Health Priorities among Women Recently Released from Jail

Abstract

Objective

To describe the health priorities of women recently released from jail.

Method

We open-coded semi-structured interview transcripts collected from 28 women within 6 months after their release from jail to identify themes associated with prioritization of health.

Results

Five out of 28 women listed health as their top post-release priority. However, many women had competing priorities after release, including housing, employment, and children. We found that women described several reasons why health was not a priority; however, participants reported regular use of the healthcare system upon release from jail, indicating that health was important to them to some degree.

Conclusions

Our findings may inform intervention efforts that connect women to healthcare resources and increase health-promoting behavior during the transition from jail to community.

Twelve million men and women move through jails in the United States (US) each year,^1,2 and, at any given time, more than one million US women are under correctional supervision.³ Eighty-three percent of these women are arrested for non-violent crimes; nevertheless, the rate of women's incarceration is increasing at a rate nearly double that of men.⁴ Women with incarceration histories bear a disproportional burden of infectious and chronic disease when compared to the general population, in addition to histories of substance use, mental health problems, and personal trauma.^1,5-9 Yet, despite these health problems, previous studies have shown that few receive care while detained,^10,11 and up to 48% do not seek healthcare services after release from jail.^11,12 According to Lee et al,^12,13 women do not seek health services after release from jail, primarily because of financial barriers (in particular lack of health insurance) and the number of other concerns demanding their attention after incarceration. For example, other researchers have found that the most difficult problems confronting women and men leaving criminal justice facilities are housing, substance use, financial support, and family reunfication. ^13,14 These studies underscore the plight of incarcerated women in general: their incarceration creates a downward cycle of economic and familial instability¹⁵ that may prevent women from effectively addressing long-standing and persistent health needs.^1,5-9

We know that many formerly incarcerated women do not seek healthcare at a level commensurate with their needs. However, we have little information as to how women prioritize their health needs.¹⁴ The purpose of this study was to identify the priorities of women recently released from jail, and in particular, the context in which they set these priorities against other reentry concerns. The justification for this study objective stems from health behavior theories that demonstrate an important relationship between individuals’ perception of disease, the impact this perception has on their health behaviors, including seeking treatment for health concerns, and ultimately, health outcomes.¹⁶

METHODS

Sites and Sampling

The 28 women who participated in semi-structured interviews were enrolled in a larger parent study aimed at identifying factors associated with women's sexual and reproductive health service use after release from jail.¹⁷ Recruitment of the 102 women for the parent study took place over 7 months from spring to fall 2012 at a municipal jail in Kansas City, Missouri that houses men and women serving a sentence of one year or less. Because of our interest in the experiences of women leaving jail, particularly our interest in those factors associated with unintended pregnancy and prevention of sexually transmitted infections (STIs), we recruited women as they were being released from the facility. Based on flow of inmates and study staff schedules, we estimate that we reached about half of the women leaving the facility during the study period.

Sampling for the semi-structured interviews was determined by the parent study's secondary aim of understanding the women's interpretation of barriers to and facilitators of access and use of sexual health services. Our goal was to conduct a total of 30 qualitative interviews with a subset of 15 baseline participants who were sexual healthcare clinic users (eg, self-reported visitors to a healthcare provider for STI screening, birth control, or any other type of reproductive health condition, such as pregnancy or Pap exam) and 15 baseline participants who were non-users. Twenty-eight participants were ultimately included in the sample, at which point we felt we had reached thematic saturation.

The original window for completing the planned 3-month follow-up study visit was ±30 days from the actual 3-month post-release date. It took, however, an average of 172 (SD=93) days, or about 5.7 months, to reach participants for follow-up after the initial interview in jail. Semi-structured interviews occurred at a local health department. Details about the baseline survey, post-release follow-up survey, and participant tracking can be found elsewhere.¹⁷ Flow of study participation is depicted in Figure 1.

Figure 1.

Flow of Study Participation

Procedures

To generate a sample of participants for the semi-structured interviews, the research associate identified the first 15 or so women who indicated in the post-release follow-up survey that they received any type of sexual healthcare since release from jail. Similarly, the research associate attempted to interview the first 15 or so women who indicated in the post-release follow-up survey that they did not receive sexual healthcare since leaving jail. Participation in the semi-structured interview was voluntary.

