctional characteristics

BACKGROUND

There is little research with people who experience intellectual/developmental disabilities and imprisonment.

METHODS

The study linked health and correctional data to examine prevalence of intellectual/developmental disabilities and health and correctional characteristics among adults experiencing their first federal incarceration between 1 January 2002 and 31 December 2011 (n = 9278) and two non-incarcerated groups (n = 10,086,802).

RESULTS

The prevalence of intellectual/developmental disabilities was 2.1% in the incarcerated group and 0.9% in the non-incarcerated group. Before incarceration, those with, versus without, intellectual/developmental disabilities were at greater risk of traumatic brain injury, mental illness, and substance use disorders. While incarcerated, those with intellectual/developmental disabilities were more likely to incur serious institutional disciplinary charges. Post-incarceration, persons with intellectual/developmental disabilities were at greater risk of emergency department visits, and psychiatric and acute hospitalizations, than the non-incarcerated groups.

CONCLUSIONS

People with intellectual/developmental disabilities are overrepresented in Canadian federal correctional institutions. The authors offer strategies to support people prior to, during, and post-incarceration.

Assessment of Satisfaction with Health Services among Prisoners—Descriptive Study

Aim: The aim of the study was to assess the access of prisoners to healthcare services, as well as the level of satisfaction with the provided services and health assessment among prisoners. Methods: The research was conducted in one of the penitentiary centers in Poland among people jailed between 1 January to 31 January 2020. The response rate of the self-administrated questionnaire was 52.05% (469/901) participants. There were 389 men and 77 women. Results: Prisoners assessed access to health services including GP doctors, specialist doctors, dentists, and hospitals in 3 categories: “bad” ranged: 27.03–67.60%; “medium” ranged: 22.54–53.57%; “good” ranged: 7.02–33.96% depending on the type of arrest, but no statistical significance was demonstrated. Satisfaction with the health services defined as “bad” ranged: 25.00–61.11%; “medium” ranged: 18.97–55.56%; “good” ranged: 5.56–34.62% depending on the type of arrest but no statistical significance was demonstrated. Of 469 prisoners, 215 prisoners (45.84%) declared no addictions. The frequency of addiction does not differ depending on the place/type of punishment served (p = 0.9). In turn, 317 prisoners (68%) declared no chronic diseases. Conclusions: Most of the prisoners described access to health services as “bad”, except female prisoners from a semi-open facility. In turn, satisfaction with healthcare services was most often assessed as “bad”, except for temporarily arrested men and female prisoners from a semi-open facility.

Adult hospitalizations from immigration detention in Louisiana and Texas, 2015-2018

Poor health conditions within immigration detention facilities have attracted significant concerns from policymakers and activists alike. There is no systematic data on the causes of hospitalizations from immigration detention facilities or their relative morbidity. The objective of this study, therefore, was to analyze the causes of hospitalizations from immigration detention facilities, as well as the percentage of hospitalizations necessitating ICU or intermediate-ICU (i.e, "step-down") admission and the types of surgical and interventional procedures conducted during these hospitalizations. We conducted a cross-sectional study of statewide adult (age 18 and greater) hospitalization data, with hospitalizations attributed to immigration facilities via payor designations (from Immigration and Customs Enforcement) and geospatial data in Texas and Louisiana from 2015-2018. Our analysis identified 5,215 hospitalizations of which 887 met inclusion criteria for analysis. Average age was 36 (standard deviation, 13.7), and 23.6% were female. The most common causes of hospitalization were related to infectious diseases (207, 23.3%) and psychiatric illness (147, 16.6%). 340 (38.3%) hospitalizations required a surgical or interventional procedure. Seventy-two (8.1%) hospitalizations required ICU admission and 175 (19.5%) required intermediate ICU. In this relatively young cohort, hospitalizations from immigration detention were accompanied with significant morbidity. Policymakers should mitigate the medical risks of immigration detention by improving access to medical and psychiatric care in facilities.

