The case for improving the health of ex-prisoners

Development of serious mental illness in young adult violent offenders: Early-life risk factors and long-term adverse outcomes

This study explored serious mental illness (SMI) in young adult offenders imprisoned for violent or sexual crimes, estimating the effects of neurodevelopmental disorders and early-life risk factors on the development of SMI, and its prospective long-term adverse outcomes. An all-male cohort of 266 violent offenders, assessed during imprisonment when aged 18-25 years (M = 21.8, SD = 1.9), was followed prospectively (Myears = 6.2, SD = 1.3) in Swedish national registers together with a general population group (n = 10,000). The baseline prevalence of SMI in late adolescence or young adulthood was 10 % (n = 26) in the violent offender cohort. Childhood-onset conduct disorder (OR 2.7 [1.0-7.1]) was associated with SMI in multivariable logistic regression analyses. Prospectively, violent offenders with, versus without, SMI exhibited heightened total crime rate (IRR 1.4 [1.0-2.2]), prison reconvictions (IRR 1.5 [1.0-2.1]), and psychiatric inpatient care (IRR 3.7 [1.6-8.4]), in zero-inflated Poisson regression models. The usage of outpatient psychiatric and somatic care was low in violent offenders with SMI, even relative to the general population group. The results emphasize the need for early identification of at-risk children, such as those with childhood-onset conduct disorder, and challenges with engaging violent offenders with SMI in healthcare.

Health and incarceration research in Australia: a scoping review

Background

People who experience incarceration often have complex healthcare needs and poorer health than the general population. Australia has the eighth-largest custodial population in the Western Pacific. Understanding the breadth and quality of research on this population's health is crucial for advancing health equity both in Australia and across the region. This scoping review synthesised health research involving people in contact with the criminal justice system in Australia.

Methods

We searched eight databases for primary, peer-reviewed research reporting on the health of people incarcerated or previously incarcerated in Australian prisons or youth detention settings.

Findings

Our search identified 11,731 unique records, and 508 met the inclusion criteria. Over half (51%) were published between 2015 and 2024. Relatively few studies provided evidence on cognitive disabilities (16%), non-communicable diseases (14%), or sexual and reproductive health (6%). Few focused on youth detention (15%) or post-release health (24%). Only 27 studies (5%) focused exclusively on the health of First Nations Australians. Most studies (86%) came from Australia's most populous states-New South Wales, Queensland, and Victoria-which account for 68% of people incarcerated each year, and 58% of incarcerated First Nations peoples.

Interpretation

Despite considerable growth in the number of peer-reviewed studies on the health of people who experience incarceration, critical health issues, key populations, and Australian jurisdictions with the highest incarceration rates require urgent attention. Further high-quality research is needed to fill these evidence gaps and translate research into evidence-based strategies that address the complex and diverse health needs of justice-involved people.

Funding

SP was supported by a Australian Government Research Training Program Scholarship.

Determinants of access to primary healthcare for formerly incarcerated women transitioning into the community: a systematic review of the literature

Background

Women with a history of incarceration experience significantly poorer health outcomes and encounter barriers to accessing healthcare, both during incarceration and after release. These challenges are more pronounced compared with both their male counterparts and women in the general population. We conducted a systematic literature review to respond to the following research questions: (1) what are the determinants of primary healthcare uptake and retention among formerly incarcerated women transitioning into the community? and (2) what are the barriers and facilitators for their access to primary healthcare postrelease?

Methods

Following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and drawing on Levesques' Patient-Centered Access to Healthcare Model, we searched and identified relevant publications from 2012 onwards in the following databases: PubMed, CINAHL, PsychInfo, Web of Science databases and Google Scholar. Records were included if they reported primary healthcare among formerly incarcerated women. Findings from the included studies were extracted and arranged under relevant themes using convergent-integrated approach.

Findings

A total of 3524 records were identified and reviewed, from which 37 publications were included in the review. Five main themes emerged as follows: (1) trends and predisposing factors, (2) barriers and facilitators to care, (3) continuity of care and arrangement between the prison and community health providers, (4) prescriptions and health insurance enrolment and (5) interventions to improve primary healthcare utilisation postrelease. Additional sub-themes, such as perceived discrimination in the healthcare system and delays in cancer screening, were identified and discussed.

Conclusion

The findings of the systematic review underscore the ongoing challenges women face in accessing primary care when transitioning from incarceration to the community. Enhancing coordination efforts between prison services and community healthcare providers requires a comprehensive assessment of women's healthcare needs during this transition, alongside evaluating the availability of transitional programmes. Further research is required to explore the long-term impact of such programmes and to address the gaps in evidence from low- and middle-income countries.

[Prevalence of mental disorders in French prisons: A systematic review]

INTRODUCTION

The prevalence of psychiatric disorders among prisoners remains a major public health issue worldwide. In France, despite the increasing number of persons who are incarcerated (+30% between 1992 and 2002 with a 120% prison overcrowding), and a historical concern about the mental health of persons in detention and its management, no systematic review has been published on this subject. The aim of this article is to present the results of a systematic review of the literature on the prevalence of psychiatric disorders in French prisons.

METHOD

The reporting of this systematic review conforms to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) checklist. We searched the PubMed and Web of Science databases. We used combinations of keywords relating to prison (prison*, jail*, inmate*), to psychiatry ("mental health", psychiatr*), and to France (France, French). This work was completed with a search through the digital libraries of the École des Hautes Études en Santé Publique (EHESP) and of the Système Universitaire de Documentation (Sudoc) to obtain data from academic works and the gray literature. References cited in studies included in this review were also examined. All references published up to September 2022, written in English or French, presenting the results of original quantitative studies on the prevalence of psychiatric disorders in correctional settings were included. Two researchers independently extracted data from included references according to a pre-established protocol.

RESULTS

Among 501 records identified, a total of 35 papers based on 24 epidemiological studies met the eligibility criteria for inclusion in this review: 16 were cross-sectional, 7 retrospective and 1 both cross-sectional and retrospective. All papers were published between 1999 and 2022. We found one European study, 5 international studies, 18 regional or local studies. Of these, 21 studies had all-male or mixed gender samples (but when the sample was mixed gender, it was always at least 92% male). Almost half of the studies (n=11) involved a small sample of fewer than 500 persons. Half of the studies involved a sample of recently incarcerated persons: 6 involved a random sample of persons in detention, and 1 involved a sample of people incarcerated for more than 5 years. The last 5 studies focused on persons aged over 50 years and incarcerated for more than one year (n=1), incarcerated for sexual offences (n=2), placed in disciplinary cells (n=1) or in a special wing for radicalized or suspected radicalized individuals (n=1). Nine studies used standardized and validated diagnostic tools. According to the 4 studies involving representative samples and using standardized and validated diagnostic tools, the prevalence of the following psychiatric disorders was: 29.4-44.4% for anxiety disorders, 5-14.2% for PTSD, 28-31.2% for mood disorders, 6.9-17% for psychotic disorders, 32% for personality disorders and 11% for ADHD.

