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

Abstract

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.

Nearly 10 million people cycle in and out of jails and prisons annually and return to U.S. communities (Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, 2020). The most vulnerable are the 1.3 million women under criminal justice supervision, nearly all of whom are poor, racial, and ethnic minorities, with complex trauma, mental health, and substance abuse histories (Kelly et al., 2014; Lorvick et al., 2018; The Sentencing Project, 2019). Convicted of low-level, nonviolent crimes, these women frequently return to their communities after detention without a stable income, housing, health care, or essential resources (Colbert et al., 2016; Emerson, 2018). Unsurprisingly, they face greater health risks than women who do not contend with the challenges of criminal justice involvement.

As COVID-19 illuminates deep disparities between who gets sick, who survives, and how people can best protect themselves (Interdisciplinary Association for Population Health Science, 2020), we sought to describe the experiences of women living in the community who simultaneously negotiate criminal justice involvement and COVID-19 in three urban areas. These women fall outside of targeted efforts to reach people held in jails and prisons but face some of the greatest risks and prevention challenges for COVID-19.

Method

We conducted unstructured telephone interviews and social media conversations between study staff and 35 community-based participants in a three-city cohort study of criminal justice–involved women’s health and cervical cancer risk. The larger cohort of women (N = 474) were enrolled in the past year (220 women in Oakland, 150 in Birmingham, and 104 in Kansas City). Observations were based on this study and others in the three sites (see Funding section).

Shelter-in-place orders went into effect in Oakland on March 16; Kansas City on March 21; and Birmingham on March 25. In-person study visits were suspended in Oakland and Birmingham by March 17, while Kansas City had already been maintaining contact with the cohort by phone. Across all three sites, we started calling and receiving calls from participants, and began asking how they were faring during the COVID-19 pandemic.

For this report we analyzed field notes from conversations with N = 35 women (out of the full cohort of 474 women) using an open coding and iterative analytic process. All authors checked analyses directly against data from all three sites. While plans are under way to make a more structured attempt at connecting with all enrolled women, for this report, we sought to ask a smaller sample of women more open-ended questions about how they were faring. By collecting data using qualitative methods, we were able to show more nuance about how the women were experiencing everyday life during COVID-19. Check-ins with participants were a routine part of our research protocol and were approved following the National Institutes of Health single institutional review board policy for multisite research.

Results

The full cohort of women (N = 474) faced many vulnerabilities to COVID-19: 74% of women had at least one chronic health condition, 31% were marginally housed, 71% smoked cigarettes every day or some days, 55% met substance dependence criteria, 28% had been in jail in the past year, and 30% experienced intimate partner violence in the past year. The mean age of the sample was 43. Sixty-one percent of women were Black and 34% were White.

Among the 35 women with whom we spoke, 15 mentioned participation in research when we called them or when they called us (see Table 1). Some asked explicitly when and how they might receive their incentives for participation in research, which they needed. The women have received $10 for quarterly check-ins and $50 for annual surveys. An Oakland participant called asking to stop by the (now closed) field site for a $10 check-in. The staff member explained the situation, but the participant said, “How come you get to collect your money but we can’t get our money?” The women also wanted the social connection from the research relationship; they were bored, lonely, and needed any sort of income. They also were concerned about the teams’ well-being. In Birmingham and Oakland, staff noted the women were anxious and frightened about the pandemic. Staff said that many women asked how we (the study team) were doing, and wanted us to stay safe and “sane” while working from home.

Table 1.

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

1. Importance of participation in research

Problem solving and connection

I explained we could do [research check-in] by phone but I would have to email her a gift card or USPS mail the cash. “You can’t slip it

through the door?” I explained that [the study] is closed because of the shelter-in-place and we aren’t at the office.

Other participants also asked for cash to be slipped through the door—not having access to cash apps or using email for gift cards.

Other women referenced social connection as benefit of continuing research: Participant is very interested in doing an interview by phone

and added, “I’m thinkin’ lots of people would want to do that because we want to be connected to people.”

Need for resources

Participant called me back to ask if she could do a check-in or any kind of survey early. She really needs some money so that she can continue her treatment. She is a few days shy from 60 days clean. She really needs a phone because she has to do phone NA [Narcotics Anonymous] sessions in order to complete Step 2, and it could really mess her up if she can’t continue.

