COVID-19 and influenza vaccine uptake in women with criminal-legal system involvement.

OBJECTIVE: Given their vulnerable health status and resource constraints, the perspectives of women with criminal-legal involvement (WCLI) are important but not usually represented in the literature on vaccine interest and vaccine hesitancy. This study aims to examine how the COVID-19 pandemic and vaccine affected the influenza vaccine uptake among WCLI. METHODS: A cross-sectional secondary analysis was conducted using data collected from the Tri-City study, which followed WCLI in three U.S. cities from 2019 to 2023. We mapped the distribution of influenza vaccine uptake in 2019-2023 and developed a composite outcome that reflected participants' patterns of Y/N to influenza vaccine, which were categorized into four groups: Influenza Vaccine Supportive, Influenza Vaccine Adaptive, Influenza Vaccine Discontinued, and Influenza Vaccine Resistant. RESULTS: Out of 507 people: 23.7% were Supportive, 8.5% Adaptive, 15.2% Discontinued and 38.3% Resistant. People who received the COVID vaccine had significantly lower odds of being identified as Discontinued (OR = 0.42, 95%CI = 0.20-0.87, p = .020) and Resistant (OR = 0.23, 95%CI = 0.13-0.43, p < .001), compared to the Supportive group. Mistrust toward COVID-19-related information was a significant independent predictor of being Adaptive (OR = 1.59, 95%CI = 1.08-2.35, p = .019), Discontinued (OR = 1.61, 95%CI = 1.15-2.25, p = .006), and Resistant (OR = 1.54, 95%CI = 1.19-2.00, p < .001) relative to Supportive. CONCLUSIONS: Vaccine hesitancy poses significant challenges to public health efforts, with apparent dampening effect across vaccines. Public health messaging and clinical interactions informed by best practices in communication tailored to the lived experience of all people, including women with criminal-legal system involvement, will be necessary to inform future interventions aimed at increasing vaccine uptake.

Decreased Homelessness among Women Involved in the Criminal Legal System after a COVID-19 Housing Intervention.

The COVID-19 outbreak fueled unprecedented public health efforts to mitigate the spread of infection, including rapid provision of non-congregate housing to people experiencing homelessness. People on community supervision (criminal probation or parole) have high levels of homelessness due to housing discrimination, poverty and racism, and are among the groups most vulnerable to COVID-19. We examined housing status in a cohort of women with probation histories in Alameda County, CA before and after the COVID-19 outbreak (N=204). Before March 2020, 38% of women in the cohort reporting being homeless (95% CI: 34-43%), a level that was consistent over 2 years. As of August 2020, 15% of the cohort was homeless (95% CI: 10-20%; relative risk [RR] 0.40, 95% CI: 0.28, 0.55; p<0.001). During a period of assertive public health efforts to reduce COVID-19 risk through provision of housing, we found meaningful reductions in homelessness in this sample of vulnerable women.

"Just another thing for me to stress off of": Responses to unintentional fentanyl use in a community-based study of people who use opioids.

The unintentional consumption of fentanyl is a serious health risk for people who use illicit drugs. In an ongoing community-based study regarding polysubstance use among people who use opioids, we found that 17 of 58 (29%) of participants who did not endorse fentanyl use in the past thirty days tested positive for fentanyl during point-of-care urinalysis (UA). This paper describes the reactions and experiences of participants who were informed they had consumed fentanyl unintentionally, as well as how the research team handled the unanticipated occurrence of discordant results. Consistent with other recent studies, we found that people learning of unintentional fentanyl use expressed strong concerns about accidental overdose. It was common for participants to reflect on recent substance use experiences that were atypical and might have involved fentanyl, as well as to examine sources of recent drug purchases. While not all participants were surprised that they had unintentionally consumed fentanyl, all felt that learning their positive results was important due to risk of overdose. Research and medical staff have an opportunity to promote awareness of possible contamination by sharing and discussing UA test results with people who use drugs in non-judgmental manner. In addition to the widely promoted harm reduction strategy of testing drugs with fentanyl test strips, self-administered point-of-care UA, particularly after an unexpected reaction to using a drug, could provide useful information for people buying and using illicit drugs.