CONCLUSION

This systematic review of the literature highlights the high prevalence of psychiatric disorders in French prisons. The data collected are in line with international studies. The great methodological heterogeneity of the papers included in this review calls for further rigorous research to better understand the rates of mental disorders in French prisons and to explore their determinants.

The Efficacy of Outsourced Employment Services for Adults Exiting Australian Prisons

Crime rates in Australia have declined or been steady over the past decade yet prison populations are at all-time highs. Similarly, unemployment rates have been low but unemployment for those ex-prisoners seeking work is very high. In this paper, we draw on the findings of an Australia-wide survey of government-funded employment service providers who support working-aged Australians including ex-prisoners in their search for work. We find that the heterogeneity of the needs of ex-prisoners coupled with the frugality and inflexibility of government policies and practices frustrates the abilities of these agencies to provide services to this target group.

The role and effectiveness of occupational therapy in prison rehabilitation programs: systematic review

PURPOSE

The purpose of this study was to research studies in the literature regarding the role of the occupational therapist within penitentiary facilities.

DESIGN/METHODOLOGY/APPROACH

The study design is a systematic review using five different databases.

FINDINGS

Findings can therefore ascertain the potential role of occupational therapists in penitentiary institutions because they can contribute to the rehabilitation of prisoners both inside and outside prisons with a view to their reintegration into society.

RESEARCH LIMITATIONS/IMPLICATIONS

It is necessary for clinical practice, and especially to increase the health of people within prisons, to update the occupational therapist interventions in the literature that are effective within prisons.

PRACTICAL IMPLICATIONS

According to this study, the intervention of occupational therapists in the prison setting reduces recidivism and contributes to social and work reintegration. This has positive effects in terms of costs related to incarceration.

ORIGINALITY/VALUE

Findings can therefore ascertain the potential role of occupational therapists in penitentiary institutions because they can contribute to the rehabilitation of prisoners both inside and outside prisons with a view to their reintegration into society.

Rates and causes of death after release from incarceration among 1 471 526 people in eight high-income and middle-income countries: an individual participant data meta-analysis

BACKGROUND

Formerly incarcerated people have exceptionally poor health profiles and are at increased risk of preventable mortality when compared with their general population peers. However, not enough is known about the epidemiology of mortality in this population-specifically the rates, causes, and timing of death in specific subgroups and regions-to inform the development of targeted, evidence-based responses. We aimed to document the incidence, timing, causes, and risk factors for mortality after release from incarceration.

METHODS

We analysed linked administrative data from the multi-national Mortality After Release from Incarceration Consortium (MARIC) study. We examined mortality outcomes for 1 471 526 people released from incarceration in eight countries (Australia, Brazil, Canada, New Zealand, Norway, Scotland, Sweden, and the USA) from 1980 to 2018, across 10 534 441 person-years of follow-up (range 0-24 years per person). We combined data from 18 cohort studies using two-step individual participant data meta-analyses to estimate pooled all-cause and cause-specific crude mortality rates (CMRs) per 100 000 person-years, for specific time periods (first, daily from days 1-14; second, weekly from weeks 3-12; third, weeks 13-52 combined; fourth, weeks 53 and over combined; and fifth, total follow-up) after release, overall and stratified by age, sex, and region.

FINDINGS

75 427 deaths were recorded. The all-cause CMR during the first week following release (1612 [95% CI 1048-2287]) was higher than during all other time periods (incidence rate ratio [IRR] compared with week 2: 1·5 [95% CI 1·2-1·8], I2=26·0%, weeks 3-4: 2·0 [1·5-2·6], I2=53·0%, and weeks 9-12: 2·2 [1·6-3·0], I2=70·5%). The highest cause-specific mortality rates during the first week were due to alcohol and other drug poisoning (CMR 657 [95% CI 332-1076]), suicide (135 [36-277]), and cardiovascular disease (71 [16-153]). We observed considerable variation in cause-specific CMRs over time since release and across regions. Pooled all-cause CMRs were similar between males (731 [95% CI 630-839]) and females (660 [560-767]) and were higher in older age groups.

INTERPRETATION

The markedly elevated rate of death in the first week post-release underscores an urgent need for investment in evidence-based, coordinated transitional healthcare, including treatment for mental illness and substance use disorders to prevent post-release deaths due to suicide and overdose. Temporal variations in rates and causes of death highlight the need for routine monitoring of post-release mortality.

FUNDING

Australia's National Health and Medical Research Council.

Multi-sector stakeholder consensus on tackling the complex health and social needs of the growing population of people leaving prison in older age

BACKGROUND

As populations age globally, cooperation across multi-sector stakeholders is increasingly important to service older persons, particularly those with high and complex health and social needs. One such population is older people entering society after a period of incarceration in prison. The 'ageing epidemic' in prisons worldwide has caught the attention of researchers, governments and community organisations, who identify challenges in servicing this group as they re-enter the community. Challenges lie across multiple sectors, with inadequate support leading to dire consequences for public health, social welfare and recidivism. This is the first study to bring together multi-sector stakeholders from Australia to form recommendations for improving health and social outcomes for older people re-entering community after imprisonment.

RESULTS

A modified nominal group technique was used to produce recommendations from N = 15 key stakeholders across prison health, corrections, research, advocacy, aged care, community services, via online workshops. The importance and priority of these recommendations was validated by a broader sample of N = 44 stakeholders, using an online survey. Thirty-six recommendations for improving outcomes for this population were strongly supported. The key issues underlying the recommendations included: improved multi-stakeholder systems and services, targeted release preparation and practices that ensure continuity of care, advocacy-focused initiatives in the community, and extended funding for effective programs.

CONCLUSIONS

There is consensus across stakeholders on ways forward, with intervention and policy updates required at the individual, systems and community levels. These recommendations entail two important findings about this population: (1) They are a high-needs, unique, and underserved group at risk of significant health and social inequity in the community, (2) Multi-sector stakeholder cooperation will be crucial to service this growing group.