Women were glad we were still working and running study appointments since as one participant said, “It’s not like I can go to work right now.” She brought this up since she had recently been let go from her part-time job since she was a nonessential employee.

2. Marginal and stressful housing situations

No control over living situation

Participant is sheltering in place in transitional housing and doing best she can. Has COPD [Chronic obstructive pulmonary disease] and counts on people bringing her things—nurses. People bring bags of dry goods and something like that (like from the doctor’s office) but she’s terrified of catching COVID. Other people in her building are socializing and hanging out in each other’s rooms and “just not getting it.” She’s very scared because she believes if she catches the virus she’ll certainly die. Wants fresh food for immune system but doesn’t get it.

Participant taking it very seriously but homeless and shifting between different friends’ homes. Currently in Pittsburg, CA, but heading back to Oakland today.

One of our women who is homeless/living temporarily with a family member was upset because she was asked to leave where she was staying because she had a cough and runny nose. She said that her family member was “way too paranoid” and did not report any further symptoms of COVID-19 during the call to staff.

The ladies at the treatment center are only allowed to leave their rooms two times a day to go outside. They are bored being in their rooms all day since they were no longer allowed to meet for treatment classes, therapy groups, or religious services. Some of our women were also suddenly burdened with providing round-the-clock child care in the center to their young children as well as homeschooling their children after the state-wide cancellation of in person classes for the rest of the year. These women reported feeling stressed and overwhelmed since the center had no child care option at that time.

3. Concern, prevention, and conspiracy

COVID-19 concern and prevention

”The virus is going to kill a lot of people and I want to talk to the people who put it out there [on the street]. But I’m sheltering in place as I’m supposed.”

Most participants were following recommendations as best they could for sheltering in place, handwashing, or wearing masks.

I ask the participant what has been the hardest for her since all of the changes. She began to describe not being able to find toilet paper or hand sanitizer. I was happy that she was at least talking about hand sanitizer! She said she doesn’t go out in the streets “like that” [for sex work] anymore, so she’s not worried about catching the virus.

Though two participants reported the contrary: “Oh, no I’m not staying inside. Everyone’s in a panic but I’m not.”

Conspiracy

”It’s all a gov’t set up … to give away [some money] or something.”

This participant wasn’t alone in thinking the pandemic was a government capitalist conspiracy. At least two others believed so, as well. One participant thought it was a pre-apocalyptic conspiracy, which she saw on Facebook, and then investigated herself online.

Participants upset because Channel 2 news said Oakland has implemented a 10 p.m. curfew and $500 fine for breaking it and added, “They’re always trying to punish poor people.”

4. Managing health and social issues

Barriers

Participant experienced clinic canceling two appointments because (she thinks) the doctors didn’t want to come in due to coronavirus.

Doctor canceled in-person meeting and scheduled telemed call for her monthly appointment for diabetes and blood pressure check-up. She’s disappointed but glad that she’ll at least get to have contact with her doctor and understands that this is necessary.

[Participant] was diagnosed with cervical cancer last time we talked and she said that they put off all procedures until after 4/7.

Another participant had an abnormal Pap test and was working with the hospital financial department to find a way to pay for the follow-up colposcopy. But since COVID-19, she can’t get anyone on the phone there.

Participant discussed going to her usual NA meeting yesterday (3/18) and for the first time, it was closed. The regular meeting takes place in a county building. Security guards, who normally work there, turned her away. There are still in person meetings she attends and she spent all day yesterday walking Oakland to find them.

She cannot see her child (all of the Division of Family Services is working from home) and all court cases are moved to August. This messes up the progress she has made, showing stability.

Good care

This participant had to go to the doctor because she had an odd lump on her breast so the doctors wanted to follow up with a mammogram. She was able to make and keep this appointment. I assume that given the potential severity, they made time for it. She called me back to say they her mammogram showed no signed of cancer. She was exited.

Some management of health care depended on switching over to electronic forms and the generosity of benefits workers: Scheduled her [disability benefits] meeting by phone and sent forms to be electronically signed. It was an advocacy person working on her behalf who set this up—told her they don’t get paid but she’s going to help her get paperwork signed up.

5. Employment

Unemployed or essential

Participant has been out of work since 3/17 due to COVID-19 and has yet to find work. She worked at a bar, out of state.