Data Collection

All participants answered the same set of interview questions. Qualitative research allows for probing and is an iterative interview process; thus, a few responses included in our analysis were obtained from unscripted questions to obtain a better understanding of our participants’ stories. The interview questions included the following topics: priorities after leaving jail, resources, social networks, and the barriers to and the facilitators of healthcare use (Figure 2 lists the questions used in this study). Semi-structured interviews lasted approximately 15-20 minutes and were audio-recorded for future transcription. Two masters-level research assistants transcribed interviews.

Figure 2.

Semi-Structured Interview Questions

Data Analysis

To generate descriptive statistics and data about participant characteristics, we matched study-generated participant IDs in semi-structured interviews to the IDs in baseline and follow-up surveys for each of the 28 participants. Analysis of semi-structured interview data occurred in a 4-step process.

First, transcripts from semi-structured interviews were loaded into Dedoose, an online application for managing and analyzing text, video, and spreadsheet data. Second, 4 co-authors of this paper (fourth-year medical students enrolled in a month-long “Health of the Public” medical school rotation) assigned codes to text using Dedoose. Because we were interested in health priorities, these medical students examined the sections of transcripts pertaining to the applicable interview questions (Figure 2). Based on those data, they assigned codes based on textual responses, using an open-coding process. There were a total of 29 codes (eg, housing, employment, child care, education, general health, sexual health, STIs, drug use). Two students coded each transcript independently. Third, the most pertinent codes were identified by consensus of all authors to develop themes from interviews. For purposes of this paper, themes included competing priorities after release from jail, reasons for low prioritization of health, and the context in which women used health resources. Finally, supporting data were extracted for each theme. We presented examples of commonalities and deviations from themes where appropriate.

RESULTS

The 28 participants averaged 35 years of age (range = 20 – 53). The majority of the participants characterized themselves as single (84.6%), black (88.5%), and having up to 2 children under the age of 18 at home. Participant characteristics are described in Table 1.

Table 1.

Participant Characteristics Prior to Incarceration and after Release from Jail N = 26^a

Mean age in years (SD)	35 (10.3) N	Pct.
Race/Ethnicity
Black	23	88.5
White	2	7.7
Other	1	3.8
Living Arrangements Prior to Incarceration
Alone in house or apartment	7	26.9
With a spouse and/or children	8	30.8
With other relatives	7	26.9
With friends or roommates	1	3.8
With significant other	1	3.8
In a shelter, homeless, or in transitional housing	2	7.7
Marital Status
Single	22	84.6
Married	1	3.8
Separated, divorced, or widowed	3	11.5
Graduated from High School	17	65
Working Prior to Incarceration	8	31
Had Health Insurance Prior to Incarceration (N = 25)	10	40
Had a Medical Home Prior to Incarceration	23	92.3
Had a Personal Doctor or Nurse Prior to Incarceration	8	30.8
Benefits Received Prior to Incarceration (N = 22)b	15	68.2
Number of Full Term Pregnancies, mean (SD)	2.3	(2.1)
Number of Children under Age 18, mean (SD)	1.73	(1.92)
Lifetime Months Spent Incarcerated, mean (SD)	14.65	(29.3)
Current Living Situation
Alone in house or apartment	6	23.1
With a spouse and/or children	5	19.2
With other relatives	9	34.6
With friends or roommates	1	3.8
In a shelter, homeless, or in transitional housing	5	19.2
Currently Working	9	35
Currently Insured (N = 25)	12	48
Current Receiving Benefits (N = 23)b	16	70
Number of Times Arrested Since Release from Jail
None	18	69.2
1	2	7.7
2	4	15.4
4-5	2	7.7
Reincarcerated Since Release from Jail	4	15.4
Sexual Health Care User Since Release from Jail	12	48

Note.

^aWe could not identify 2 participants in the semi-structured interview transcripts, and thus, could not extract demographic data for them from the baseline and post-release follow-up surveys in which they participated

^bBenefits included public benefits such as food stamps, disability, social security, or cash assistance.

Key Themes

We identified 3 key themes releated to women's prioritization of health after release from jail: their competing priorities post-release; expressed reasons for health being a low priority; and the context in which women were actually using the healthcare system (Table 2).

Table 2.