Mental and physical health morbidity among people in prisons: an umbrella review

BACKGROUND

People who experience incarceration are characterised by poor health profiles. Clarification of the disease burden in the prison population can inform service and policy development. We aimed to synthesise and assess the evidence regarding the epidemiology of mental and physical health conditions among people in prisons worldwide.

METHODS

In this umbrella review, five bibliographic databases (Web of Science, PubMed, PsycINFO, Embase, and Global Health) were systematically searched from inception to identify meta-analyses published up to Oct 31, 2023, which examined the prevalence or incidence of mental and physical health conditions in general prison populations. We excluded meta-analyses that examined health conditions in selected or clinical prison populations. Prevalence data were extracted from published reports and study authors were contacted for additional information. Estimates were synthesised and stratified by sex, age, and country income level. The robustness of the findings was assessed in terms of heterogeneity, excess significance bias, small-study effects, and review quality. The study protocol was pre-registered with PROSPERO, CRD42023404827.

FINDINGS

Our search of the literature yielded 1909 records eligible for screening. 1736 articles were excluded and 173 full-text reports were examined for eligibility. 144 articles were then excluded due to not meeting inclusion criteria, which resulted in 29 meta-analyses eligible for inclusion. 12 of these were further excluded because they examined the same health condition. We included data from 17 meta-analyses published between 2002 and 2023. In adult men and women combined, the 6-month prevalence was 11·4% (95% CI 9·9-12·8) for major depression, 9·8% (6·8-13·2) for post-traumatic stress disorder, and 3·7% (3·2-4·1) for psychotic illness. On arrival to prison, 23·8% (95% CI 21·0-26·7) of people met diagnostic criteria for alcohol use disorder and 38·9% (31·5-46·2) for drug use disorder. Half of those with major depression or psychotic illness had a comorbid substance use disorder. Infectious diseases were also common; 17·7% (95% CI 15·0-20·7) of people were antibody-positive for hepatitis C virus, with lower estimates (ranging between 2·6% and 5·2%) found for hepatitis B virus, HIV, and tuberculosis. Meta-regression analyses indicated significant differences in prevalence by sex and country income level, albeit not consistent across health conditions. The burden of non-communicable chronic diseases was only examined in adults aged 50 years and older. Overall, the quality of the evidence was limited by high heterogeneity and small-study effects.

INTERPRETATION

People in prisons have a specific pattern of morbidity that represents an opportunity for public health to address. In particular, integrating prison health within the national public health system, adequately resourcing primary care and mental health services, and improving linkage with post-release health services could affect public health and safety. Population-based longitudinal studies are needed to clarify the extent to which incarceration affects health.

FUNDING

Research Foundation-Flanders, Wellcome Trust, National Institutes of Health.

Mortality in women with a history of incarceration in Norway: a 20-year national cohort study

BACKGROUND

Women carry a substantial burden of psychiatric, somatic and lifestyle-related morbidity in the prison context. By describing causes of death and estimating the risk and burden of mortality compared with the general population, this study investigates how mortality operates in this highly marginalized and under-researched population.

METHODS

In this registry-based study of all women incarcerated in Norwegian prisons from 2000 to 2019 (N = 11 313), we calculated crude mortality rates, years of lost life and, by using mortality in age-matched women from the general population as a reference, age-standardized mortality ratios and years of lost life rates.

RESULTS

Over a mean follow-up time of 10.7 years, at a median age of 50 years, 9% of the population had died (n = 1005). Most deaths (80%) were premature deaths from an avoidable cause. Drug-induced causes and deaths from major non-communicable diseases (NCDs) were most frequent (both 32%). Compared with women in the general population, women with a history of incarceration were more likely to die from any cause. Trends in annual age-standardized years of lost life rates suggest that the mortality burden associated with major NCDs has gradually replaced drug-induced causes.

CONCLUSIONS

Women with a history of incarceration die at a greater rate than their peers and largely from avoidable causes. The profile of causes contributing to the substantial burden of mortality placed on this population has changed over time and has important implications for future efforts to reduce morbidity and the risk of premature death following release from prison.

Make or break: Succeeding in transition from incarceration

Several factors impact successful reintegration after incarceration. We sought to better understand these factors such as pre-release preparedness or access to financial resources in provincial correctional facilities in Ontario, Canada with an underlying focus on the role of personal identification (PID) among people at risk of homelessness. We conducted a qualitative study with one-on-one telephone interviews. Eligibility criteria included having been released from a provincial correctional facility in the preceding 2 years, being over the age of 18, speaking English and having telephone access. Participants were recruited between February 2021 and July 2021. All interviews were audio recorded and transcribed. Data was analyzed using a thematic analysis framework along with strategies from grounded theory research. We interviewed 12 individuals and identified six key themes including 1) Degree of Preparedness Pre-Release 2) Managing Priorities Post-Release 3) Impact of Support Post-Release 4) Obstacles with Accessing Services 5) Influence of Personal Identification 6) Emotions and Uncertainty. We found that people with mental health and addiction challenges are uniquely at risk post-release. Solutions must include comprehensive and proactive case management that bridges the pre-release and post-release periods, simplified processes for obtaining PID, better connections to health and social services, and improved pre-release planning for community support.

Learnings from a prison-based drug treatment program on planning for release: A qualitative study

INTRODUCTION

Prison-based drug and alcohol group treatment programs operate in all Australian jurisdictions. With more than two-thirds of people in prison having a history of substance use prior to incarceration, such programs are needed. There have been few published papers on the impact of attending group treatment programs in Australian prisons, and the research published to date has been predominately quantitative. We aim to report the experiences of males in prison who completed and those who did not complete a group-based drug and alcohol program, to gain insight into their strategies for reducing harm from drug and alcohol post-release.

METHODS

Qualitative thematic analysis of in-depth interviews with 12 males who completed or were about to complete and 10 males who discontinued a prison-based group drug and alcohol treatment program.

RESULTS

Program completers were more likely to have well-developed plans to reduce drug and alcohol harms and maintain abstinence upon return to the community, which included creating healthier social networks. They also showed stronger insights into the factors that led to offending. Those who did not complete the drug and alcohol program appeared to rely on self-will as the main way to reduce drug and alcohol harms, with less awareness of options for support services to reduce or stop drug and alcohol use.

DISCUSSION AND CONCLUSIONS

Prison-based drug and alcohol program engagement imparted useful information for program completers. Controlled trials are needed to examine whether such differences equate to improved outcomes after release.

