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.

Opioid toxicity deaths in Black persons who experienced provincial incarceration in Ontario, Canada 2015-2020: A population-based study.

OBJECTIVE: In the context of mass incarceration and the opioid toxicity crisis in North America, there is a lack of data on the burden of opioid toxicity deaths in Black persons who experience incarceration. We aimed to describe absolute and relative opioid toxicity mortality for Black persons who experienced incarceration in Ontario, Canada between 2015 and 2020. METHODS: We linked data for all persons incarcerated in provincial correctional facilities and all persons who died from opioid toxicity in Ontario between 2015 and 2020, and accessed public data on population sizes. We described the characteristics of Black persons who were incarcerated and died from opioid toxicity, and calculated absolute mortality rates, as well as age-standardized mortality rates compared with all persons in Ontario not incarcerated during this period. RESULTS: Between 2015 and 2020, 0.9% (n = 137) of 16,177 Black persons who experienced incarceration died from opioid toxicity in custody or post-release, for an opioid toxicity death rate of 0.207 per 100 person years. In the two weeks post-release, the opioid toxicity death rate was 1.34 per 100 person years. Standardized for age and compared with persons not incarcerated, the mortality ratio (SMR) was 17.8 (95%CI 16.4-23.1) for Black persons who experienced incarceration. CONCLUSIONS: We identified a large, inequitable burden of opioid toxicity death for Black persons who experience incarceration in Ontario, Canada. Work is needed to support access to culturally appropriate prevention and treatment in custody and post-release for persons who are Black, and to prevent incarceration and improve determinants of health.

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.

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.

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.

Infant and Maternal Outcomes for Women Who Experience Imprisonment in Ontario, Canada: A Retrospective Cohort Study.

OBJECTIVE: To describe the population-level risk of infant and maternal outcomes for women who experience imprisonment and compare outcomes with the general population. METHODS: We conducted a retrospective cohort study. We used linked correctional and health data for women released from provincial prisons in 2010. We defined three exposure groups for Ontario singleton deliveries from 2005-2015: deliveries to women who were in prison during pregnancy but not necessarily for delivery, prison pregnancies; deliveries to women who had been in prison but not while pregnant, prison controls; and general population deliveries. We compared groups using generalized estimating equations. Primary outcomes were preterm birth, low birth weight, and small for gestational age birth weight. Secondary outcomes included NICU admission, neonatal abstinence syndrome, placental abruption, and preterm prelabour rupture of membranes. RESULTS: In prison pregnancies (n = 544) and prison controls (n = 2156), respectively, preterm birth risk was 15.5% and 12.5%, low birth weight risk was 13.0% and 11.6%, and small for gestational age birth weight risk was 18.1% and 19.2%. Adjusted for maternal age and parity and compared with general population deliveries (N = 1 284 949), odds ratios were increased for prison pregnancies and prison controls, respectively, at 2.7 (95% CI 2.2-3.4) and 2.1 (95% CI 1.9-2.4) for preterm birth, 3.1 (95% CI 2.4-3.9) and 2.7 (95% CI 2.3-3.1) for low birth weight, and 1.6 (95% CI 1.3-2.1) and 1.8 (95% CI 1.6-2.0) for small for gestational age birth weight. CONCLUSION: There is an increased risk of adverse infant outcomes in women who experience imprisonment compared with the general population, whether they are in prison during pregnancy or not.

Improving Health and Healthcare Access for People Who Experience Imprisonment in Ontario.

People who experience imprisonment have worse health status than other Ontarians - about 40% lack access to primary care in the community, and the period after release from prison is associated with high risks of adverse health outcomes. Population-based correctional and health administrative data suggest that access to quality healthcare in prison and in the community needs to improve if we are to improve population health and deliver on healthcare obligations to people experiencing imprisonment.

Interactions between Police and Persons Who Experience Homelessness and Mental Illness in Toronto, Canada: Findings from a Prospective Study.