Understanding polysubstance use at the daily and event levels: protocol for a mixed-methods qualitative and ecological momentary assessment study in a community-based sample of people who use illicit drugs in Oakland, California, USA.

INTRODUCTION: Polysubstance use is extremely common among people who use illicit opioids in the USA. It is associated with poor substance use treatment outcomes, infectious disease risk and alarming rates of drug overdose. Nearly all extant literature examines polysubstance use over broad time frames, such as 30 days or 6 months. However, both substance use and overdose risk are episodic. To build a stronger understanding of polysubstance use and overdose risk, we need to expand the knowledge base to include daily-level and event-level data that examine how substances are used together, in which combinations and in which contexts. The study described in this protocol will use qualitative and ecological momentary assessment (EMA) methods to examine polysubstance use and overdose risk on a daily and event level. METHODS AND ANALYSIS: This is a mixed-methods observational study with three phases. The first phase is formative, consisting of qualitative interviews with people who use multiple substances (N=20), to inform the development of items for the EMA component. The second phase is EMA data collection with people who use multiple substances (N=120), three times daily for 28 days. The third phase consists of mixed-methods inquiries with a subset of participants (N=20), using participant-level EMA data and qualitative techniques to build a nuanced understanding of the motivations and contexts of polysubstance use in everyday life. Analytical induction methods will be used to interpret qualitative data. Hierarchical linear modelling methods will be used to analyse EMA data. ETHICS AND DISSEMINATION: This research has been reviewed and approved by the Institutional Review Board at RTI International (#MOD00001782 for EMA procedures and #MOD00001241 for qualitative procedures). Participants engage in an informed consent procedure for each component of the study. Data will be managed and shared per the National Institutes of Health extramural data sharing policy.

"Just another thing for me to stress off of:" Responses to Unintentional Fentanyl Use in a Community-based Study of People who Use Opioids.

The unintentional consumption of fentanyl is a serious health risk for people who use illicit drugs. In an ongoing community-based study regarding polysubstance use among people who use opioids, we found that 17 of 58 (29%) of participants who did not endorse fentanyl use in the past thirty days tested positive for fentanyl during point-of-care urinalysis (UA). This paper describes the reactions and experiences of participants who were informed they had consumed fentanyl unintentionally, as well as how the research team handled the unanticipated occurrence of discordant results. Consistent with other recent studies, we found that people learning of unintentional fentanyl use expressed strong concerns about accidental overdose. It was common for participants to reflect on recent substance use experiences that were atypical and might have involved fentanyl, as well as to examine sources of recent drug purchases. While not all participants were surprised that they had unintentionally consumed fentanyl, all felt that learning their positive results was important due to risk of overdose. Research and medical staff who routinely conduct urinalysis have an opportunity to promote awareness of possible contamination by sharing and discussing UA test results with people who use drugs in non-judgmental manner. In addition to the widely promoted harm reduction strategy of testing drugs with fentanyl test strips, self-administered UA, particularly after an unexpected reaction to using a drug, could provide useful information for people buying and using illicit drugs.

Nonurgent Emergency Department Use Among Women Sentenced to Probation.

Like women who are incarcerated, women sentenced to probation have high levels of physical and mental health morbidities. They rely heavily on hospital emergency departments (EDs) for health care in community settings. We examined the prevalence of nonurgent ED use in a cohort of women with a history of probation system involvement in Alameda County, California. We found that two-thirds of ED visits were nonurgent, even though most women had health insurance. Factors associated with nonurgent ED use included having one or more chronic health conditions, severe substance use, low health literacy, and recent arrest. Among a subgroup of women who also received primary care, dissatisfaction with a recent primary care visit was also associated with nonurgent ED use. The heavy use of the ED for nonurgent care in this study may reflect a need to provide options better attuned to the multiple forms of instability and barriers to wellness faced by women with criminal legal system involvement.