Effects of the Connections program on return-to-custody, mortality and treatment uptake among people with a history of opioid use: Retrospective cohort study in an Australian prison system

BACKGROUND AND AIMS

Connections is a voluntary health program that facilitates access to opioid agonist treatment (OAT) and social services for people with opioid use exiting prison. This study aimed to measure the effectiveness of Connections in reducing recidivism and improving health outcomes for people with a history of opioid use on leaving prison.

DESIGN

Retrospective cohort study with quasi-random allocation to the program.

SETTING

Public adult prisons in New South Wales, Australia, 2008-2015.

PARTICIPANTS

Adults released from custody with a history of opioid use. Of 5549 eligible releasees, 3973 were allocated to Connections and 1576 to treatment-as-usual.

MEASUREMENTS

Outcomes were return-to-custody, all-cause mortality, and OAT participation.

FINDINGS

Regression analyses on an intention-to-treat basis, and adjusting for baseline propensity scores, comparing patients allocated to Connections versus treatment-as-usual showed no difference in rates of return-to-custody within 2 years (hazard ratio [HR]: 1.01; 95% confidence interval [CI]: 0.92 -1.12). Patients allocated to the Connections program were more likely to access OAT (odds ratio [OR]: 1.21; 95% CI: 1.06-1.39) and had lower mortality within 28 days of release (0.25% vs. 0.66%; HR: 0.38; 95% CI: 0.14-1.03). Differences in mortality did not persist beyond 28 days. Subgroup analyses showed that allocation to Connections was associated with higher risk of return-to-custody within 28 days for Aboriginal and/or Torres Strait Islander (Indigenous) and female releasees.

CONCLUSIONS

The Connections program for people with opioid use exiting prison did not reduce the likelihood of return-to-custody but did facilitate opioid agonist treatment participation on release from prison.

Fifty Years of U.S. Mass Incarceration and What It Means for Bioethics

A growing body of literature has engaged with mass incarceration as a public health problem. This article reviews some of that literature, illustrating why and how bioethicists can and should engage with the problem of mass incarceration as a remediable cause of health inequities. "Mass incarceration" refers to a phenomenon that emerged in the United States fifty years ago: imprisoning a vastly larger proportion of the population than peer countries do, with a greatly disproportionate number of incarcerated people being members of marginalized racial and ethnic groups. Bioethicists have long engaged with questions of health justice for incarcerated people, including consent issues for those participating in research and access to health care. This article provides an overview of the individual and public health impacts of mass incarceration. The article argues that mass incarceration is a bioethics issue that should be addressed in medical education, identifies opportunities for bioethicists to guide hospitals' interactions with law enforcement officials, and calls on bioethicists to be in conversation with medical and nursing students and health care professionals about these groups' advocacy efforts concerning structural racism, police violence, and mass incarceration.

Cancer equity for those impacted by mass incarceration

The cancer disparities between people with incarceration histories compared with those who do not have those histories are vast. Opportunities for bolstering cancer equity among those impacted by mass incarceration exist in criminal legal system policy; carceral, community, and public health linkages; better cancer prevention, screening, and treatment services in carceral settings; expansion of health insurance; education of professionals; and use of carceral sites for health promotion and transition to community care. Clinicians, researchers, persons with a history of incarceration, carceral administrators, policy makers, and community advocates could play a cancer equity role in each of these areas. Raising awareness and setting a cancer equity plan of action are critical to reducing cancer disparities among those affected by mass incarceration.

Peer-Facilitated Tobacco Cessation in a Prison Setting: A Proof of Concept Study

Background

Despite the vast human and economic costs associated with tobacco use among U.S. inmates, smoking remains a largely ignored public health epidemic. Incarcerated individuals smoke at 3 to 4 times the rate of the general population and face tobacco-related health disparities.

Purpose

This paper reports results from a single arm, pre/post pilot study designed to test the feasibility and initial effectiveness of an inmate-administered group tobacco cessation intervention within a men’s pre-release program run by the Arizona Department of Corrections.

Methods

Corrections staff and inmate peer mentors were trained in the DIMENSIONS: Tobacco Free Program, a manualized 6-session tobacco cessation group curriculum. Group sessions used evidence-based interventions for assisting inmates develop skills to live tobacco and nicotine free. In 2019-2020, 39 men who reported tobacco use voluntarily participated in one of three cessation groups. Wilcoxen signed-rank tests evaluated changes across group sessions in frequency of tobacco use and attitudes about nicotine-free living post release.

Results

Most participants attended all six group sessions (79%) and made one or more quit attempts (78%). Overall, 24% of the sample reported quitting tobacco, and significant reductions in tobacco use were reported after only two sessions. Participants further reported significant positive changes in knowledge, plans, support, and confidence to live tobacco-free lives post-release.

Conclusions

To our knowledge, this is the first study to demonstrate that, with minimal investment, implementation of an evidence-based, peer-led tobacco free program is feasible and effective within an incarcerated population uniquely vulnerable to the burden of tobacco.

Sex differences in suicide, suicidal ideation, and self-harm after release from incarceration: a systematic review and meta-analysis

PURPOSE

People released from incarceration are at increased risk of suicide compared to the general population. We aimed to synthesise evidence on the incidence of and sex differences in suicide, suicidal ideation, and self-harm after release from incarceration.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, Web of Science and PubMed between 1 January 1970 and 14 October 2021 for suicide, suicidal ideation, and self-harm after release from incarceration (PROSPERO registration: CRD42020208885). We calculated pooled crude mortality rates (CMRs) and standardised mortality ratios (SMRs) for suicide, overall and by sex, using random-effects models. We calculated a pooled incidence rate ratio (IRR) comparing rates of suicide by sex.

RESULTS

Twenty-nine studies were included. The pooled suicide CMR per 100,000 person years was 114.5 (95%CI 97.0, 132.0, I2 = 99.2%) for non-sex stratified samples, 139.5 (95% CI 91.3, 187.8, I2 = 88.6%) for women, and 121.8 (95% CI 82.4, 161.2, I2 = 99.1%) for men. The suicide SMR was 7.4 (95% CI 5.4, 9.4, I2 = 98.3%) for non-sex stratified samples, 14.9 for women (95% CI 6.7, 23.1, I2 = 88.3%), and 4.6 for men (95% CI 1.3, 7.8, I2 = 98.8%). The pooled suicide IRR comparing women to men was 1.1 (95% CI 0.9, 1.4, I2 = 82.2%). No studies reporting self-harm or suicidal ideation after incarceration reported sex differences.