OBJECTIVE: We aimed to describe interactions between police and persons who experience homelessness and serious mental illness and explore whether housing status is associated with police interactions. METHOD: We conducted a secondary analysis of 2008 to 2013 data from the Toronto, Canada, site of the At Home/Chez Soi study. Using police administrative data, we calculated the number and types of police interactions, the proportion of charges for acts of living and administration of justice, and the proportion of occurrences due to victimization, involuntary psychiatric assessment, and suicidal behavior. Using generalized estimating equations, we estimated the odds of police interaction by housing status. RESULTS: This study included 547 adults with mental illness who were homeless at baseline. In the year prior to randomization, 55.8% of participants interacted with police, while 51.7% and 43.0% interacted with police in Study Years 1 and 2, respectively. Of 2,228 charges against participants, 12.6% were due to acts of living and 21.2% were for administration of justice. Of 518 occurrences, 41.1% were for victimization, 45.6% were for mental health assessment, and 22.2% were for suicidal behavior. The odds of any police interaction during the past 90 days was 47% higher for those who were homeless compared to those who were stably housed (95% CI 1.26 to 1.73). CONCLUSIONS: For people who experience homelessness and mental illness in Toronto, Canada, interactions with police are common. The provision of stable housing and changes in policy and practice could decrease harms and increase health benefits associated with police interactions for this population.

Using concept mapping to inform the development of a transitional reintegration intervention program for formerly incarcerated people with HIV.

BACKGROUND: Accessing HIV-related care is challenging for formerly incarcerated people with HIV. Interventions informed by the perspectives of these individuals could facilitate engagement with care and address competing priorities that may act as barriers to this process. METHODS: We used concept mapping to identify and prioritize the main obstacles to engaging with HIV-related care following prison release. In brainstorming sessions, formerly incarcerated people with HIV generated responses to a focused prompt regarding the main barriers to reengaging with care. These were consolidated in 35 statements. Next, participants sorted the consolidated list of responses into groups and rated each from lowest to highest in terms of its importance and feasibility of being addressed. We used cluster analysis to generate concept maps that were interpreted with participants. RESULTS: Overall, 39 participants participated in brainstorming sessions, among whom 18 returned for rating and sorting. Following analysis, a seven-cluster map was generated, with participants rating the 'Practical Considerations' (e.g. lack of transportation from prison) and 'Survival Needs' (e.g. securing housing and food) clusters as most important. Although ratings were generally similar between women and men, women assigned greater importance to barriers related to reconnecting with children. CONCLUSIONS: Using concept mapping, we worked with formerly incarcerated people with HIV to identify and prioritize key challenges related to accessing health and social services following prison release. Transitional intervention programs should include programs and processes that address meeting basic subsistence needs and overcoming logistical barriers related to community re-entry.

Access to Primary Care for Persons Recently Released From Prison.

We aimed to determine if a history of recent imprisonment affects access to primary care. Using patient roles, we telephoned to request an initial appointment with all family physicians (n = 339) who were accepting new patients in British Columbia, Canada. We sequentially assigned patient scenarios: male or female recently released from prison; male or female control. Controls were 1.98 (95% CI, 1.59-2.46) times as likely to be offered an appointment compared with persons recently released from prison, with an absolute risk difference of 41.8% (95% CI, 31.0-52.5). Our study suggests discrimination is a barrier to primary care for people released from prison, even with universal health insurance. We need to improve access to primary care during the high-risk period following prison release.

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.

The Unmet Contraceptive Need of Incarcerated Women in Ontario.

OBJECTIVE: Studies from the United States have shown that women in correctional facilities have higher rates of unintended pregnancy and unmet need for contraception compared with the general population, and that the provision of family planning services in correctional facilities may improve access to contraception. No study has examined these issues in women in correctional facilities in Canada. We aimed to describe the rates of unintended pregnancy and contraceptive use for incarcerated women in Ontario. METHODS: Women in a provincial correctional facility in Ontario completed a written survey in 2014. We calculated the prevalence of prior unintended pregnancy, prior therapeutic abortion, and contraception use. We calculated the unmet need for contraception, defined as the proportion of women who were not using reliable contraception among women who were sexually active and were not trying to conceive. RESULTS: Of 85 participants, 82% had been pregnant, and of these women, 77% had experienced an unintended pregnancy and 57% reported having undergone a therapeutic abortion. Regarding the most recent pregnancy, 72% of women scored their pregnancy intention as unplanned or ambivalent. Of women who were at risk for unintended pregnancy prior to incarceration, 80% were not using a reliable form of contraception. CONCLUSION: Incarcerated women in Ontario have higher rates of unintended pregnancy and unmet need for contraception than does the general population. The provision of family planning services during and after incarceration may improve the health of individuals and reduce costs for society overall.