Themes Related to Formerly Incarcerated Women's Prioritization of Health

Competing Priorities after Release from Jail
Health as Priority	“I think it fit in the beginning because it was my main priority. I mean, if there's stress, I mean, all types of other things going on, then there's no way I can be happy and things like that. And stress, as we all know, kills. So that was my main priority: to relieve this stress in my life.” Phyllisa, 53
Non-Health Priorities	“I wanted to try to get back on my feet, as far as income. Try to get some money together. Because, I wanted tojust... I wanted to turn my life around and do some things right, instead of just constantly in the street hustling.” Erica, 41
	“I figured that if I found employment that would help me stay out of jail because it would give me something healthy and positive for me to do...That was part of the reason why I was out there, doing the sexual favors that I was doing.” Mary, 47
	“[I need to] make sure my son gets up and goes to school and that my kids are OK. They need to understand where I was and need to let 'em know that I didn't leave them and stuff like that.” Faith, 26
Reasons for Health Being a Low Priority
Sexual Health	“Sexual health was the last thing on my mind. I mean sex doesn't interest me. I was pregnant when I was fourteen, so sexjust ain't, you know...” Monica, 49
	“I wasn't fooling with a whole lot of people. I might have been with strangers but I made sure I knew who it was. Like they gotta go get a condom. It's just that simple. I wasn't worried about catching nothing because I always had protection.” Sade, 47
	“I guess if [sexually transmitted infection, STIs] is not hurting me or I'm feeling fine, I'm alright. I think I'm good.” Mary, 47
	“I am not really concerned [about being tested for STIs] because I trust the mate that I am with.” Keisha, 37
Money	“I had to make sure I had the money so that I could be there. At first they would want me to pay for my medication, then I had to wait to get on a special thing so that they could pay for all my medication. And I just recently got MO-Net's health like within the last couple of weeks because I didn't have insurance.” Erica, 41
	“Well, I've been having trouble getting to appointments lately because I do not have money to get on the bus and stuff like that.” Dominique, 20
	“I don't know where to go. I don't have health insurance, and so I don't know what to do.” Veronica, 34
	“Money [is an issue, I need it] for transportation, legal issues, the prescriptions, everything.” Yolanda, 34
Transportation	“You know just because not having transportation you don't feel like going out there to get on the bus, you know what I'm saying?” Dominique, 20
	“Them is the basics. Like if I had transportation, and correct child-care. I'll be there [seeking health care]” Margarita, 23
Employment	“Employment is a priority more than anything because without that I have nothing. But then I have to realize, it was kind of a conscious thing on my mind like 'but what about your health?' You know without that you can't keep no job.” Mary, 47
	“My priority is to get my job back, and I was supposed to have surgery that I had been prolonging. So yes I wanted my job back in order for me to have that surgery.” Shondra, 36
Children	“I didn't really care [about my health] because my children were like, top priority.” Keisha, 37
	“I was thinking about my kids and that was all that was runnin' through my head.” Jade, 23
Substance Use	“When you are all caught up with drugs or alcohol, it's like you probably don't wonder or expect your period. You don't really notice if something is wrong.” Janet, 53
	“[Drug use has great impact on health] because when you are on drugs youjust do whatever and I was at risk. I could have got AIDS or something like that.” Veronica, 34
	“Yes, [I have issues with employment] because I have possession of marijuana on my record.” Monica, 49
	“[One ofthe challenges I faced was my] background with drugs. I have one felony conviction, a possession charge, and so that's kind of hurt, like hindering me from jobs and housing.” Aretha, 36
Identification	“My biggest challenge was that I didn't have an ID at the time. Picture ID, which I have since replaced. Food pantries, shelters, a lot of different things. Most services require a picture ID even when you come here to the free clinic.” Janet, 53
Context for Use of the Health System
Preventive Care	“I go once a year now, I used to go twice when I had to get my Pap smear every six months due to cancer cells on my cervix. They gradually went away, so now I go every year and get a Pap smear.” Janelle, 29
	“I always try to keep my health on alert, because these STDs [sexually transmitted diseases] are running rampant, and I ain't trying to catch anything. Actually, before I got incarcerated, I went to a health provider. Probably prior two months before that I went to Planned Parenthood.” Krystal, 49

Note.

^aPseudonyms were used to identify all participants.

Competing priorities after release from jail

When we designed this study, we were interested in understanding the priorities of incarcerated wommen after release from jail, specially those pertaing to their general and sexual health. We identified 2 main sub-categories of resonses about top priorities after release from jail for this sample of 28 women: health and non-health priorities. The 4 most common responses to the question: “When you got out of jail, what were your top priorities or things you needed to take care of?” were employment, general health, housing, and children. Figure 3 shows the ranking of these women's priorities.

Figure 3.

