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

Abstract

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.

What is known about this topic

• People in prison experience substantially poorer physical and mental health than the general population with high rates of substance use.

• Young people exiting prison with a history of substance use have higher rates of death and return to custody compared to their older counterparts.

What this paper adds

• Intersecting social disadvantage and co‐occurring mental distress and substance use creates significant barriers to service accessibility for young people exiting prison.

• Transitional support workers' knowledge of service gaps and barriers can inform ways to improve service accessibility and health equity for young people exiting prison.

1. INTRODUCTION

There has been a dramatic increase in the global prison population over the past decade (Fair & Walmsley, 2021). During this time, the Australian prison population increased from approximately 29,000 people in 2011 (Australian Bureau of Statistics, 2011) to nearly 43,000 people in 2021 (Australian Bureau of Statistics, 2021). Due to the annual population ‘flow’ in Australian prisons, the number of people exiting prison each year far exceeds the number of people in custody on any one day (Avery & Kinner, 2015), with nearly 66,000 people released from prison in Australia in 2020 (Australian Bureau of Statistics, 2021).

Understanding and addressing the health needs of people exiting prison has been acknowledged as a significant public health and human rights concern (Kinner & Wang, 2014). People in prison worldwide are characterised as a vulnerable health population (Fazel & Baillargeon, 2011) who experience an elevated risk of mortality on release (Chang et al., 2015; Kinner et al., 2011). International research on the health of people in prison shows high rates of substance use (Håkansson & Berglund, 2012; Thomas et al., 2015), mental distress and cognitive disability (Baldry et al., 2013; Wilson et al., 2013) intersecting with social determinants of health such as homelessness and unemployment (Baldry et al., 2006; Roth, 2015). These circumstances are also risk factors for return to custody (Håkansson & Berglund, 2012; Kinner & Wang, 2014; Roth, 2015; Thomas et al., 2015; van Dooren et al., 2011; Wilson et al., 2013). First Nations people globally are over‐represented in prison, linked directly to the ongoing impacts of colonisation, racism and systemic discrimination (Australian Institute of Health and Welfare, 2015; Chartrand, 2019).

Young people (aged 18–24) in prison are a particularly vulnerable group. There is an over‐representation of young people in prison with multiple co‐morbidities, including a high prevalence of cognitive disabilities and diagnosis of mental health disorders (Baldry et al., 2018; Cunneen et al., 2016). Many young people in prison have been in the child protection and juvenile justice systems prior to incarceration (Australian Institute of Health Welfare, 2020; Gerard et al., 2019; Malvaso & Delfabbro, 2015). These circumstances diminish young people's opportunities to build the resources, skills and relationships to support their health and well‐being and survive in the community (Arditti & Parkman, 2011; Halsey, 2008). On exiting prison, young people experience an elevated risk of mortality and return to custody compared to their older counterparts. Elevated risk of mortality post‐release has been associated with injury, suicide and drug use in the community (van Dooren et al., 2013). Higher rates of return to custody have been associated with co‐occurring substance use and mental illness (Håkansson & Berglund, 2012; Hoeve et al., 2013; Roth, 2015).

Although these intersecting health and social disadvantages are well documented, there has been limited qualitative investigation into the barriers to service accessibility for young people exiting prison, with a few notable exceptions (Denton et al., 2017; Walker et al., 2018). Research including the perspectives of community transition support workers is also rare (Carlton & Segrave, 2016; Schwartz et al., 2020). There is also limited understanding of the health of young people at the point of exiting prison to inform effective service provision for this group (Kinner & Young, 2018).

This study aimed to address these gaps by (1) describing the health characteristics of young people exiting prison on a transitional support program, the Connections Program (Connections) in New South Wales (NSW) Australia and (2) identifying the barriers and facilitators to service accessibility for young people exiting prison, drawing on the experiences of Connections caseworkers. Connections is a transitional support program for adults with problematic substance use exiting prison in NSW, provided by the drug and alcohol service within the state government prison health system. The program includes a routine pre‐release questionnaire and 4 weeks of one‐on‐one post‐release support from a caseworker. The program remit is to link persons on the program to community health and social services.