Routine and preventive health care use in the community among women sentenced to probation.

BACKGROUND: Women involved in the criminal legal (CL) system in the United States have much higher levels of chronic and infectious illness than women in the general population. Over 80% of women in the CL system are on community supervision, which means they receive health care in community settings. While the use of Emergency Department care among CL involved populations has been examined fairly extensively, less is known about engagement in routine and preventive medical care among people on community supervision. METHODS: We conducted a longitudinal study of health care utilization among women with Medicaid who were currently or previously sentenced to probation in Alameda County, CA (N = 328). At baseline, 6- and 12-months, we interviewed participants about every medical care visit in the six months prior, and about potential influences on  health care utilization based on the Behavioral Model for Vulnerable Populations (BMVP). Associations between BMVP factors and utilization of routine or preventive care were estimated using Poisson regression models with robust standard errors. Generalized estimating equations (GEE) were used account for repeated measures over time. RESULTS: A diagnosis of one or more chronic illnesses was reported by 82% of participants. Two-thirds (62%) of women engaged in routine or preventive care in the six months prior to interview. A quarter of women engaging in routine or preventive care did not have a primary care provider (PCP). Having a PCP doubled the likelihood of using routine or preventive care (adjusted Relative Risk [adjRR] 2.27, p < 0.001). Subsistence difficulty (adjRR 0.74, p = 0.01) and unmet mental health care need (adjRR 0.83, p = 0.001) were associated with a lower likelihood of using routine or preventive care. CONCLUSION: Findings underscore the importance of meeting the basic needs of women on community supervision and of connecting them with primary health care providers.

Associations among betrayal trauma, dissociative posttraumatic stress symptoms, and substance use among women involved in the criminal legal system in three US cities.

BACKGROUND: Betrayal trauma, as defined by (Freyd, 1996), refers to a subcategory of trauma characterized by a significant violation of trust surrounding interpersonal maltreatment (physical, sexual, or emotional). Previous research has shown that people with betrayal trauma histories experience greater dissociative symptoms of posttraumatic stress disorder and co-morbid substance use disorder symptoms. Women in the criminal legal system commonly have significant histories of betrayal trauma and related posttraumatic stress symptoms and substance use. However, no studies have specifically explored the impact of dissociative posttraumatic stress symptoms on substance use outcomes in this population. Additionally, no studies have explored whether betrayal trauma relates to nonfatal overdoses. METHODS: This cross-sectional survey study of N = 508 women with criminal legal system involvement examined the indirect effects of betrayal trauma history on substance use outcomes through dissociative posttraumatic stress symptoms. RESULTS: Multivariate analyses supported an indirect effect of betrayal trauma on substance use severity, daily substance use, and history of overdose, but not alcohol use severity, through dissociative symptoms. CONCLUSIONS: Women in the criminal legal system with betrayal trauma and dissociative symptoms may be at risk for substance use and related outcomes (i.e., overdose). Future work is needed to examine whether targeting such symptoms may improve substance use treatment and prevention of serious outcomes in this population.

Differences in abortion-related knowledge among women involved in the criminal legal system in three US cities.