CONCLUSION

People released from incarceration are greater than seven times more likely to die by suicide than the general population. The rate of suicide is higher after release than during incarceration, with the elevation in suicide risk (compared with the general population) three times higher for women than for men. Greater effort to prevent suicide after incarceration, particularly among women, is urgently needed.

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.

Mortality after release from incarceration in New Zealand by gender: A national record linkage study

Background

People who enter and leave places of incarceration experience considerable health inequities and are at increased risk of premature death compared to the general population. Causes of premature death in this population vary markedly between countries and so country-specific information is needed. Additionally, there is a lack of large population-based studies which can disaggregate mortality risk based on person and incarceration factors. This study is the first examination of mortality in the period following release from incarceration in New Zealand.

Methods

We linked deidentified administrative data on incarceration and release between 1 January 1998 and 31 December 2016 with national mortality data for the same period to examine mortality after release in those who had been incarcerated for at least 1 day. Age standardised mortality rates and mortality ratios compared to the general New Zealand population were calculated separately for men and women, for releases from remand compared with prison, and by cause of death and time since release.

Results

90,195 individuals (13% women, 49% Māori) were followed up for 9.4 years after release from incarceration, with 4,764 deaths over the follow-up period. The overall standardised mortality ratio was 3.3 (95% CI 3.2, 3.4) compared to the general population, and higher for women (3.8) than men (2.7). The most common causes of death were cardiovascular disease, cancer and suicide. Rates of death were similar following release from remand versus prison, however suicide rates were highest following release from remand. Regardless of the type of incarceration, mortality was highest in the first month after release.

Conclusion

Experience of incarceration in New Zealand is associated with high rates of mortality from both chronic conditions and external causes. There are urgent policy imperatives to recognise and actively address the increased health and mortality risks faced by people released from New Zealand prisons.

Stakeholder-engaged research is necessary across the criminal-legal spectrum

People with lived experience of incarceration have higher rates of morbidity and mortality compared to people without history of incarceration. Research conducted unethically in prisons and jails led to increased scrutiny of research to ensure the needs of those studied are protected. One consequence of increased restrictions on research with criminal-legal involved populations is reluctance to engage in research evaluations of healthcare for people who are incarcerated and people who have lived experience of incarceration. Ethical research can be done in partnership with people with lived experience of incarceration and other key stakeholders and should be encouraged. In this article, we describe how stakeholder engagement can be accomplished in this setting, and further, how such engagement leads to impactful research that can be disseminated and implemented across disciplines and communities. The goal is to build trust across the spectrum of people who work, live in, or are impacted by the criminal-legal system, with the purpose of moving toward health equity.

Understanding health and social service accessibility for young people with problematic substance use exiting prison in Australia

Incarcerated young people (aged 18-24) with a history of problematic substance use are a particularly vulnerable group, with a higher risk of mortality and return to custody compared to their older counterparts. Yet, there is limited research investigating service accessibility for this population. This study aimed to address this gap by investigating the characteristics of young people exiting prison on the 'Connections Program' (Connections) and their access to support services. Connections is a transitional program with a remit to link people with problematic substance use exiting prison in New South Wales, Australia, to health and social services in the community. We used an explanatory sequential mixed methods approach including (1) a retrospective cohort study of young people on Connections (n = 359), utilising self-reported data collected in a routine pre-release questionnaire from January 2008 to February 2015 and (2) a qualitative survey with Connections caseworkers (n = 10). In stage one, descriptive statistics were calculated to produce a profile of sociodemographic and health characteristics of young people with problematic substance use exiting prison. In stage two, qualitative data were thematically analysed to explore the accessibility of services to meet young people's needs from the perspective of caseworkers. The study found young people experienced substantially poorer mental health than the general population, and the vast majority had received treatment for a mental health issue (96.5%). Illicit substance use prior to incarceration was common (91.5%). Caseworkers reported substantial barriers to service accessibility in the community related to intersecting social disadvantage and co-occurring mental distress and substance use. Caseworkers have front-line knowledge of how gaps and barriers in services impact transition from prison and identified longer-term case coordination, inter-agency collaboration and holistic care as vital strategies to support young people in transition from prison to community.

Crisis stabilization units for jail diversion: A preliminary assessment of patient characteristics and outcomes

Crisis stabilization units (CSUs), which offer a range of short-term psychiatric and psychological services, are one of several treatment programs that may create "alternative to arrest" options for law enforcement. Here, we examined the characteristics of the population who was referred to a newly established CSU in its first year of operation and examined the impact of the CSU on regional jail bookings. Administrative medical records and regional jail booking data were merged to form our study sample. Adults who had at least one jail booking and/or one CSU admission during our study period were included. We found that from September 1, 2018 to August 30, 2019, 458 people were admitted into the CSU. Approximately one-third (33.8%) had a jail booking during the study period. In the 3 months following CSU admission, 4.1% had an increase in jail bookings, 11.1% had a decrease, and 66.2% had no change. CSU patients self-reported high depressive and posttraumatic stress disorder symptoms, while also reporting low quality of life scores overall. We conclude that CSUs may be promising components of jail diversion efforts, providing critical services to populations experiencing significant mental health symptoms and who are at risk for incarceration. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Impact of smoking bans and other smoking cessation interventions in prisons, mental health and substance use treatment settings: A systematic review of the evidence

ISSUES

We conducted a systematic review to examine whether smoking bans alone are effective in achieving smoking cessation in people released from prison, and patients discharged from mental health or substance use settings.

APPROACH

We searched health, criminology and social science databases. Detailed search strings were used to combine terms related to smoking bans and cessation interventions in prison, mental health and substance use treatment settings. We used backward and forward snowballing and manual hand searching to find additional studies. Studies were included if they: were published between 1 January 2000 and 25 February 2022; included a complete smoking ban; measured people released from prison and/or mental health and/or substance use patients smoking post-release/discharge from a smoke-free facility; and reported smoking cessation intervention and/or smoking ban outcomes. Methodological quality was assessed using the Effective Public Health Practice Project's Quality Assessment Tool for Quantitative Studies and reviewed by two authors.

KEY FINDINGS

People released from prison, mental health and substance use in-patients who experience a smoking ban while incarcerated or in in-patient settings often relapse to smoking shortly after release or discharge. We found that although smoking bans alone do not promote cessation, multi-component interventions in combination with smoking bans can significantly increase cessation rates post-release/discharge provided they support participants during this time.