This study is embedded in a National Health and Medical Research Council (NHMRC) funded data‐linkage project: ‘Recidivism, health and social functioning following release to the community of NSW prisoners with problematic drug use: an evaluation of the Connections Program’ (APP1109009). The study was approved by the following ethics committees: Aboriginal Health & Medical Research Council (reference number 1187/16), NSW Population & Health Services Research (HREC/16/CIPHS/17), Justice Health and Forensic Mental Health Network (HREC/16/JH/15), Corrective Services NSW (D16/569544), University of Technology Sydney (ETH18‐2861) and University of Newcastle (H‐2020‐0074).

1.1. Conceptual framework

A participatory health services research framework was utilised, prioritising stakeholder collaboration and perspectives (Barratt et al., 2017). The research was facilitated through a longstanding partnership between the researchers and Connections staff. The participatory framework was reflected through collaborative processes throughout the project including (1) the research team investing time to build relationships with Connections staff and understand the systemic context in which Connections is provided and (2) working with Connections staff in all stages of the research, including identifying research problems, study design, interpretation, dissemination, translation and co‐authorship.

2. METHODS

We applied an explanatory sequential mixed methods approach (Fetters et al., 2013) to develop a contextualised picture of transitional support service accessibility for young people exiting prison. In stage one, quantitative methods were utilised to describe the health characteristics of young people exiting prison. Quantitative data were self‐reported by young people on the routine Connections pre‐release questionnaire. In stage two, a qualitative survey with Connections caseworkers was undertaken to investigate service accessibility for young people in transition from prison.

2.1. Stage 1: Quantitative study

2.1.1. Study population

The quantitative study was a population‐based, secondary, retrospective cohort study. Participants were all young people in prison who had their first engagement with Connections between January 2008 and February 2015. All participants have a history of problematic substance use, as per the eligibility criteria for the program (Sullivan et al., 2019). There was a total of 3922 people who had their first engagement with Connections during the study period. Consistent with reporting of custody rates by age in NSW (Bureau of Crime Statistics and Research, 2020), this group was stratified by age into a cohort of ‘younger people’ aged 18–24 years (n = 359).

2.1.2. Data collection

Data were collected using the Connections pre‐release questionnaire. This is a voluntary questionnaire administered by Connections caseworkers during a pre‐release interview immediately before the person's release from custody. The questionnaire contains sections for self‐reported sociodemographic information, health status and any previous imprisonment. Standardised and validated health tests are also used, including the Short Form‐12 Health Survey (SF‐12; Ware Jr et al., 1996). The SF‐12 measures both mental and physical health and in each, lower scores are indicative of poorer health, with scores below 49 indicating a level of disability (Andrews, 2002).

2.1.3. Data analysis

The secondary descriptive statistics were conducted using IBM Statistical Package for Social Science (SPSS; Version 25.0) software. Using the self‐reported sociodemographic information, health status and any previous imprisonment of young people, descriptive statistics were calculated.

2.2. Stage 2: Qualitative study

2.2.1. Study population

The survey was distributed to all Connections caseworkers (n = 17) via email. Participation was voluntary and confidential. The response rate was 58.8%, with a final sample size of 10 (n = 10). Caseworkers were based in metropolitan, regional and rural locations in NSW.

2.2.2. Data collection

The qualitative survey data were collected in July 2018. The link to the survey was emailed to each Connections caseworker. The survey included 25 questions themed around the transitional support needs of young people on Connections and issues related to service accessibility for young people transitioning from prison to the community. The survey questions were open‐ended and invited caseworkers to provide detailed responses based on their practice experience.

2.2.3. Data analysis

We employed an inductive thematic analysis following Braun and Clarke (2006). NVivo12 (QSR International Pty Ltd) was used to manage the data set. Our analysis involved two researchers (LG and SKJ) independently coding manuscripts of the surveys line by line to find patterns and themes across the data set. This was a three‐step process of coding (labelling) the data, categorising the codes and identifying concepts within the data set to identify overarching themes. Our process involved developing an analytic table of subthemes and refining the table until all subthemes were categorised under overarching themes. We presented the themes to Connections staff as a final stage of co‐analysis and validation.