OBJECTIVE: We examined if abortion-related knowledge among women with criminal legal system involvement differed in three U.S. cities in states with varying abortion policies. STUDY DESIGN: Respondents were self-identified women with criminal legal system involvement. Data come from a cross-sectional baseline survey of 381 women in three U.S. cities: Oakland, California, Kansas City, Kansas/Missouri, and Birmingham, Alabama. The primary outcome, high abortion-related knowledge, was based on a 10-item scale dichotomized into low vs high abortion-related knowledge. We used descriptive statistics, bivariable associations, and logistic regression to assess the association between high abortion-related knowledge, city of residence, and other possible related factors. RESULTS: Respondents in Kansas City, KS/MO and Birmingham, AL had lower odds of high abortion-related knowledge compared to respondents in Oakland, CA (OR: 0.19, 95% CI: 0.10-0.38 and OR: 0.17, 95% CI: 0.11-0.28, respectively). In adjusted analysis, the association remained after controlling for race/ethnicity, insurance status, and community supervision past year. CONCLUSIONS: Findings underscore the need for communicating clear and accurate information about abortion care, especially in states where laws and ongoing political challenges make it difficult to access both reliable information and services. IMPLICATIONS: Efforts to disseminate accurate information regarding abortion care, particularly among marginalized people, should utilize multiple venues in addition to traditional healthcare information sources. Reproductive justice advocates should connect with jails and probation offices to reach people with criminal legal system involvement and foster increased knowledge of reproductive rights and services.

Criminal Justice-Involved Women Navigate COVID-19: Notes From the Field.

In March-April, 2020, we communicated with a cohort of criminal justice-involved (CJI) women to see how they were navigating COVID-19, chronic illness, homelessness, and shelter-in-place orders in Oakland, Birmingham, and Kansas City. We report on conversations with N = 35 women (out of the cohort of 474 women) and our own observations from ongoing criminal justice involvement studies. Women reported barriers to protecting themselves given widespread unstable housing and complex health needs, though many tried to follow COVID-19 prevention recommendations. Women expressed dissatisfaction with the suspension of research activities, as the pandemic contributed to a heightened need for study incentives, such as cash, emotional support, and other resources. COVID-19 is illuminating disparities between those who can follow recommended actions to prevent infection and those who lack resources to do so. Concerted efforts are required to reduce inequities that put the 1.3 million U.S. women under criminal justice supervision at risk for infection and mortality.

Several Common Bonds: Addressing the Needs of Gay and Bisexual Men in LGBT-Specific Recovery Housing.

Recovery housing is a promising way to augment the substance use continuum of care, but we know little about the experiences of members of the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community who live in them or about residences specifically for them. Within the LGBTQ community, gay, bisexual, and other men who have sex with men (MSM) often experience co-occurring syndemic conditions (e.g., trauma, depression, HIV) that present unique recovery challenges. Using qualitative data gathered from residents living in a recovery residence specifically for gay and bisexual men and from community key informants, we examine the experiences of men living in the home and factors that facilitate operating it. Findings highlight the need for residences that can address syndemic burden among gay and bisexual men in recovery and identify programmatic and community-level factors critical to operating residences for this population.

Improving Recovery Outcomes among MSM: The Potential Role of Recovery Housing.

BACKGROUND: Gay, bisexual, and other men who have sex with men (MSM) face unique recovery challenges. Recovery housing may play an important role in improving outcomes among MSM, but little is known about their experiences in these settings. METHODS: This study examined 3-month outcomes among MSM (N=22) living in a group of recovery residences in Texas, one of which is a home specifically designated for gay and bisexual men. Upon intake, adult MSM were recruited to participate in the study, which involved a baseline and 3-month phone interview and allowing study staff to access records maintained by the program about their stay. RESULTS: At follow-up, only two (9.1%) reported used of any substances in the past 30 days. The vast majority (73%) had attended outpatient substance use treatment in the past three months, and 86% reported working for pay during the past 30 days. All participants reported attending four or more 12-step meetings in the past 30 days. Use of dysfunctional coping strategies significantly decreased, however so did scores on health-related quality of life. CONCLUSIONS: MSM have complex treatment needs. Recovery housing may help improve outcomes among MSM by bridging formal substance use treatment with community-based recovery support.

Pathways to Recovery: Recovery housing models for men who have sex with men (MSM).