”Thank the Lord my job is essential to the grocery stores. I’ve still been reporting to work.” Staff member asks, “Are they giving you what you need to stay healthy?” Participant says, “We have to have our temps checked every day and every time we re-enter the building. Face masks and gloves are a part of our uniform. So a lil comfortable.”

”I still gotta work.” Staff member asks, “Is your job providing sanitizer or masks, or whatever is needed for extra hygiene?” Participant said, “We made our own hand sanitizers cause we couldn’t find any.”

She went out and got a job at the Dollar Store she says she wouldn’t have normally gotten. She knew people would be hiring because of COVID-19, so went out applying! Down side, she got hired for a manager’s position, which requires transportation, which she doesn’t have.

The reality for many of the women, however, was unemployment, even before COVID-19. Many were concerned they didn’t have enough food stamps or money to get enough food for over a month in quarantine.

Note. Field notes written by staff in italics. Direct quotes shown with quotation marks. All other observations by authors in plain text.

The second most common issue was related to marginal and stressful housing situations. Thirteen participants reported homelessness, and while some were able to stay with family for a short time, others were unsheltered and living in cars, encampments, and other unsuitable arrangements. For some their unstable living situations prevented them from being able to follow recommended social distancing practices. One woman in Kansas City said the drug dealer she was living with wouldn’t let her quarantine so she wore a mask inside: “I have a bandana on. I look like a bank robber. A cute bank robber.” Some participants in Birmingham were in residential drug treatment. That setting presented serious challenges for the women as it went on lockdown when someone tested positive for COVID-19 at the treatment facility. Women reported being extremely anxious due to a lack of general knowledge about the virus and not being able to leave the center to be with their families.

The women had varying degrees of concern about COVID-19. Twenty were following the recommendations as best they could, and only two were explicitly ignoring recommendations. In Kansas City, we conducted a closed Facebook group poll on March 30, with the question, “Are you staying home?” Five women indicated, “Nothing has changed for me”; three said, “Hell yeah, I’m following the doctors’ orders”; and two said, “I’m doing what I can do.” There were a few women across sites that heard COVID-19 was part of a larger government conspiracy, like retribution against the United States for the killing of an Iranian leader.

Another theme was how women were managing health issues during COVID-19, ranging from cancer treatment to pulmonary disease, mental health, and drug treatment. Taking care of health came with risks. One participant in Oakland, a single parent with a toddler, received methadone treatment requiring a daily clinic visit with child in tow, which caused her distress because she wanted to shelter in place, as directed by city and state officials.

Though we did not ask everyone across sites about changes in employment, some reported working in the service sector, with various degrees of protection. One Kansas City participant said she had to make their own sanitizer at work.

Discussion

Despite many barriers to staying clear of COVID-19, most women we talked to were doing the best they could to follow recommendations about staying home, social distancing, handwashing, and wearing masks. This is not unlike the wide variation in behaviors of most Americans (Fowler, 2020). As for geographic differences, the women in Oakland were much more used to the language of sheltering in place, since those orders came down the earliest. But by the time we talked to all women, all three cities were essentially closed down. Some women accepted this, but others bought into conspiracy theories about the virus, capitalism, and government.

The women faced several barriers to COVID-19 prevention, namely, lack of control over their circumstances. Almost 40% were unstably housed, and some were unable to control the behaviors of others in their precarious housing situations, expressing deep concern about this. The Centers for Disease Control and Prevention (2020) cites homelessness as a specific risk factor for moderate or severe disease related to COVID-19.

This study also revealed the desperation for the research check-ins, where sadly this was one of the few “legit” sources of money for these vulnerable women in a society with little social safety net and few employment options for women with long criminal justice histories. The typical resources poor and homeless women rely on, for example, have either gone away or are no longer safe to pursue (Ellis, 2020). The small amount we provide only compensates their time as research participants. It is no substitute for the larger sums from stable sources they need to stay safe and healthy.

Implications.

COVID-19 illuminates the most persistent disparities attributable to social determinants of health and structural inequities, as seen by early published morbidity and mortality data (Garg et al., 2020). For criminal justice–involved women in the community, lack of means combined with mistrust in authority figures and government are important barriers to consider in developing a comprehensive public health response.