Emergency department presentations in the first weeks following release from prison among men with a history of injecting drug use in Victoria, Australia: A prospective cohort study

OBJECTIVE

Rates of emergency department (ED) use are higher among people released from prison than in the general population. However, little is known about ED presentations specifically among people with a history of injecting drug use (IDU) leaving prison. We measured the incidence of ED presentation in the three months following release from prison, among a cohort of men with histories of IDU, and determined pre-release characteristics associated with presenting to an ED during this period.

METHODS

We analysed linked survey and administrative data from the Prison and Transition Health (PATH) study (N = 400) using multiple-failure survival analysis.

RESULTS

Twenty-one percent (n = 81/393) of the cohort presented to an ED at least once within the three months after release from prison. The incidence of ED presentation was highest in the first six days after release. Cox proportional hazards modelling showed that a history of in-patient psychiatric admission and housing instability were associated with increased hazard of an ED presentation, and identifying as Aboriginal and Torres Strait Islander was associated with decreased hazard.

CONCLUSIONS

In our study, ED presentations following release from prison among people with a history of IDU was linked to acute health risks related to known mental health and social vulnerabilities in this population. Greater collaboration and systems integration between prison and community health and support services is needed to reduce presentations to ED and associated morbidities among people with a history of IDU after release from prison.

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.

Slipping through: mobility's influence on infectious disease risks for justice-involved women in Canada

BACKGROUND

The relationship between incarceration and women's vulnerability to sexually transmitted and blood-borne infections (STBBI) is understudied in Canada, despite numerous studies showing that justice-involved women experience very high rates of infection. Justice-involved women in Canada are highly mobile, as a result of high rates of incarceration and extremely short sentences. From a public health perspective, it is productive to understand how the mobility of justice-involved women shapes their vulnerability to STBBI.

RESULTS

This narrative review demonstrates that mobility between incarceration facilities and communities drives sexually transmitted and blood-borne disease risk for justice-involved women in Canada. Associations and interactions between epidemics of gender-based and intimate partner violence, substance use, and STBBIs shape the experiences of justice-involved women in Canada. In correctional facilities, the pre-existing vulnerability of justice-involved women is compounded by a lack of comprehensive STBBI care and limited harm reduction services. On release, unstable housing, disruptions to social support networks, interruptions in medical care, and relapse to or continuation of substance use, significantly increase individual disease risk and the likelihood of community transmission. High rates of incarceration for short periods perpetuate this cycle and complicate the delivery of healthcare.

CONCLUSIONS

The review provides evidence of the need for stronger gender-transformative public health planning and responses for incarcerated women, in both federal and provincial corrections settings in Canada. A supportive, evidence-based approach to STBBI identification and treatment for incarcerated women - one that that removes stigma, maintains privacy and improves access, combined with structural policies to prevent incarceration - could decrease STBBI incidence and interrupt the cycle of incarceration and poor health outcomes. A coordinated and accountable program of reintegration that facilitates continuity of public health interventions for STBBI, as well as safe housing, harm reduction and other supports, can improve outcomes as well. Lastly, metrics to measure performance of STBBI management during incarceration and upon release would help to identify gaps and improve outcomes for justice-involved women in the Canadian context.

Rates of opioid agonist treatment prescribing in provincial prisons in Ontario, Canada, 2015-2018: a repeated cross-sectional analysis

OBJECTIVE

To describe opioid agonist treatment prescribing rates in provincial prisons and compare with community prescribing rates.

DESIGN

We used quarterly, cross-sectional data on the number and proportion of people prescribed opioid agonist treatment in prison populations. Trends were compared with Ontario surveillance data from prescribers, reported on a monthly basis.

SETTING

Provincial prisons and general population in Ontario, Canada between 2015 and 2018.

PARTICIPANTS

Adults incarcerated in provincial prisons and people ages 15 years and older in Ontario.

MAIN OUTCOMES AND MEASURES

Opioid agonist treatment prescribing prevalence, defined as treatment with methadone or buprenorphine/naloxone.