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

We systematically reviewed randomized controlled trials of interventions to improve the health of people during imprisonment or in the year after release. We searched 14 biomedical and social science databases in 2014, and identified 95 studies. Most studies involved only men or a majority of men (70/83 studies in which gender was specified); only 16 studies focused on adolescents. Most studies were conducted in the United States (n = 57). The risk of bias for outcomes in almost all studies was unclear or high (n = 91). In 59 studies, interventions led to improved mental health, substance use, infectious diseases, or health service utilization outcomes; in 42 of these studies, outcomes were measured in the community after release. Improving the health of people who experience imprisonment requires knowledge generation and knowledge translation, including implementation of effective interventions.

Research on the health of people who experience detention or incarceration in Canada: a scoping review.

BACKGROUND: We conducted a scoping review to define the extent and type of quantitative health status research conducted from 1993 to 2014 with people who have experienced detention or incarceration in correctional facilities in Canada. METHODS: We searched 15 databases, reviewed reference lists and relevant websites, and consulted with key stakeholders to identify eligible studies. We reviewed records for eligibility and extracted relevant data from eligible articles. RESULTS: We identified 194 studies that were eligible for inclusion. Most studies were conducted with males and with persons in federal facilities, and focused on mental health, substance use, and social determinant of health outcomes. CONCLUSIONS: Health status data are limited for several outcomes, such as chronic disease, injury and sexual and reproductive health, and for persons in provincial facilities and post-release. Efforts should be made to improve data collection and knowledge dissemination, so that relevant data can be used more effectively to improve health and health care in this population.

"We wish we had the option": a qualitative study of women's perspectives and experiences with contraception in a provincial prison in Ontario, Canada.

BACKGROUND: Evidence suggests that women who are incarcerated desire access to contraception while incarcerated, and that this need is not currently being met. Our objective in this study was to explore the perspectives and experiences of women in prisons regarding contraception and contraception access using data from focus groups with women in a provincial prison. We analyzed focus group data collected in a provincial prison in Ontario, Canada using content analysis and a constructivist epistemology. RESULTS: We conducted three focus groups, each approximately one hour in length. Discussions revolved around (1) knowledge and decision making about contraception, (2) accessing contraception, and (3) ideas for increasing access to contraception in the prison setting. Decision making about contraception was mainly related to concerns about side effects, consistent access to care, impacts on future fertility, and autonomy around decision-making. Participants discussed a wide range of experiences with contraception. Ideas for increasing access to contraception included information sessions, inclusion of discussions about contraception as a component of admission and release planning, and time spent in prison as a crucial juncture for decision-making about contraception. CONCLUSIONS: More qualitative research is needed to better understand the needs of women in prisons related to contraception. The findings of this study suggest that programs should focus on consistency and continuity of access to care, education opportunities, and integration of discussions about contraception into official admission and release procedures.

Intimate partner violence is associated with HIV infection in women in Kenya: a cross-sectional analysis.