BACKGROUND & AIMS: Gay, bisexual, and other men who have sex with men (MSM) face distinct recovery challenges. This mixed-methods study examines the service needs and help-seeking pathways of MSM (N=25) living in a group of recovery residences operated in Texas, one of which is a home specifically designated for gay and bisexual men. METHODS: Upon intake, adult MSM were recruited to complete an interview assessing the extent of their service needs as well as their recovery goals and expectations about their stay. Men were recruited regardless of whether they moved into the home designated for gay and bisexual men or into another one of the men's homes. RESULTS: MSM in the sample reported high rates of health conditions, depression, victimization, and sex risk behaviors. A greater number of them entering the gay and bisexual men's home reported being in recovery from amphetamine use, having a chronic medical problem, and being physically assaulted as an adult. The majority of MSM, regardless of home type, were seeking emotional and social support as well as accountability in their recovery home experience, but MSM in the gay and bisexual men's home talked about emotion and social support most frequently and within the context of emotional safety. CONCLUSIONS: MSM entering recovery housing have complex service needs. Recovery housing may play an important role in supporting recovery among MSM. Residences specifically for them could be tailored to address their unique needs by fostering connections to other sexual minorities in recovery and facilitating social identity transformation.

A longitudinal study of the comparative efficacy of Women for Sobriety, LifeRing, SMART Recovery, and 12-step groups for those with AUD.

BACKGROUND: Despite the effectiveness of 12-step groups, most people reporting a prior alcohol use disorder (AUD) do not sustain involvement in such groups at beneficial levels. This highlights the need for research on other mutual help groups that address alcohol problems and may attract those who avoid 12-step groups. The current study addresses this need, offering outcome data from the first longitudinal, comparative study of 12-step groups and their alternatives: The Peer ALlternatives for Addiction (PAL) Study. METHODS: Adults with a lifetime AUD were surveyed at baseline (N=647), 6months (81% response rate) and 12months (83% response rate). Members of the largest known secular mutual help alternatives, namely Women for Sobriety (WFS), LifeRing, and SMART, were recruited in collaboration with group directors; current 12-step attendees were recruited from an online meeting hub. Online surveys assessed demographic and clinical variables; mutual help involvement; and alcohol and drug use and severity. Analyses involved multivariate logistic GEEs separately modelling alcohol abstinence, alcohol problems, and total abstinence across 6 and 12months. Key predictors were baseline primary group affiliation (PGA); primary group involvement (PGI) at both baseline and 6months; and the interaction between baseline PGA and 6-month PGI. The critical effects of interest were the interactions, expressing whether associations between changes in PGI from baseline to 6months and substance use outcomes differed by primary group. RESULTS: None of the interactions between baseline PGA and 6-month PGI were significant, suggesting no differences in the efficacy of WFS, LifeRing, or SMART, vs. 12-step groups. Nevertheless, some PGA main effects emerged. Compared to 12-step members, those identifying SMART as their primary group at baseline fared worse across outcomes, and those affiliating with LifeRing showed lower odds of total abstinence. Still, these effects became nonsignificant when controlling for baseline alcohol recovery goal, suggesting that any group differences may be explained by selection of those with weaker abstinence motivation into LifeRing and (especially) SMART. CONCLUSIONS: This study makes a valuable contribution in view of the extremely limited evidence on mutual help alternatives. Results tentatively suggest that WFS, LifeRing, and SMART are as effective as 12-step groups for those with AUDs, and that this population has the best odds of success when committing to lifetime total abstinence. An optimal care plan may thus involve facilitating involvement in a broad array of mutual help groups and supporting abstinence motivation.

Delivering LGBT-sensitive substance use treatment to sexual minority women.

Epidemiologic studies have consistently found elevated rates of alcohol and other substance use among sexual minority women (SMW), and despite calls for "LGBT-specific" services and culturally-tailored interventions, few such services exist. This study involved qualitative interviews with directors from substance use treatment programs (N=10) about how they addressed the needs of SMW. Strategies implemented primarily focused on creating a safe and welcoming environment for sexual minority clients. Findings highlight challenges involved in meeting the treatment needs of SMW and provide guidance to researchers and service providers on how to improve the quality of care for them.

Problems and Service Needs Among Ex-Offenders with HIV Risk Behaviors Entering Sober Living Recovery Homes.