RESULTS

In prison, 6.9%-8.4% of people were prescribed methadone; 0.8% to 4.8% buprenorphine/naloxone; and 8.2% to 13.2% either treatment over the study period. Between 2015 and 2018, methadone prescribing prevalence did not substantially change in prisons or in the general population. The prevalence rate of buprenorphine/naloxone prescribing increased in prisons by 1.70 times per year (95% CI 1.47 to 1.96), which was significantly higher than the increase in community prescribing: 1.20 (95% CI 1.19 to 1.21). Buprenorphine/naloxone prescribing prevalence was significantly different across prisons.

CONCLUSIONS

The increase in opioid agonist treatment prescribing between 2015 and 2018 in provincial prisons shows that efforts to scale up access to treatment in the context of the opioid overdose crisis have included people who experience incarceration in Ontario. Further work is needed to understand unmet need for treatment and treatment impacts.

Strategies to maximise study retention and limit attrition bias in a prospective cohort study of men reporting a history of injecting drug use released from prison: the prison and transition health study

Background

There are significant challenges associated with studies of people released from custodial settings, including loss to follow-up in the community. Interpretation of findings with consideration of differences between those followed up and those not followed up is critical in the development of evidence-informed policies and practices. We describe attrition bias in the Prison and Transition Health (PATH) prospective cohort study, and strategies employed to minimise attrition.

Methods

PATH involves 400 men with a history of injecting drug use recruited from three prisons in Victoria, Australia. Four interviews were conducted: one pre-release (‘baseline’) and three interviews at approximately 3, 12, and 24 months post-release (‘follow-up’). We assessed differences in baseline characteristics between those retained and not retained in the study, reporting mean differences and 95% confidence intervals (95% CIs). 

Results

Most participants (85%) completed at least one follow-up interview and 162 (42%) completed all three follow-up interviews. Retained participants were younger than those lost to follow-up (mean diff − 3.1 years, 95% CI -5.3, − 0.9). There were no other statistically significant differences observed in baseline characteristics.

Conclusion

The high proportion of participants retained in the PATH cohort study via comprehensive follow-up procedures, coupled with extensive record linkage to a range of administrative datasets, is a considerable strength of the study. Our findings highlight how strategic and comprehensive follow-up procedures, frequent contact with participants and secondary contacts, and established working relationships with the relevant government departments can improve study retention and potentially minimise attrition bias.

Emergency department use in people who experience imprisonment in Ontario, Canada

OBJECTIVES

The aims of this study were to describe emergency department (ED) utilization by people in provincial prison and on release, and to compare with ED utilization for the general population.

METHODS

We linked correctional and health administrative data for people released from provincial prison in Ontario in 2010. We matched each person by age and sex with four people in the general population. We compared ED utilization rates using generalized estimating equations, by sex and for high urgency and ambulatory care sensitive conditions.

RESULTS

People who experienced imprisonment (N = 48,861) had higher ED utilization rates compared with the general population (N = 195,444), with rate ratios of 3.2 (95% CI 3.0-4.4) for men and 6.5 (95% CI 5.6-7.5) for women in prison and a range of rate ratios between 3.1 and 7.7 for men and 4.2 and 8.8 for women over the 2 years after release. Most ED visits were high urgency, and between 1.0% and 5.1% of visits were for ambulatory care sensitive conditions. ED utilization rates increased on release from prison.

CONCLUSIONS

People experiencing imprisonment in Ontario have higher ED utilization compared with matched people in the general population, primarily for urgent issues, and particularly in women and in the week after release. Providing high-quality ED care and implementing prison- and ED-based interventions could improve health for this population and prevent the need for ED use.

Prevalence and Predictors of Reincarceration after Correctional Center Release: A Population-based Comparison of Individuals with and without Schizophrenia in Ontario, Canada: Prévalence et prédicteurs de la réincarcération après la libération d'un centre correctionnel : une comparaison dans la population-de personnes souffrant ou non de schizophrénie en Ontario, Canada

OBJECTIVES

Individuals with schizophrenia are overrepresented in correctional facilities relative to their population-based prevalence. The purpose of this study was to determine the rate and predictors of reincarceration of individuals with schizophrenia after release from correctional facilities.