CONCLUSIONS

There is limited evidence to suggest tobacco bans alone in prison, mental health and substance use treatment settings are effective in achieving long-term smoking cessation. This review suggests that combining smoking bans and cessation interventions including pre- and post-release/discharge support can be effective in achieving smoking cessation.

An Economic Analysis of the Cost of a Regional Crisis Stabilization Unit

Crisis stabilization units (CSUs) are one type of "alternative to arrest" program used for jail diversion. We aimed to estimate the economic costs of starting and operating a CSU in Arkansas. We estimated the economic costs of the Pulaski County Regional CSU (PCRCSU) located in Little Rock, Arkansas, from September 1, 2018, to August 31, 2019. We collected data through interviews about start-up and ongoing management costs. We calculated total annual economic cost, average admission cost, and average 24 hr admission cost. There were 536 admissions to the CSU during the study period. The average length of stay was 60.27 hr. The total annual cost of the PCRCSU was $1,636,831 and average per admission cost was $3,054. Our results provide valuable economic data to government stakeholders who are considering establishing a CSU.

Mental and physical health problems before and after detention: A matched cohort study

Background

Individuals with poor health are largely overrepresented in prison populations. However, it remains unclear whether their poor health status already exists prior to their detention or reflects an effect of detention. We examined the health of detainees in the year before and after their detention and compared this with the health of matched non-detainees.

Methods

In this matched cohort study, we linked national data on all persons detained in the Netherlands in 2014/2015 to electronic health records (EHR's) of a representative sample of general practitioners in the Netherlands. Participants include 952 detained persons and 4760 matched non-detained persons (matched on age, sex and general practice). Prevalence rates of health problems in the year before and after detention and odds ratios with 95% confidence intervals were calculated. Rates for a variety of physical and mental health problems are presented.

Findings

Detainees and matched controls differed statistically significant in their pre-detention health status. Compared with controls, male detainees were more likely to report psychological (odds ratio [OR] 3·64 [95% CI 3·11–4·26]), social (1·96 [1·46–2·64]), neurological (1·34 [1·02–1·76]), digestive (1·23 [1·02–1·49]), genital system-related (1·36 [1·07–1·72]), and unspecified health problems (1·32 [1·10–1·59]) in the year before their detention. For example, 43·7% of detainees and 17·6% of controls reported psychological problems in this pre-detention year. To some extent these pre-detention health differences were related to socioeconomic differences. Nevertheless, after taking these characteristics into account, a number of pre-detention health differences between detainees and controls remained statistically significant. No statistically significant changes in prevalence rates from pre- to post-detention and no differences in the levels of change across detainees and controls were observed. For female detainees a similar pattern was found.

Interpretation

People who experience detention have high and complex health needs both pre- and post-detention. While this study did not show a health deteriorating effect of detention, it also did not show a health improving effect. This latter finding may indicate a missed opportunity for health care services to address detainees’ health, especially since persons entering detention have elevated health problems. Knowledge on detainees’ specific health problems may help health care providers in prisons and in the community to adequately address the health care needs of this vulnerable group.

Funding

None.

Implementing a Culture of Health Among Probationers

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

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.

Health, social and criminal justice factors associated with dual diagnosis among incarcerated adults in Brazil and Australia: a cross-national comparison

PURPOSE

To estimate the prevalence of dual diagnosis and identify health, social and criminal justice factors associated with dual diagnosis among incarcerated adults in Australia and Brazil.

METHODS

We compared data from cross-sectional surveys of incarcerated adults (aged ≥ 18 years) in Australia and Brazil. Using data from linked emergency department, hospital, and in-prison medical records in the Australian sample, and from the Composite International Diagnostic Interview (CIDI) in the Brazilian sample, participants were categorised as having: (1) no mental disorder; (2) substance use disorder only; (3) mental illness only; or (4) dual diagnosis. A multivariate multinomial logistic regression model was fitted to identify factors associated with dual diagnosis in each country.

RESULTS

Approximately one quarter of participants in both Australia (22%) and Brazil (25%) met the diagnostic criteria for dual diagnosis. In both countries, dual diagnosis was associated with being female [relative risk (RR) = 2.25 (95% CI 1.47-3.43) Australia; RR = 2.59 (95% CI 1.79-3.74) Brazil], having a history of prior incarceration [RR = 2.99 (95% CI 1.99-4.48) Australia; RR = 2.27 (95% CI 1.57-3.29) Brazil], and having comorbid physical health problems [RR = 1.54 (95% CI 1.08-2.19) Australia; RR = 2.53 (95% CI 1.75-3.65) Brazil].

CONCLUSIONS

Despite differences in health, social, and criminal justice systems between Australia and Brazil, the prevalence of and factors associated with dual diagnosis in incarcerated adults appear to be similar in the two countries. A number of generalisable principles can be inferred and should be considered in health and criminal justice policy making.

Prisoners' experience and perceptions of health care in Australian prisons: a qualitative study

PURPOSE

Patient-centred care is a key approach used in Australia for the delivery of quality health care, and understanding experiences and perceptions is a key part to this. This paper aims to explore prisoners' experiences and perceptions of health-care service provision in New South Wales, Australia.

DESIGN/METHODOLOGY/APPROACH

In February and March 2017, 24 focus groups, consisting of 128 participants, were undertaken using semi-structured interviews that explored experiences of health care in prison.

FINDINGS

A conceptualisation of the prisoners' health-care experience around the core category of access to health care emerged from the data. Enablers or barriers to this access were driven by three categories: a prison construct - how the prisoners "see" the prison system influencing access to health care; a health-care system construct - how the prisoners "see" the prison health-care system and the pathways to navigate it; and personal factors. Communication was the category with the greatest number of relational connections.

RESEARCH LIMITATIONS/IMPLICATIONS

This study takes a pragmatic approach to the analysis of data, the findings forming the basis for a future quantitative study. The findings identify communication as a key issue for access to health care.

ORIGINALITY/VALUE

This study provides first-hand accounts of enablers and barriers to accessing health-care services in the prison environment. To the best of the authors' knowledge, this study is the first of its kind to identify access to health care as a core category and is of value to health workers and researchers that work with the prison population.

Systematic Review of Factors Influencing Smoking Following Release From Smoke-Free Prisons

INTRODUCTION

Given the current proliferation of prison smoke-free policies internationally, and the multiple benefits of continued smoking abstinence for correctional populations, improved understanding of factors influencing postrelease smoking abstinence is required to inform support strategies aimed at individuals exiting smoke-free prisons.