3. RESULTS

3.1. Quantitative

3.1.1. Sociodemographic characteristics

Table 1 shows younger people (age range 18–24 years) accounted for 9.2% of the cohort. Women accounted for 22.3% of younger people. The majority (58.1%) of young people had educational attainment of year 9 or less, meaning they left school without a qualifying certificate. Nineteen percent (19.4%) were in custody for the first time and 46.4% identified as an Aboriginal and Torres Strait Islander person.

TABLE 1.

Young people's sociodemographic characteristics

Characteristics	Age (years)
	18–24 (n = 359)
	n (%)
Sex
Female	80 (22.3)
Male	279 (77.7)
Employment before prison
Employed	242 (71.2)
Unemployed	98 (28.8)
Education level
Primary school or less	17 (5.2)
Year 9 or less	190 (58.1)
School certificate/HSC	110 (33.6)
Trade/diploma/tertiary	10 (3.1)
Aboriginal or Torres Strait Islander
Yes	156 (46.4)
No	180 (53.6)
First incarceration
Yes	66 (19.4)
No	274 (80.4)

Note: Excludes not stated values. n: sample size.

3.1.2. Physical and mental health

Table 2 represents the self‐reported physical and mental health of young people on Connections during the pre‐release assessment. Physical health issues were reported by 51.6% of young people and almost all (96.5%) reported receiving treatment for a mental health issue.

TABLE 2.

Young people's physical and mental health

Health factors	Age (years)
	18–24 (n = 359)
	n (%)
Physical health problems
Yes	175 (51.6)
No	164 (48.4)
Professional treatment of a mental health problem
Yes	223 (96.5)
No	8 (3.5)
Overall rating of general health
Excellent	35 (10.6)
Very good	109 (33.0)
Good	155 (47.0)
Fair	30 (9.1)
Poor	1 (0.3)

	18–24 (n = 359)
	Mean (SD) (<49 indicates disability)
SF‐12 mental component	48.6 (±10.0)
SF‐12 physical component	54.5 (±6.2)

Note: Excludes not stated values. n: sample size.

Abbreviation: SF‐12, Short Form‐12 Health Survey.

The SF‐12 included physical and mental health components, where a higher score indicated better health and a score below 49 indicated a level of disability. The mean physical health of young people was 54.5 (SD = 9.4) and the mean mental health score for younger people was 48.6 (SD = 10.0).

3.1.3. Substance use

Table 3 depicts drug and alcohol use before incarceration. The most used substances reported by young people were heroin (63.5%), amphetamines (53.9%) and cannabis (50.6%). Nearly a third (30.3%) of young people reported no drug and/or alcohol treatment plan to continue or complete on release to the community. More than half of the young people (62.9%) stated that they would like additional drug and alcohol treatment in prison (e.g. counselling, relapse prevention or rehabilitation program) to what they currently receive.

TABLE 3.

Young people's drug and alcohol use and risk factors

Drug and alcohol use and risk factors	Age (years)
	18–24 (n = 359)
	n (%)
Had a drug problem before custody
Yes	311 (91.5)
No	29 (8.5)
Heroin
Yes	197 (63.5)
No	113 (36.5)
Cocaine
Yes	45 (14.5)
No	265 (85.5)
Amphetamines
Yes	167 (53.9)
No	143 (46.1)
Cannabis
Yes	157 (50.6)
No	153 (49.4)
Benzodiazepines
Yes	70 (22.6)
No	240 (77.4)
Street methadone
Yes	22 (7.1)
No	288 (92.9)

Note: Excludes not stated values. n: sample size.

3.1.4. Qualitative

Reinforcing what young people self‐reported on the pre‐release questionnaire, caseworkers identified co‐occurring mental health and substance use as the most significant health issue experienced by young people on Connections. Caseworkers highlighted that this health issue presents a significant challenge to young people's transitions from prison due to intersecting social disadvantages and service gaps and barriers. The following two themes were developed to capture this context: (1) survival mode and (2) enhancing service accessibility.