METHODS

This was a retrospective cohort study that included all people released from Ontario's provincial correctional facilities from January 1 to December 31, 2010. Individuals with schizophrenia were identified using a population-based algorithm. The primary outcome was time to reincarceration. Covariates included sociodemographic characteristics (age, sex, neighborhood income quintile, urban/rural residence), health service utilization (primary care physician visits, psychiatrist visits, psychiatric and nonpsychiatric hospitalizations, emergency department visits), and other clinical comorbidity. Survival analysis was used to examine the association between schizophrenia and reincarceration.

RESULTS

Among 46,928 individuals, N = 3,237 (7%) had a diagnosis of schizophrenia. Approximately 67.5% of these individuals were reincarcerated within 5 years following their first release in 2010, compared to 58.8% of individuals without schizophrenia. Individuals with schizophrenia were 40% (HR = 1.39, 95% CI, 1.33 to 1.45) more likely to be reincarcerated following release than the control group after adjusting for demographic characteristics. This association reduced to 8% (HR = 1.08, 95% CI,1.03 to 1.14) after adjusting for prior health service utilization, prior correctional involvement, and comorbidities.

CONCLUSION

Individuals with schizophrenia were more likely to experience reincarceration after release from correctional facilities. This risk is partly explained by prior correctional involvement, health service utilization, and comorbidities. Future research should focus on risk factors predicting the higher reincarceration rate and interventions to reduce correctional involvement.

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.

Quality of Antenatal Care for Women Who Experience Imprisonment in Ontario, Canada

IMPORTANCE

Women who experience imprisonment have high morbidity and an increased risk of adverse pregnancy outcomes. Antenatal care could modify pregnancy-related risks, but there is a lack of evidence regarding antenatal care in this population.

OBJECTIVES

To examine antenatal care quality indicators for women who experience imprisonment and to compare these data with data for the general population.

DESIGN, SETTING, AND PARTICIPANTS

This population-based, retrospective cohort study used linked correctional and health administrative data from women released from provincial prison in Ontario, Canada, in 2010 and women in the general population with deliveries at 20 weeks' gestation or greater from January 1, 2005, to December 31, 2015. Data analysis was performed from January 1, 2017, to May 4, 2020.

EXPOSURES

Pregnancies in women with time in prison during pregnancy (prison pregnancies), pregnancies in women with time in prison but not while pregnant (prison control pregnancies), and pregnancies in women in the general population (general population pregnancies).

MAIN OUTCOMES AND MEASURES

Antenatal care quality indicators: first-trimester visit, first-trimester ultrasonography, and 8 or more antenatal care visits.

RESULTS

A total of 626 prison pregnancies in 529 women (mean [SD] age, 26.6 [5.4] years), 2327 prison control pregnancies in 1570 women (mean [SD] age, 26.2 [5.4] years), and 1 308 879 general population pregnancies in 884 063 women (mean [SD] age, 30.3 [5.3] years) were studied. Of 626 prison pregnancies, 193 women (30.8%; 95% CI, 27.1%-34.6%) had a first-trimester visit, 272 (48.4%; 95% CI, 44.4%-52.4%) had at least 8 antenatal care visits, and 209 (34.6%; 95% CI, 31.0%-38.4%) received first-trimester ultrasonography. In 2327 prison control pregnancies, 1106 women (47.5%; 95% CI, 45.3%-49.8%) had a first-trimester visit, 1356 (59.2%; 95% CI, 56.9%-61.4%) had 8 or more antenatal care visits, and 893 (38.5%; 95% CI, 36.4%-40.6%) received first-trimester ultrasonography. Compared with 1 308 879 general population pregnancies, the odds of antenatal care were lower for the first-trimester visit (odds ratios [ORs], 0.11 [95% CI, 0.09-0.13] in prison pregnancies and 0.23 [95% CI, 0.21-0.25] in prison control pregnancies), 8 or more antenatal care visits (ORs, 0.16 [95% CI, 0.14-0.19] in prison pregnancies and 0.25 [95% CI, 0.23-0.28] in prison control pregnancies), and first-trimester ultrasonography (ORs, 0.43 [95% CI, 0.36-0.50] in prison pregnancies and 0.51 [95% CI, 0.46-0.55] in prison control pregnancies).