METHODS

We systematically searched health, social science, and criminal justice databases for studies relating to smoking behaviors among people released from smoke-free prisons. Studies were included if: they were published between January 1, 2000 and July 26, 2017; they were published in English; the population was people who were incarcerated or formerly incarcerated in prisons with total smoke-free policies; and the reported outcomes included measures of: (1) prerelease intention to smoke or remain abstinent from smoking following release, (2) smoking relapse or abstinence following release, or (3) quit attempts following postrelease smoking relapse. Both authors independently screened returned citations to assess eligibility and reviewed studies for methodological quality using the Effective Public Health Practice Project's Quality Assessment Tool for Quantitative Studies.

RESULTS

Fifteen of 121 publications were included. The evidence base in this area is small, almost exclusively US-based, and is mostly methodologically weak. Interventions delivered both pre and postrelease, that strengthen intention to quit, integrate with other substance-use treatment, and facilitate social support for quitting may help maintain postrelease smoking abstinence.

CONCLUSIONS

There is an urgent need for high-quality research to inform interventions to reduce high smoking relapse rates upon release from smoke-free prisons, to extend the multiple benefits of continued smoking abstinence into the community.

IMPLICATIONS

Interventions designed to help people remain abstinent from tobacco following release from smoke-free prisons are an important opportunity to improve the health, finances, and well-being of this vulnerable population.

"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.

Estimating the impact of wide scale uptake of screening and medications for opioid use disorder in US prisons and jails

BACKGROUND

Medications for opioid use disorder (OUD) are the most effective treatment for OUD, but uptake of these life-saving medications has been extremely limited in US prisons and jail settings, and limited data are available to guide policy decisions. The objective of this study was to estimate the impact of screening and treatment with medications for OUD in US prisons and jails on post-release opioid-related mortality.

METHODS

We used data from the National Center for Vital Statistics, the Bureau of Justice Statistics, and relevant literature to construct Monte Carlo simulations of a counterfactual scenario in which wide scale uptake of screening and treatment with medications for OUD occurred in US prisons and jails in 2016.

RESULTS

Our model predicted that 1840 (95% Simulation Interval [SI]: -2757 - 4959) lives would have been saved nationally if all persons who were clinically indicated had received medications for OUD while incarcerated. The model also predicted that approximately 4400 (95% SI: 2675 - 5557) lives would have been saved nationally if all persons who were clinically indicated had received medications for OUD while incarcerated and were retained in treatment post-release. These estimates correspond to 668 (95% SI: -1008 - 1812) and 1609 (95% SI: 972 - 2037) lives saved per 10,000 persons incarcerated, respectively.

CONCLUSIONS

Prison and jail-based programs that comprehensively screen and provide treatment with medications for OUD have the potential to produce substantial reductions in opioid-related overdose deaths in a high-risk population; however, retention on treatment post-release is a key driver of population level impact.

The health of adolescents in detention: a global scoping review

Adolescents detained within the criminal justice system are affected by complex health problems, health-risk behaviours, and high rates of premature death. We did a global synthesis of the evidence regarding the health of this population. We searched Embase, PsycINFO, Education Resources Information Center, PubMed, Web of Science, CINCH, Global Health, the Cochrane Database of Systematic Reviews, the Campbell Library, the National Criminal Justice Reference System Abstract Database, and Google Scholar for peer-reviewed journal articles, including reviews, that reported the prevalence of at least one health outcome (physical, mental, sexual, infectious, and neurocognitive) in adolescents (aged <20 years) in detention, and were published between Jan 1, 1980, and June 30, 2018. The reference lists of published review articles were scrutinised for additional relevant publications. Two reviewers independently screened titles and abstracts, and three reviewed full texts of relevant articles. The protocol for this Review was registered with PROSPERO (CRD42016041392). 245 articles (204 primary research articles and 41 reviews) were included, with most primary research (183 [90%]) done in high-income countries. A high lifetime prevalence of health problems, risks, and conditions was reported in detained adolescents, including mental disorders (0-95%), substance use disorders (22-96%), self-harm (12-65%), neurodevelopmental disabilities (2-47%), infectious diseases (0-34%), and sexual and reproductive conditions (pregnant by age 19 years 20-37%; abnormal cervical screening test result 16%). Various physical and mental health problems and health-risk behaviours are more common among adolescents in detention than among their peers who have not been detained. As the social and structural drivers of poor health overlap somewhat with factors associated with exposure to the criminal justice system, strategies to address these factors could help to reduce both rates of adolescent detention and adolescent health inequalities. Improving the detection of mental and physical disorders, providing appropriate interventions during detention, and optimising transitional health care after release from detention could improve the health outcomes of these vulnerable young people.

The Mortality After Release from Incarceration Consortium (MARIC): Protocol for a multi-national, individual participant data meta-analysis

INTRODUCTION

More than 30 million adults are released from incarceration globally each year. Many experience complex physical and mental health problems, and are at markedly increased risk of preventable mortality. Despite this, evidence regarding the global epidemiology of mortality following release from incarceration is insufficient to inform the development of targeted, evidence-based responses. Many previous studies have suffered from inadequate power and poor precision, and even large studies have limited capacity to disaggregate data by specific causes of death, sub-populations or time since release to answer questions of clinical and public health relevance.

OBJECTIVES

To comprehensively document the incidence, timing, causes and risk factors for mortality in adults released from prison.

METHODS

We created the Mortality After Release from Incarceration Consortium (MARIC), a multi-disciplinary collaboration representing 29 cohorts of adults who have experienced incarceration from 11 countries. Findings across cohorts will be analysed using a two-step, individual participant data meta-analysis methodology.

RESULTS

The combined sample includes 1,337,993 individuals (89% male), with 75,795 deaths recorded over 9,191,393 person-years of follow-up.

CONCLUSIONS

The consortium represents an important advancement in the field, bringing international attention to this problem. It will provide internationally relevant evidence to guide policymakers and clinicians in reducing preventable deaths in this marginalized population.

KEY WORDS

Mortality; incarceration; prison; release; individual participant data meta-analysis; consortium; cohort.