Priorities among Women Recently Released from Jail, N = 28

Of the 28 women interviewed, 4 (14.3%) listed their general health as their top priority, and one woman listed sexual health, specifically, as an important issue to address upon release from jail. For example, one participant said her general health was an important motivating factor in helping her move forward in life, although participants like this person comprised a minority in this sample. As the women reflected on their post-jail experience, they instead reported a wide range of priorities or tasks that they felt needed immediate attention upon community reentry. For example, housing was listed as a top priority for 4 women (14.3%) after their release from jail. Two women reported that they were homeless or lived in transitional housing prior to their incarceration. After incarceration, 5 women reported that they were homeless. At least one participant cited the complication of a felony drug conviction as a barrier to securing housing.

Employment and need for money were other concerns for several women upon leaving jail. Eight women (28.6%) listed employment as their top priority, and 2 women (7.1%) reported concern over their lack of adequate finances for basic needs. Needs for education and transportation were related closely to the women's employment and financial needs. One participant reported that she had been working on enrolling in school prior to her incarceration. It remained her top priority upon returning to the community. For her, education went hand-in-hand with employment. For another woman, transportation was the top priority as the participant needed to secure a monthly bus pass to get her housing, employment, and her dental issues resolved, in that order.

Given our sample's characteristics – with the majority being single and having children – it was no surprise that we found that children were key priorities for these women after their release from jail. Four women (14.3%) reported that children were their top priority. For example, when one participant returned home, she learned that she lost her job and child care privileges due to her incarceration. Another participant reported that she had a history of substance abuse, and she had been sent to jail for lack of supervision of her children. Her priorities after jail were to stay off drugs and complete all of the requirements set by the Family Support Division Services to get her children back.

As the women reflected on their top priorities after release from jail, they clearly showed concern about the pressing reentry issues of housing, employment/income, and children. Even when participants cited health as a top priority, they failed to cite specific health problems. Given the layering of health problems that we know incarcerated women face, we concluded that several key social problems competed with prioritization of health. The women, for the most part, failed to rank health as important against a backdrop of other concerns.

Health as a low priority

The second theme illuminated by the data was how women reasoned through their low prioritization of health. The main reasons cited by participants for ranking health as a low priority were that it was not a necessity and, for many, that the right resources were not in place to facilitate healthcare use or access. We identified several sub-categories of this theme (Table 2). Participants specifically described the ways in which resources – money and transportation, for example – got in the way of seeking healthcare. The women also framed their health concerns in the context of their perceptions on sexual risk and drug use. The data point to their rationalizing why they were not at risk for sexually transmitted infections. The women also openly talked about drug use as both a behavioral and structural barrier to good health and reentry success.

Context in which women used the health-care system

Lastly, we discovered that whereas the majority of the women interviewed did not list health among their top priorities, they in fact utilized the healthcare system regularly, which forced us to consider the context in which our sample of women took advantage of the healthcare opportunities in their community. In examining the data, it appeared that the women's attitudes and behaviors (their actual use of healthcare systems) indicated that health was, in fact, important to them despite no explicit articulation of health as a top priority.

By way of background, we found that our sample of women used the healthcare system frequently, both before and after incarceration. In the year prior to their incarceration, 76.9% of the women reported going to the emergency room for care at least once (on average, the women went to the emergency room twice). Up to 20% of our sample had been hospitalized for at least one night in the year prior to incarceration. Fifty-three percent of women had been to a clinic at least once for checkup or treatment of a medical problem (the women reported an average of 2 clinic visits). In the year before incarceration, 15% of the women went to a medical facility specifically to be tested for STIs; 19.2% visited a medical facility for birth control; and 34.6% of women sought other sexual or reproductive health services (eg, receive prenatal care or Pap test).

After their release from jail, 15.4% of the women sought medical care in the emergency department (we interviewed women on average 5.7 months after their release); 3.8% had been hospitalized for at least one day; and 34.6% of the women had visited a clinic for a check-up or treatment. Regarding their sexual health after incarceration, 19.2% of the women went to a medical facility to be tested for STIs; 15.4% of the women sought contraceptive services; and 30% sought other sexual or reproductive care.

Our participants reported utilizing healthcare for routine check-ups. For example, one participant said that she attended health appointments every 2 months for close management of her chronic diseases (high blood pressure and depression). Another reported weekly prenatal appointments for her pregnancy. Other participants engaged in regular preventive sexual healthcare, including follow-up Pap tests, contraceptive injections, and STI screenings. As illustrated by these cases, the women in our sample went to healthcare providers when they recognized that they had a health problem, felt they were at high risk of contracting a disease, or felt their problem would adversely affect their general well-being. Whereas the women may not have prioritized health, some seemed to be adept at utilizing the healthcare system when necessary.