CONCLUSIONS AND RELEVANCE

This study found that women who experienced imprisonment were substantially less likely to receive adequate antenatal care than were women in the general population whether or not they were in prison during pregnancy. Efforts are needed to improve antenatal care for this population both in prison and in the community.

The prevalence and health status of people with developmental disabilities in provincial prisons in Ontario, Canada: A retrospective cohort study

BACKGROUND

Data on the prevalence of developmental disabilities in people who experience imprisonment and on their characteristics are lacking.

METHODS

The present authors identified adults with developmental disabilities who were released from Ontario provincial prisons in 2010 and a general population comparator group using administrative data. The present authors examined demographic characteristics, morbidity and healthcare use.

RESULTS

The prevalence of developmental disabilities was 2.2% in the prison group (N = 52,302) and 0.7% in the general population (N = 10,466,847). The prevalence of psychotic illness, substance-related disorder and self-harm was higher among people in the prison group with developmental disabilities. People with developmental disabilities were more likely to have emergency department visits and hospitalizations in prison and in the year after release.

CONCLUSIONS

People with developmental disabilities are overrepresented in provincial prisons and have a high burden of disease. Strategies are indicated to prevent incarceration and to improve health.

Returning to care after incarceration with HIV: the French Guianese experience

Background

HIV prevalence in correctional facilities may be 2 to 10 times higher than in the general adult population. Antiretroviral therapy (ART) interruption is frequent after an incarceration. This, in combination with post-release high-risk behaviors, may have detrimental consequences on the epidemic. Although return to care after release from correctional facilities has been described in many North American settings, data from South America seemed scarce.

French Guiana is the only French territory located in South America. In 2014, HIV prevalence was estimated at 1.2% among pregnant women and oscillated around 4% in the only correctional facility.

Method

HIV-infected adults released from the French Guiana correctional facility between 2007 and 2013 were included in a retrospective cohort survey. The first objective was to describe the cascade of care in the 4 years following release. The secondary objectives were to describe contacts with care and to identify factors associated with return to HIV care, 1 year after release.

Results

We included 147 people, mostly males (81.6%). The median time before the first ambulatory consultation was 1.8 months. Within 1 year after release, 27.9% came for unscheduled emergency consultations, 22.4% were hospitalized. Within 4 years after release, 40.0–46.5% were in care, 22.4% archieved virological success.

Being on ART when incarcerated was associated with HIV care (aIRR: 2.0, CI: 1.2–3.0), whereas being HIV-diagnosed during the last incarceration was associated with poor follow-up (aIRR: 0.3, CI: 0.1–0.9).

Conclusion

The risk of HIV-follow-up interruption is high, after an incarceration with HIV. ART supply should be sufficient to cover the timespan following release, several months if possible. Those not on ART at the time of incarceration may require special attention, especially those newly HIV-diagnosed while in custody. Comprehensive programs are necessary to support ex-offenders to stay on ART after incarceration.

Association between traumatic brain injury and prison charges: a population-based cohort study

BACKGROUND

Traumatic Brain Injury (TBI) is a serious hidden health issue disproportionately affecting people who experience incarceration.

OBJECTIVE

We examined the association between TBI and serious disciplinary charges among men and women sentenced by the courts to terms of two or more years.

METHODS

The study originated in Ontario, Canada and used linked administrative health and correctional data. The cohort included adults experiencing their first federal sentence between 1998 and 2011 (N = 12,038). We examined disciplinary charges incurred 2 years post-sentence commencement. TBI was defined using the International Classification of Diseases (ICD-9 and ICD-10) diagnostic codes. Robust Poisson regression was conducted to assess the association between TBI and disciplinary charges.