3.1.5. Survival mode

Social disadvantage was a major barrier to young people accessing mental health and substance use services and support after prison. Caseworkers reported many young people do not have support from family members or peer networks and are released from custody without secure accommodation, employment or finances. In this context, young people are forced to prioritise their basic survival needs over engaging with services, as this caseworker explained;

“Young people who are homeless seem to engage less as they are more transient, focused on survival and the program cannot offer them accommodation so it is not the main priority”. (Participant 1)

Social disadvantage produces cycles of mental distress and substance use, as access to subsidised community mental healthcare typically involves a waiting period, during which time often the young person's mental health deteriorates. Long waiting times for affordable mental healthcare in the community, particularly in rural areas, undermine the young person's chance of survival;

“Lack of access to a psychiatrist who bulk bills and doesn't have an extensive waitlist in the community is a major issue. It impacts on the patient's success on release as they are unable to have their psych medication reviewed and a mental health assessment from a Psychiatrist”. (Participant 8)

Other caseworkers said that even when affordable mental healthcare is available, homelessness, lack of transportation and lack of finances are barriers to accessing these services. In the context of not having the basic resources for survival, young people can become distressed, resulting in a return to substance use. In turn, this can impede their ability to engage with services that might be helpful;

“Mental health is the biggest issue, bulk billing doctors can be found but if there are no discharge medications, or if they are homeless, have no money, have no mobile phone, have no opal card [travel card] for transport if their addiction issues are not under control then individuals can become chaotic and return to drug use, or just become confused, unable to problem solve. Engagement will be poor if they are unwell or contact cannot be established”. (Participant 9)

Lack of social support and resources combined with an immediate need for mental health and substance use services (which are frequently not available) creates a catch‐22 situation where young people are unable to prioritise their health. In turn, deteriorating mental health and substance use make it increasingly difficult to survive independently.

Limited access to drug and alcohol services was identified as a compounding issue. Caseworkers described young people as more likely to engage in polysubstance use and be active users of amphetamines or stimulants in comparison to older people. There is no pharmacological substitution treatment for amphetamine use or dependence with a strong evidence base (Pérez‐Mañá et al., 2013). In prison, drug and alcohol group programs are available for people with polysubstance use, however, these are focused on reducing re‐offending and only available to people who have been sentenced. In the community, Stimulant Treatment Programs providing counselling, health checks and group support are available, however only in metropolitan areas, and only very few focus on support for young people and First Nations people.

3.1.6. Enhancing service accessibility

Caseworkers identified numerous ways in which to enhance service accessibility for young people exiting prison, underpinned by an emphasis on coordinated, inter‐agency approaches and more time to work with young people. In prison, caseworkers indicated that young people needed increased access to (1) early, comprehensive assessments, including mental health, cognitive and intellectual disability and functional assessments; (2) health and social care planning from reception to release, including in‐reach from relevant community services so that relationship building can begin prior to release; (3) a structured pathway from prison to community that encompasses coordinated discharge planning by corrective services, prison health services and community‐based services (e.g. local health districts), including direct access to community drug and alcohol rehabilitation; and (4) tailored youth services, including specialised youth workers and an education curriculum to support the development of literacy and numeracy, health literacy and independent living skills prior to release. Increased opportunities for work experience and education and training courses establishing pathways for young people on release were also recommended.