Global Prison Health Care Governance and Health Equity: A Critical Lack of Evidence

The large and growing population of people who experience incarceration makes prison health an essential component of public health and a critical setting for reducing health inequities. People who experience incarceration have a high burden of physical and mental health care needs and have poor health outcomes. Addressing these health disparities requires effective governance and accountability for prison health care services, including delivery of quality care in custody and effective integration with community health services.Despite the importance of prison health care governance, little is known about how prison health services are structured and funded or the methods and processes by which they are held accountable. A number of national and subnational jurisdictions have moved prison health care services under their ministry of health, in alignment with recommendations by the World Health Organization and the United Nations Office on Drugs and Crime. However, there is a critical lack of evidence on current governance models and an urgent need for evaluation and research, particularly in low- and middle-income countries.Here we discuss why understanding and implementing effective prison health governance models is a critical component of addressing health inequities at the global level.

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.

Perceived oral health and access to care among men with a history of incarceration

OBJECTIVES

To explore the perceptions of oral health and access to care experiences of men with a history of incarceration and to identify factors contributing to current oral health inequities within their community.

METHODS

A qualitative approach was used via focus group discussions among 18 men with a history of incarceration and 10 staff members of a non-profit organization working with individuals who are involved in or at risk of involvement with the criminal justice system. All discussions were audiorecorded and transcribed verbatim. A thematic analysis was undertaken using N-Vivo 10^™, a qualitative data management program.

RESULTS

The participants ranged in age from 29 years to 69 years, came from a variety of ethnic backgrounds, and had different prison setting experiences. Five major themes emerged: not on the radar, stigma of incarceration, being shot down, caught in the system, and institutional conditioning.

CONCLUSIONS

The personal backgrounds, experiences with health and dental care during prison time, and the unique challenges faced by men with a history of incarceration influenced their perceptions and their ability to access dental services. Dental professionals can help to change these perceptions and experiences by creating a safe space for these individuals to access and receive care comfortably.

Criminal Justice Involvement and Young Adult Health: The Role of Adolescent Health Risks and Stress

BACKGROUND

Although some studies have found that incarceration is associated with young adults' poor health, confounding factors including adolescent health risks, and mediating influences such as stress have not been examined in the same study. We assessed whether variation in criminal justice system experience (none, arrest only, incarceration) influenced young adults' self-reported depressive symptoms and poor physical health after accounting for prospective risks to health including adolescent health risks. We then assessed whether stress mediated associations between criminal justice involvement and the two health indicators.

METHODS

Data are from Toledo Adolescent Relationships Study (TARS) (n =990), which included young adults, age 22-29, who have matured during the era characterized by mass incarceration. The dependent variables included a depressive symptoms scale and self-reported poor health. The adolescent health risks included economic disadvantage, body mass index, delinquency, problems with drugs, and prior depressive symptoms. We considered stress as a mediating variable. Sociodemographic characteristics included race/ethnicity, age, and gender. We used ordinary least squares regression and logistic regression analyses. We tested gender, race/ethnicity, and age interactions.

RESULTS

In multivariable models, incarceration, and adolescent health risks (economic disadvantage, prior depression, problems with drugs) were associated with young adults' depressive symptoms, and stress was a mediating influence. Adolescent delinquency and stress, but not incarceration, were significantly associated with young adults' self-reported poor health.

CONCLUSION

This study provided a more nuanced understanding of incarceration and health by accounting for several key confounding factors and testing stress as a mechanism underlying the association. Care for prisoner health during and after incarceration is important for successful reintegration.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

AIMS/HYPOTHESES

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

METHODS

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

RESULTS

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

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

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

The effect of forensic events on health status and housing stability among homeless and vulnerably housed individuals: A cohort study

We sought to characterize the association between a forensic event (arrest or incarceration) with housing vulnerability and mental and physical health status over a four-year follow-up among a cohort of homeless and vulnerably housed individuals in Vancouver, Toronto and Ottawa. Data were obtained from the Health and Housing in Transition Study, a prospective cohort study of homeless and vulnerably housed individuals between 2009 and 2012. Participants were interviewed in-person at baseline (N = 1190) and at four annual follow-up time points. We used generalized estimating equations to characterize the independent associations between a forensic event and the number of residential moves and SF-12 physical and mental health component scores over the four-year follow-up period. We analyzed data from 1173 homeless and vulnerably housed participants. Forensic events were reported by 446 participants at baseline. In multivariate analyses, a history of forensic event in the preceding twelve months was independently associated with an increased number of residential moves over the four-year follow-up period (ARR 1.24; 95% CI 1.19-1.3). It was not, however, independently associated with a change in physical or mental health status (respective ß-estimates; 95% CI: -0.34; -1.02, 0.34, and -0.69; -1.5, 0.2). Female gender and a history of problematic substance use were significantly associated with all three primary outcomes. This suggests arrest or incarceration is associated with increased housing vulnerability. The results underline the importance of supporting individuals experiencing arrest or incarceration with post-release planning in order to obtain stable housing after discharge.

Medical nutrition therapy in Canadian federal correctional facilities

Background

Under- and over nutrition as well as nutrition risk factors such as communicable and non-communicable diseases are a common and major cause of morbidity and mortality in correctional facilities. Consequently, medical nutrition therapy (MNT), a spectrum of nutrition services aimed at optimizing individual well-being, is being recognized as integral to the health of people who experience incarceration. However, there is a paucity of research that explores the delivery of MNT in correctional facilities.

Methods

A scoping review combined with secondary analysis of qualitative data (field notes, in-depth stakeholder interviews) from a 2-year ethnographic study about food insecurity and incarceration was undertaken to gain insights about the delivery of corrections-based MNT in Canada. Thematic analysis of all documents was done using an interpretive framework.

Results

An understanding about MNT was developed within three themes: 1) specialized service provision in a unique environment; 2) challenges with the provision of MNT; and 3) consideration of corrections-based MNT alternatives. An incarcerated individual’s nutritional health was conceptualized as culminating from various factors that included dietary intake and health status, enabling environments, access to quality health services, and clinical nutrition services. Nutrition care practices, which range from health promotion to rehabilitation, are challenged by issues of access, visibility, adequacy, and environmental barriers. Their success is dependent on demand (e.g., ability of recipient to act) and factors that enable quality health and food services. Advancing corrections-based MNT will require policies that provide supportive food and health environments and creating sustainable services by integrating alternatives such as peer approaches and telehealth.

Conclusions

Professional associations, government, researchers and other stakeholders can help to strengthen corrections-based MNT by fostering shifts in thinking about the role of health practitioners in these contexts, preparing future health professionals with the specialized skills needed to work in these environments, generating evidence that can best inform practice, and cultivating collaborations aimed at crime prevention, successful societal reintegration, and the reduction of recidivism.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3926-3) contains supplementary material, which is available to authorized users.

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

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

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

ACTRN12617000217303; Pre-results.