FINDINGS

The prevalence of TBI for the full sample was 13.2%. One-third of adults with a recent TBI had a serious disciplinary charge. The unadjusted risk of incurring a serious charge for those with a history of TBI was 39% higher than those with no history of TBI (CI: 1.29-1.49). The adjusted risk was 1.14 (CI: 1.06-1.22).

CONCLUSIONS

TBI is a serious health concern that makes it difficult for incarcerants to adjust to prison. Additional support/resources are needed to support those with histories of TBI.

"When you first walk out the gates…where do [you] go?": Barriers and opportunities to achieving continuity of health care at the time of release from a provincial jail in Ontario

We aimed to explore continuity of health care and health barriers, facilitators, and opportunities for people at the time of release from a provincial correctional facility in Ontario, Canada. We conducted focus groups in community-based organizations in a city in Ontario, Canada: a men’s homeless shelter, a mental health service organization, and a social service agency with programs for people with substance use disorders. We included adults who spoke English well enough to participate in the discussion and who had been released from the provincial correctional facility in the previous year. We conducted three focus groups with 18 total participants. Participants had complex health needs on release, including ongoing physical and psychological impacts of time in custody. They identified lack of access to high quality health care; lack of housing, employment, social services, and social supports; and discrimination on the basis of incarceration history as barriers to health on release. Access to health care, housing, social services, and social supports all facilitated health on release. To address health needs on release, participants suggested providing health information in jail, improving discharge planning, and developing accessible clinics in the community. This pilot study identified opportunities to support health at the time of release from jail, including delivery of programs in jail, linkage with and development of programs in the community, and efforts to support structural changes to prevent and address discrimination. These data will inform ongoing work to support health and continuity of care on release from a provincial correctional facility.

Thirty-day readmission after medical-surgical hospitalization for people who experience imprisonment in Ontario, Canada: A retrospective cohort study

We aimed to compare 30-day readmission after medical-surgical hospitalization for people who experience imprisonment and matched people in the general population in Ontario, Canada. We used linked population-based correctional and health administrative data. Of people released from Ontario prisons in 2010, we identified those with at least one medical or surgical hospitalization between 2005 and 2015 while they were in prison or within 6 months after release. For those with multiple eligible hospitalizations, we randomly selected one hospitalization. We stratified people by whether they were in prison or recently released from prison at the time of hospital discharge. We matched each person with a person in the general population based on age, sex, hospitalization case mix group, and hospital discharge year. Our primary outcome was 30-day hospital readmission. We included 262 hospitalizations for people in prison and 1,268 hospitalizations for people recently released from prison. Readmission rates were 7.7% (95%CI 4.4-10.9) for people in prison and 6.9% (95%CI 5.5-8.3) for people recently released from prison. Compared with matched people in the general population, the unadjusted HR was 0.72 (95%CI 0.41-1.27) for people in prison and 0.78 (95%CI 0.60-1.02) for people recently released from prison. Adjusted for baseline morbidity and social status, hospitalization characteristics, and post-discharge health care use, the HR for 30-day readmission was 0.74 (95%CI 0.40-1.37) for people in prison and 0.48 (95%CI 0.36-0.63) for people recently released from prison. In conclusion, people recently released from prison had relatively low rates of readmission. Research is needed to elucidate reasons for lower readmission to ensure care quality and access.