In the community, caseworkers identified alliances across the service system (corrections, health, mental health, drug and alcohol, housing, disability, youth and social services) as a strategy to circumvent the long waiting lists for social housing and provide coordinated support to young people with complex needs. Caseworkers reported that stigma associated with complex needs and incarceration was a barrier to accessing these services, including those specifically funded for young people with mental health and substance use issues;

“Coming from prison is seen as a major negative with services who should be assisting youth. They are judged from being in prison because the Youth Service/Workers have no experience with youth who are incarcerated. They are put in the too hard basket”. (Participant 2)

Due to the program remit, Connections caseworkers have limited time to work with young people and link them to services, particularly if the young person is hesitant to contact their caseworker on release. Caseworkers reported this is more likely to occur if the person is lacking social support or there is a deterioration in mental health or substance use. More time and continuity of care were identified as key elements to facilitating young people's transitions from prison to community, as young people often need more support to engage with services and programs;

“Sometimes the younger ones really want services to help them as they don't want to come back to gaol. Then there are the ones who are still young enough to think they are immortal and don't need any help”. (Participant 6)

“[Young People] are in the midst of realising how hard it is to come out of adult jail and not return home or want to go home and that you come out of jail to nothing”. (Participant 2)

Moreover, as many young people exiting prison have multiple mental health diagnoses, occurring in a context of trauma and cognitive disability, it was felt that young people should be provided with the opportunity for long‐term support and time to build trust. Caseworkers indicated that proactive, one‐to‐one, ‘trauma‐informed’ support is required for a minimum of 12 months after prison, ideally from persons with whom the young person can work with prior to release and have a continuing relationship.

4. DISCUSSION

Our study findings strengthen existing research on young people with substance use exiting prison and their service needs. Substance use among young people on Connections was reflective of the high prevalence of substance use across the prison population in NSW (Justice Health and Forensic Mental Health Network, 2017; Rodas et al., 2011) and worldwide (Fazel et al., 2017; Håkansson & Berglund, 2012; Mitchell et al., 2007). Amphetamine use among young people on Connections corresponded with previous studies showing people in prison who engage in amphetamine use are significantly younger compared to non‐users (Cartier et al., 2006; Håkansson & Berglund, 2012).

More than half the young people in our study indicated they wanted more drug and alcohol services in prison than they were currently receiving and that they did not have planned drug and alcohol treatment to continue or complete on release. This aligned with caseworkers' concerns around therapeutic support in prison and the community for polysubstance and amphetamine use. The recent ‘Special Commission of Inquiry into crystal methamphetamine and other amphetamine‐type stimulants’ in NSW similarly found that thousands of individuals who regularly use amphetamines are incarcerated every year, yet both treatment and harm reduction measures in the correctional system are limited (Howard, 2020, p. 49). International research has also shown the need to improve therapeutic options for people in prison with polysubstance and amphetamine use (Fazel et al., 2017; Wilson et al., 2013). Links have been made between psycho‐social interventions and specific counselling services and programs for people with amphetamine use problems and a reduction in substance use (McKetin et al., 2012). Currently, the primary drug and alcohol support in prison for polysubstance and amphetamine use is group programs with a focus on reducing re‐offending, which are often perceived by young men as unhelpful due to the risks associated with disclosure of personal information to other group members (Walker et al., 2018). Attempts to improve therapeutic options need to take these aspects of the prison environment into account and consider other contextual factors that could be barriers to accessing substance use treatment and support during incarceration.

Our study also found that increased resourcing for substance use treatment and support services is urgently required in the community to support young people's survival post‐release. Caseworkers reported that young people are often unable to access drug and alcohol services after prison due to unavailability or long waiting lists, particularly in non‐metropolitan areas. Inequality of resource allocation between metropolitan and non‐metropolitan areas is not unique to Australia and presents as an issue globally (Staton‐Tindall et al., 2011). Engagement with drug and alcohol services on release is a known protective factor for mortality and return to custody (Mitchell et al., 2007; Scott et al., 2011; Staton‐Tindall et al., 2011; van Dooren et al., 2013), and our study provides further impetus for resourcing of polysubstance and amphetamine services to assist young people after prison in preventing mental distress, substance use and return to custody.

A key finding of this study is that young people are a distinct group within the general adult prison population in terms of their mental health. Nearly all young people on Connections (96.5%) had received mental health treatment (either in prison or the community) from a psychiatrist, doctor or mental health team. This is markedly higher than the most recent NSW prison health survey, where 49.2% of all adult prisoners (18–85+ years) reported having received psychiatric care at least once before coming to prison (Justice Health and Forensic Mental Health Network, 2017). Caseworker survey responses indicated that while young people might have numerous contacts with psychiatric services in and after prison, they may not be accessing the support they need to survive in the community. In particular, the need for immediate access to subsidised community mental health services to ensure continuity of care and assessment as well as access to long‐term holistic care for mental health, trauma and substance use.