There is currently a nationwide effort to decrease the number of persons who are incarcerated in jails and prisons. However, many ex-offenders on probation or parole do not have access to affordable housing and larger proportions have histories of HIV risk as well as substance abuse problems. In California, sober living houses (SLHs) are becoming an increasingly popular housing option for these individuals. Based largely on the principles of Alcoholics Anonymous (AA), SLHs require abstinence from alcohol and drugs and provide peer support for recovery. The current study examined the types of problems experienced among 330 ex-offenders with lifetime risk for HIV during the six months prior to entering SLHs. Nearly three fourths (74%) of all ex-offenders entering the houses had at least one HIV risk. The importance of housing was evident in the finding that housing status and participants' perceptions of their housing situation were associated with a variety of problem areas, including substance use, HIV risk, psychiatric severity, and legal problems. SLHs represent an important housing option for ex-offenders, but many residents may need additional services to address various problems.

Recovery Housing: Evolving Models to Address Resident Needs.

Recovery housing is a service delivery modality that simultaneously addresses the social support and housing needs of those in recovery from substance use disorders. This article describes a group of recovery homes in Texas (N = 10) representing a lesser-studied type of recovery housing, one which explicitly bridges treatment and peer support by providing a variety of recovery support services. All residents meet with a recovery coach, undergo regular drug screening, and have access to intensive outpatient treatment-a program that was developed specifically to support the needs of residents in the homes. Unlike the Oxford HouseTM model and California sober living houses, which are primarily financed through resident fees, these homes are supported through a mix of resident fees as well as private and public insurance. While adhering to some aspects of the social model of recovery, none of these homes would meet criteria to be considered a true social model program, largely because residents have a limited role in the governance of the homes. Residences like the ones in this study are not well-represented in the literature and more research is needed.

Comparison of 12-step groups to mutual help alternatives for AUD in a large, national study: Differences in membership characteristics and group participation, cohesion, and satisfaction.

BACKGROUND: Many studies suggest that participation in 12-step groups contributes to better recovery outcomes, but people often object to such groups and most do not sustain regular involvement. Yet, research on alternatives to 12-step groups is very sparse. The present study aimed to extend the knowledge base on mutual help group alternatives for those with an alcohol use disorder (AUD), sampling from large, active, abstinence-focused groups including Women for Sobriety (WFS), LifeRing, and SMART Recovery (SMART). This paper presents a cross-sectional analysis of this longitudinal study, using baseline data to describe the profile and participation characteristics of attendees of these groups in comparison to 12-step members. METHODS: Data from participants 18 and over with a lifetime AUD (N=651) were collected using Web-based surveys. Members of alternative 12-step groups were recruited in collaboration with group directors, who helped publicize the study by emailing meeting conveners and attendees and posting announcements on social media. A comparison group of current (past-30-day) 12-step attendees was recruited from an online meeting hub for recovering persons. Interested parties were directed to a Webpage where they were screened, and eligible participants completed an online survey assessing demographic and clinical variables; in-person and online mutual help involvement; and group satisfaction and cohesion. Analyses involved comparing those identifying WFS, SMART, and LifeRing as their primary group to 12-step members on the above characteristics. RESULTS: Compared to 12-step members, members of the mutual help alternatives were less religious and generally higher on education and income. WFS and LifeRing members were also older, more likely to be married, and lower on lifetime drug and psychiatric severity; meanwhile, LifeRing and SMART members were less likely to endorse the most stringent abstinence goal. Finally, despite lower levels of in-person meeting attendance, members of all the 12-step alternatives showed equivalent activity involvement and higher levels of satisfaction and cohesion, compared to 12-step members. CONCLUSIONS: Results suggest differences across 12-step groups and their alternatives that may be relevant when advising clients on a choice of mutual help group. Meanwhile, findings for high levels of participation, satisfaction, and cohesion among members of the mutual help alternatives suggest promise for these groups in addressing addiction problems.