Prevalence of mental disorders among all justice-involved: A population-level study in Canada

More than 10 million people are imprisoned around the world, with many more who encounter the justice system. However, most studies examining the mental health burden in the justice system have examined only incarcerated individuals, with few looking at both criminal offending and victimization at the population-level. This study aimed to describe the population-level prevalence of mental disorders among the entirety of justice-involved individuals in a Canadian sample. The study was conducted using linked health and justice administrative data for all residents of Manitoba, Canada ages 18-64 between April 1, 2007 and March 31, 2012. All justice involvement (crime accusations and victimizations) and inpatient and outpatient mental disorder diagnoses (mood/anxiety, substance use, psychotic, personality disorders and suicidal behavior) were retrieved. Five-year age- and sex-adjusted prevalence of mental disorders and suicidal behaviour among those with any crime accusation and any victimization were compared to the general population of Manitoba. The study found that age- and sex-adjusted prevalence of any mental disorder was significantly higher among both adults accused of a crime and those victimized (38.9% and 38.6%, respectively) compared to the general population (26.1%). Rate ratios for specific mental disorders and suicidal behaviour were 1.4-3.6 among those accused of a crime, and 1.4-3.7 among those who were victims, compared to the general population. These findings highlight the need for urgent and expanded attention to this intersection of vulnerability. Victimization is especially an area of justice-related health that requires more attention.

90-90-90 for everyone?: Access to HIV care and treatment for people with HIV who experience imprisonment in Ontario, Canada

We examined HIV care and treatment in prison and after release for people with HIV in Ontario, Canada, and compared HIV care and treatment with the general population. We used administrative data to identify people with HIV released from provincial prison in 2010 and in the general population. We calculated the proportion of people with HIV who accessed HIV care in prison. We compared HIV care use between people with HIV on prison release and in the general population. We estimated the proportion of people with HIV on antiretroviral therapy in prison as the ratio of the average numbers of people prescribed antiretroviral therapy in prison in 2009/2010 and people with HIV in prison in January 2010. We compared the proportion of people with HIV on public drug benefits that filled an antiretroviral therapy prescription within 6 months for people postrelease and in the general population. Of 344 people with HIV on prison admission, 34.0% received HIV care in prison. Over 1 year, 63.6% of 330 people with HIV on prison release and 67.7% of 15,819 people with HIV in the general population accessed HIV care (p = 0.118), and 43.3% of people with HIV on prison release and 55.2% of people with HIV in the general population had 2 or more HIV care visits (p < 0.001). In prison, 52.4% of people with HIV (39.5/75.4) were on antiretroviral therapy. Of those accessing drug benefits, 60.1% of 226 people with HIV on prison release and 79.6% of 7458 people with HIV in the general population claimed an antiretroviral therapy prescription within 6 months (p < 0.001). Access to HIV care and treatment were suboptimal in prison, and sustained HIV care and treatment were worse for people post-release compared to the general population. Interventions are needed to support HIV care for this population.

A comparison of the observed and expected prevalence of HIV in persons released from Ontario provincial prisons in 2010

OBJECTIVE

To estimate the prevalence of HIV infection in persons released from Ontario prisons in 2010 using administrative health data, and to compare this observed prevalence with the expected prevalence based on the most recently available biological sampling data.

METHODS

We linked identifying data for all adults released from Ontario provincial prisons in 2010 with administrative health data, and applied a validated algorithm to determine the observed HIV prevalence. We calculated the expected HIV prevalence using 2003-2004 age stratum-specific data from a published study using salivary sampling. We calculated an indirect standardized prevalence ratio of the observed to expected prevalence and 95% confidence intervals. Finally, we conducted sensitivity analyses to adjust for the sensitivity of the algorithm to identify persons with HIV and for undiagnosed HIV infection.

RESULTS

Of 52,313 persons released from Ontario prisons in 2010, we identified 363 persons with HIV, for an observed prevalence of 0.69%. The expected prevalence was 2.38%. Standardized for age, we found a prevalence ratio of 0.29 (95% CI, 0.17-0.77). Sensitivity analyses adjusting for the algorithm's sensitivity and further adjusting for undiagnosed HIV infection produced standardized prevalence ratios of 0.30 and 0.38, respectively.

CONCLUSION

Our findings suggest that a high proportion of persons with HIV recently released from provincial prisons either do not know they have HIV infection or do know about their infection but are not engaged in care. Interventions are required to screen people for HIV in prison and to link persons with care following release.