DISCUSSION

After release from jail, the immediate priorities of secure housing, income, and employment may compete with health needs.^13,14 When women articulated why health needs were such a low priority after release, their narratives revealed a low perception of susceptibility to disease, behavioral and policy barriers linked to past drug use, as well as the practical barriers of lack of money, health insurance, and transportation. Despite these barriers, some women leaving jail still sought out healthcare based on perceived need and, in some cases, for prevention. In total, the experiences and motivators for healthcare use and prevention were varied across our sample.

We know from previous research that women leaving jail are forced to navigate a complex set of living arrangements (some have none in place), child care solutions during their absence, past sexual partnerships, including violent ones, and a variety of means of generating income, some of which include illegal activity.^13,18-20 The literature also shows that the risk of death, drug use, overdose, and HIV are great for both women and men in the days and weeks immediately after release from jail or prison.^19,21,22 The few studies of women's priorities after release from jail reflect the reality of logistical barriers to reentry success, though do not highlight women's acknowledgment of these dangerous post-release health outcomes.^13,14 We also found little evidence that women's priorities mirrored the reality of poor post-release health outcomes documented in the literature.^19,21,22 The distinction between a woman's real health risks after jail and her priorities is important – ultimately, her set of priorities will drive her actions.¹⁶ The alignment of risks, priorities, and reentry realities for women could be examined further in future studies.

We also found that when our participants were symptomatic or believed they were at high risk for developing disease (eg, STIs), they did place a high priority on health needs. The aggregate rates of healthcare use by women in our sample, particularly emergency department use, indicates that a group of women were not entering the healthcare system until their issues were severe enough to warrant urgent treatment, a finding that is consistent with previous research.^10,12,23 As a result of these patterns of healthcare use, the women may have little continuity of care and experience high medical costs that could exacerbate their existing burdens. We feel that the women seeking preventive healthcare in our sample were an exception to this pattern.

Limitations

Our study had several limitations. First, this was a secondary data analysis of interviews that were conducted as part of a larger parent study that had different aims. The questions included in the analysis were limited to what had already been collected through the parent study. In addition, the sample for this study was recruited from only one jail. Whereas the demographics of inmates in this facility are similar to other jails around the country, there is always the chance that this facility is an anomaly when considering unmeasured characteristics that could affect the ability of this study to be generalized. The small sample size of the study also limits its potential to be generalized. We reached, however, thematic saturation with the responses from our participants. Lastly, because the questions included in the interview were self-reported, the results may be subject to recall bias.

Despite these limitations, our study provides interesting findings that can shed light on areas for future study. By assessing the priorities of women after incarceration, we can contribute to the literature on how incarceration affects the lives of women and changes the ways they navigate their communities after release. Future studies could explore the differences in the patterns of preventive behaviors and healthcare use among women leaving jail. These studies also might test interventions that seek to connect people to health services, beyond those specific to chronic conditions. ²⁵

Conclusion

Health is rarely the stated top priority for women leaving the criminal justice system.^13,14 More immediate priorities after release become barriers to taking care of their health and seeking health-care.^13,14,18-20 Nevertheless, women do value their health and are generally competent at gaining access to healthcare services when they feel they are needed. Our findings have implications at both the individual and policy levels as it relates to improving reentry outcomes for women. At the individual level, our findings may guide intervention efforts to increase women's access to healthcare resources and to increase health-promoting behavior after leavint jail. Specifically, public helath interventions might focus both on perceived susceptibility to disease, but more importantly, on self-efficacy to deal with barriers to care.²⁴ In addition, moving away from the notion of individual responsibility and toward a more contextual approach is fitting. ²⁵ Only if women's real obstacles are addressed at the community and policy level will their reentry have more than marginal success. For example, welfare and housing policies that exclude drug felons, the shortage of transitional housing, employment practices that discriminate against people with criminal justice records, and the patchwork of approaches to child welfare for incarcerated parents have to be revisited.^15,20,26 To break the cycle of recidivism and create an environment in which women can reenter communities successfully, new policies and practices should address women's primary priorities after release from jail – housing, employment, and children. Once women can overcome these barriers to successful reentry, they may be more motivated and able to address their health concerns.

Human Subjects Statement

The University of Kansas Medical Center Institutional Review Board approved the protocol for this study, and we obtained a Federal Certificate of Confidentiallity to further protect participants confidentiality