Recent reviews of mental health services in Australia have found that prison mental health services are under‐resourced compared to available benchmarks and international standards (Davidson et al., 2019), and that numerous service gaps in mental health services persist in the community (Productivity Commission, 2019). For young people with a diagnosis of both a mental health disorder and cognitive disability, this service gap is widened by a poor understanding of cognitive disability within the criminal justice context and the inadequacy of existing services to address complex needs and dual diagnosis (Baldry et al., 2013). Community mental health services are only available to those with acute psychiatric symptoms or who require minimal support such as a support group or short‐term counselling. For people with mental health support needs that fall in the middle of these two ends of service delivery, access to treatment is significantly under‐resourced (Productivity Commission, 2019). Caseworkers in our study reported that many young people experience a deterioration in their mental health and develop acute symptoms because they are unable to access timely mental healthcare after prison.

Others have argued the need to shift away from short‐term, symptomatic management to more long‐term care (Chang et al., 2015; Scott et al., 2011). Our findings align with this research and show there is also a need to shift the perspectives and practices of service providers. Caseworkers reported that young people exiting prison are unable to access existing community mental health services due to the stigma attached to ‘complex needs’ and incarceration (Baldry et al., 2018). There is a lack of integrated mental health and drug and alcohol services for people exiting prison with co‐occurring mental health and substance use (Baillargeon et al., 2009). Co‐morbidity guidelines outline that public mental health and drug and alcohol services should adopt a ‘no wrong door’ policy, however, in practice, people are often transferred between these services and unable to access comprehensive care (Marel et al., 2016). Further research is needed to enhance the accessibility of mental health and drug and alcohol services and improve understanding among service providers of the social, systemic and structural factors that lead to young people's incarceration.

A key finding of our qualitative study was that significant social disadvantage combined with a systemic lack of accessible, affordable, and timely health and social services which meet the needs of young people exiting prison are drivers of substance use and mental distress. This is a health equity and social justice issue. Without supportive relationships, finances or long‐term housing, young people are forced to prioritise their basic needs for survival, which affects their health and ability to engage with transition support caseworkers. If the young person is also waiting for mental health care and drug and alcohol support, they become vulnerable to deteriorations in their mental health and substance use, which in turn can lead to return to custody. The front‐line practitioner knowledge in our study complements recent qualitative research with men exiting prison with a history of substance use, which found that homelessness, unsafe housing, unemployment and stigma‐positioned men in ‘high risk’ environments for substance use relapse and return to custody (Denton et al., 2017; Walker et al., 2018). Caseworkers in our study reported that inter‐agency (corrective services, prison health, community mental health, drug and alcohol, youth services and housing) cooperation is required to improve cross‐sector understanding of the needs of young people, reduce stigma among service providers and deliver comprehensive services for this population. Moreover, young people require access to long‐term housing and pre‐ and post‐release support, as these have been linked to improved transitional outcomes (Hancock et al., 2018).

4.1. Limitations

Our study provides descriptive statistics but not an analysis, and this should be a priority for future research, accounting for differences among young people such as gender, disability and whether the young person is a First Nations person. The quantitative data was obtained from a transitional health program for people with problematic substance use exiting prison in NSW on completion of a prison sentence, focusing on those aged 18–24 years. Therefore, the findings might not be generalisable to other jurisdictions or other populations, including people exiting prison after a period of incarceration on remand, who typically do not have access to prison programs. As this study was a secondary data analysis of routinely collected data, the pre‐release questionnaire completed by young people on Connections was not designed specifically for the purposes of this research. Due to the logistics of recruitment of young people exiting prison and the short time frame of this study (a 6‐month sub‐study within the broader research project), it was not feasible to interview young people or to produce an analysis of particular barriers to service accessibility experienced by First Nations people, which requires extended time to work closely with participants and First Nations community organisations. This research is being undertaken by researchers on the broader NHMRC project.