BACKGROUND: The relationship between intimate partner violence (IPV) and women's risk of HIV infection has attracted much recent attention, with varying results in terms of whether there is an association and what the magnitude of association is. Understanding this relationship is important for HIV surveillance and intervention programs. METHODS: We analyzed data from the 2008-2009 Demographic and Health Survey (DHS) in Kenya, on 1,904 women aged 15-49. A generalized linear mixed model was adapted to explore the relationship between IPV and HIV prevalence, controlling for sociodemographic variables, and treating DHS survey clusters, province and ethnicity as random effects. We used principal components analysis (PCA) to calculate a single IPV score for each woman. The effect of HIV risk behaviours on the association between IPV and HIV was also assessed. RESULTS: Controlling for relevant sociodemographic factors, we found that HIV risk was significantly associated with IPV (P <0.01). After adjustment for risk factors as well as sociodemographic variables, the positive association between IPV and HIV remained significant (P=0.035). The estimated effect size of this model corresponds to an odds ratio of 1.55 for HIV infection comparing a woman who experienced no IPV and a woman at the 95th percentile for our IPV index. CONCLUSION: This study provides further evidence that IPV and HIV are associated. In addition, we found that this association remains even when we controlled for several HIV risk factors. This implies that IPV can be used as a marker of potential HIV risk, and may be causally associated with HIV risk. Further, these results suggest that IPV monitoring and prevention may have a useful role in HIV prevention in Kenya. Further research, ideally based on longitudinal observations, is needed to disentangle these relationships.

Risk factors for intimate partner violence in women in the Rakai Community Cohort Study, Uganda, from 2000 to 2009.

BACKGROUND: Intimate partner violence (IPV) is a significant public health problem. There is a lack of data on IPV risk factors from longitudinal studies and from low and middle income countries. Identifying risk factors is needed to inform the design of appropriate IPV interventions. METHODS: Data were from the Rakai Community Cohort Study annual surveys between 2000 and 2009. Female participants who had at least one sexual partner during this period and had data on IPV over the study period were included in analyses (N = 15081). Factors from childhood and early adulthood as well as contemporary factors were considered in separate models. Logistic regression was used to assess early risk factors for IPV during the study period. Longitudinal data analysis was used to assess contemporary risk factors in the past year for IPV in the current year, using a population-averaged multivariable logistic regression model. RESULTS: Risk factors for IPV from childhood and early adulthood included sexual abuse in childhood or adolescence, earlier age at first sex, lower levels of education, and forced first sex. Contemporary risk factors included younger age, being married, relationships of shorter duration, having a partner who is the same age or younger, alcohol use before sex by women and by their partners, and thinking that violence is acceptable. HIV infection and pregnancy were not associated with an increased odds of IPV. CONCLUSIONS: Using longitudinal data, this study identified a number of risk factors for IPV. These findings are useful for the development of prevention strategies to prevent and mitigate IPV in women.

The impact of COVID-19 on opioid toxicity deaths for people who experience incarceration compared to the general population in Ontario: A whole population data linkage study.

BACKGROUND: To inform preparedness and population health action, we need to understand the effects of COVID-19 on health inequities. In this study, we assess the impact of COVID-19 on opioid toxicity deaths among people who experience incarceration compared to others in the general population in Ontario, Canada. METHODS: We conducted a retrospective cohort study for the period of January 1, 2015 to December 31, 2020. We accessed and linked coronial data on all opioid toxicity deaths in Ontario with correctional data for people aged 18 years and older who were incarcerated in a provincial correctional facility. We used data from the Statistics Canada Census to calculate whole population rates. We used an interrupted time series design and segmented regression to assess for change in the level or rate of increase in deaths due to opioid toxicity coinciding with the COVID-19 pandemic. We compared the impact of COVID-19 on the opioid toxicity death rates for people exposed and not exposed to incarceration. RESULTS: Rates of opioid toxicity death increased with a linear positive slope in both persons exposed to incarceration and those not exposed over the study period. The start of COVID-19 measures coincided with a marked upward shift in the trend lines with modification of the effect of COVID-19 by both sex and exposure to incarceration. For persons exposed to incarceration, the risk ratio (RR) was 1.50 (95%CI 1.35-1.69) for males and 1.21 (95%CI 1.06-1.42) for females, and for persons not exposed to incarceration, the RR was 1.25 (95%CI 1.13-1.38) for males and not significant for females. CONCLUSIONS: COVID-19 substantially exacerbated the risk of opioid toxicity death, impacting males and females who experienced incarceration more than those who had not, with an immediate stepwise increase in risk but no change in the rate of increase of risk over time. Public health work, including pandemic preparedness, should consider the specific needs and circumstances of people who experience incarceration.