Colorectal and Breast Cancer Screening Status for People in Ontario Provincial Correctional Facilities

INTRODUCTION

Primary care represents an opportunity to improve health for people who experience imprisonment, and screening for colorectal and breast cancer indicate primary care quality. The study objectives were to examine the proportion of people released from provincial correctional facilities who were overdue for colorectal or breast cancer screening on admission to the correctional facility and who were still overdue after 3 years, and to compare findings with data for the general population.

METHODS

Administrative data were used to identify people eligible for colorectal and breast cancer screening who were released from provincial correctional facilities in 2010 (N=3,803 and N=249, respectively) and in the general population (N=2,757,584 and N=1,099,942, respectively) in Ontario, Canada. Chi-square tests and log binomial regression models were used to compare the proportion of individuals overdue for screening on admission or on July 1, 2010 for the general population, and still overdue after 3 years. Analyses were conducted in 2017 and 2018.

RESULTS

Compared with the general population, people in the corrections group were 1.53 times (95% CI=1.50, 1.55) more likely to be overdue for colorectal cancer screening: 77.1% (95% CI=74.3, 79.9) vs 50.5% (95% CI=50.5, 50.6), and 2.25 times (95% CI=2.06, 2.46) more likely to be overdue for breast cancer screening: 65.9% (95% CI=56.2, 76.8) vs 29.3% (95% CI=29.2, 29.4, both p<0.001). They were also more likely to still be overdue 3 years later: 62.6% (95% CI=60.1, 65.2) vs 33.6% (95% CI=33.5, 33.6) for colorectal cancer and 52.2% (95% CI=43.6, 62.0) vs 20.2% (95% CI=20.1, 20.3) for breast cancer (both p<0.001).

CONCLUSIONS

People who experience imprisonment are less likely than the general population to access colorectal and breast cancer screening. This suggests the need to strengthen primary care for this population. Specifically, efforts should be made to improve access to colorectal and breast cancer screening, through health promotion, program delivery, and linkage to community services while in correctional facilities.

Impact of oral conditions on the quality of life of incarcerated women in Brazil

Imprisoned women represent a growing population worldwide with important health needs. In this study, we aimed to analyze the impact of oral health conditions on the quality of life of female inmates in a maximum security correctional facility. Participants were examined and answered the OHIP-14 questionnaire. A total of 305 inmates were included in the study. Prevalence of untreated caries was 84%. Worse quality of life was associated with dental caries, dental pain, deep periodontal pocket, prosthetic use, and age. Sociodental indicators should be incorporated into healthcare and health policies in order to promote wellbeing among this vulnerable population.

Primary care utilization in people who experience imprisonment in Ontario, Canada: a retrospective cohort study

Background

Access to primary care is an important determinant of health, and data are sparse on primary care utilization for people who experience imprisonment. We aimed to describe primary care utilization for persons released from prison, and to compare utilization with the general population.

Methods

We linked correctional data for all persons released from provincial prison in Ontario, Canada in 2010 with health administrative data. We matched each person by age and sex with four general population controls. We compared primary care utilization rates using generalized estimating equations. We adjusted rate ratios for aggregated diagnosis groups, to explore this association independent of comorbidity. We examined the proportion of people using primary care using chi squared tests and time to first primary care visit post-release using the Kaplan-Meier method.

Results

Compared to the general population controls, the prison release group had significantly increased relative rates of primary care utilization: at 6.1 (95% CI 5.9-6.2) in prison, 3.7 (95% CI 3.6-3.8) in the week post-release and between 2.4 and 2.6 in the two years after prison release. All rate ratios remained significantly increased after adjusting for comorbidity. In the month after release, however, 66.3% of women and 75.5% of men did not access primary care.

Conclusions

Primary care utilization is high in prison and post-release for people who experience imprisonment in Ontario, Canada. Increased use is only partly explained by comorbidity. The majority of people do not access primary care in the month after prison release. Future research should identify reasons for increased use and interventions to improve care access for persons who are not accessing care post-release.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3660-2) contains supplementary material, which is available to authorized users.