Finally, the qualitative findings are not generalisable due to the small sample of participants, however, this is typical of qualitative research and the analysis was undertaken to the point where no further themes could be identified (saturation point). Answers to the open‐ended survey only reflect the views of respondents at the time of data collection. The open‐ended survey method of data collection precluded the opportunity to collect data from participants in an iterative and dialogical manner, however, we did engage in a discursive process of feedback and co‐analysis with Connections staff during the data analysis stage.

5. CONCLUSION

The transition from prison to the community is recognised as an extremely challenging experience due to the immediate need for housing, finances and support for substance use and mental health (Baldry et al., 2006; Hancock et al., 2018; Kendall et al., 2018). Young people exiting prison are a distinct and vulnerable group, often leaving prison without housing, finances, supportive relationships or access to mental health and drug and alcohol services. Social and health disadvantages intersect with service gaps and barriers producing cycles of mental distress, substance use and return to custody. This is a health equity and social justice issue, as young people exiting prison are unable to access the resources they need to survive in the community and experience stigma from service providers. These are avoidable drivers of mental distress and incarceration.

The requirement to address the specific needs of young people exiting prison (and other vulnerable groups) is stated in the United Nations Standard Minimum Rules for the Treatment of Prisoners (Rule 2.2; United Nations, 2015) and in Article 22 of the United Nations Declaration on the Rights of Indigenous People (United Nations General Assembly, 2007), which notes that specific attention should be paid to the ‘rights and special needs of Indigenous elders, women, youth, children and persons with disabilities’. Based on our findings, increased funding for (1) affordable safe housing; (2) integrated community mental health and drug and alcohol services, especially in regional and rural areas; (3) inter‐agency collaboration between corrections, health and social services; and (4) community organisations offering holistic long‐term (pre‐ and post‐release) support are mechanisms that could facilitate a rights‐based approach. This will require a shift in resource allocation from incarceration to rehabilitation (Staton‐Tindall et al., 2011). Moreover, to be effective, this will need to occur alongside preventative measures addressing the health and social inequities implicated in the criminalisation and incarceration of young people.

AUTHOR CONTRIBUTIONS

Lauren Gilchrist conducted the analysis and wrote the original draft. Sacha Kendall Jamieson conceptualised the study, supervised the qualitative study, wrote the original draft and provided critical comments on the manuscript. Reem Zeki conceptualised the study, supervised the quantitative study and provided critical comments on the manuscript. Stephen Ward conceptualised the study and provided critical comments on the manuscript. Sungwon Chang conceptualised the study, supervised the quantitative study and provided critical comments on the manuscript. Elizabeth Sullivan conceptualised the study, acquired the funding, provided oversight for the whole study, and provided critical comments on the manuscript.

FUNDING INFORMATION

This study was undertaken as part of a National Health and Medical Research Council project grant, ‘Recidivism, health and social functioning following release to the community of NSW prisoners with problematic drug use: an evaluation of the Connections Program’ (APP1109009).

CONFLICT OF INTEREST

Professor Elizabeth Sullivan is a part‐time Custodial Health Research Lead at the Justice Health and Forensic Mental Health Network. Stephen Ward was the Acting Service Director of Drug and Alcohol at the Justice Health and Forensic Mental Health Network at the time of this study and was the previous Manager of Connections. Dr Reem Zeki is a Senior Research Officer at the Justice Health and Forensic Mental Health Network.

Gilchrist, L. , Jamieson, S. K. , Zeki, R. , Ward, S. , Chang, S. , & Sullivan, E. (2022). Understanding health and social service accessibility for young people with problematic substance use exiting prison in Australia. Health & Social Care in the Community, 30, e4735–e4744. 10.1111/hsc.13880

DATA AVAILABILITY STATEMENT

Primary data cannot be shared publicly because they are confidential data owned by Justice Health and Forensic mental Health Network. Ethics approval for this project only authorizes specific researchers named in the original ethics application.