Introduction

Compared with the general population in Canada, people who experience incarceration have worse health, with high rates of mental illness, infectious disease, premature mortality, and poor social determinants of health [1]. This excess burden of disease influences population health through transmission of infectious disease, costs of healthcare and recidivism, impacts on family and community health, and impacts on public safety [2–5]. People who are Indigenous, who are Black, and who have low socioeconomic status are overrepresented in Canada’s prison population [1,5,6]. This overincarceration is produced by legacies and ongoing practices of colonization, racism, and systemic economic inequality, which create disproportionate health challenges among these communities [7–12]. Improving health in people who experience incarceration is therefore an important pathway to improving public health and health equity in Canada [2].

The period after release from custody is particularly challenging to health, as indicated by increased risks of morbidity and mortality [13–16]. People face urgent issues on release from jail and prison, including finding housing and employment, reconnecting with family, and meeting conditions of release [17–23], which may compete with addressing health and health care needs [24]. In the US, lack of health insurance poses a significant barrier to accessing health care after release, especially in states where Medicare and Medicaid are revoked upon arrest [18–20,23, 25–27]. People may face discrimination relating to their criminal record, including from health care providers [17,26,28]. Finally, inadequate discharge planning in custody may contribute to difficulty navigating community services on release [20,22]. In this context, stakeholders have identified continuity of health care and community re-integration as priorities for prison health research in Canada [29].

There is growing international research on transitional programs to link people with health care and other services in the community after release from prison and jail, which range from providing pamphlets and telephone calls to specialized clinics and intensive case management, and have shown success in engagement and retention in health care in the community [30–36]. Such promising programs may have value for people on release from provincial correctional facilities in Ontario, given provincial and local data showing that one third or more of people who experience imprisonment do not have access to primary care in the community [37,38].

As we consider strategies to support health and access to health care in people on release from a provincial correctional facility in southern Ontario, we need current, local data on the experiences and perspectives of people who have recently been incarcerated [39]. Data from the US and Australia may not be generalizable to the Canadian setting, given national differences in criminal justice systems, social and economic policy, and health care systems, and data are limited on health challenges and opportunities in the post-release period for people in Canada [24,36,40,41]. Further, programs and services may vary substantially by province, region and correctional facility, and needs and opportunities change over time based on service availability and population health issues, for example, the current opioid overdose crisis [42].

Our study objective was to explore continuity of health care and health barriers, facilitators, and opportunities for people at the time of release from a provincial correctional facility in Ontario, Canada.

Methods

We used a qualitative design, in which we conducted focus groups with people recently released from a provincial correctional facility in Ontario, Canada. Provincial correctional facilities hold people who are admitted to custody without sentencing and people sentenced to less than two years in custody [43]. Recent data indicate that the median length of stay for people in provincial correctional facilities in Ontario is 10 days with an interquartile range of 3 days to 52 days [13]. For Ontario residents, hospitalizations and medically necessary physician services including primary care and emergency department visits are paid for through the public health insurance system, the Ontario Health Insurance Plan, including while in provincial correctional facilities. Health care in provincial correctional facilities is administered by the Ministry of the Solicitor General.

A priori, we planned to conduct between three and six focus groups with the goals of exploring diverse perspectives and achieving saturation. We recognized that we might not achieve saturation with this number of focus groups, but we set this as the target number in consideration of available funding. Our interest was in continuity of health care and continuity of health, defined by the World Health Organization as: “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” [44]. We therefore aimed to include people who may face particular challenges to continuity of care in the post-release period, such as people with mental illness and people with substance use disorders. We conducted one focus group at each of three community-based organizations in September and October 2018: a men’s homeless shelter, a mental health service organization, and a social service agency providing voluntary and court-ordered programs for people with substance use disorders. The focus group guide (S1 File) was developed by three project team members (Catherine Hu, Jessica Jurgutis, and Fiona Kouyoumdjian) based on the study objectives and issues identified in previous research [36].

We included adults (aged 18 and older) who had been released from the provincial correctional facility within the past 12 months, who consented to participate, and who spoke English well enough to participate in the focus group, and we used convenience sampling. At each site, organizational staff posted information about the study and shared information with potentially eligible clients about the study and the scheduled time for the focus group. Focus group facilitators assessed capacity to consent at the time of reviewing the information and consent forms by determining whether potential participants understood the nature of the research, including the goals of the research, risks and benefits. All participants signed up for the focus groups through case workers, program facilitators, and shelter staff at the respective organizations, and no potential participants were deemed to be lacking or at risk for lacking capacity to consent. Though some participants were accessing services for support with mental illness and substance use, it is also important that this research did not inappropriately exclude participants on the basis of additional forms of social marginalization such as health status as long as they were capable to consent.

At the scheduled time, two focus group facilitators met with interested participants. The focus groups were co-facilitated by two women: Jessica Jurgutis, a PhD candidate with extensive experience in qualitative research, and Catherine Hu, an undergraduate student who was coached by Jessica Jurgutis and self-trained in focus group facilitation for the purposes of the project. Neither facilitator had a prior relationship with the study participants. The facilitators did not provide information on their personal goals or reasons for conducting the research, or on their ideas or assumptions regarding the topics discussed. The facilitators completed the informed consent process, obtaining written consent for participation and for audio recording of the focus group. They led a semi-structured discussion based on a guide, which included questions on challenges at the time of release from custody, barriers to addressing health issues on release, barriers to accessing primary care on release, gaps in services in the jail and in the community, and opportunities to support the transition to the community before, during, and after release (S1 File). The focus groups lasted between one and one and a half hours. No one was present for the focus groups besides the participants and researchers. The focus groups were audio recorded and the facilitators also made field notes. Each participant was provided $30 and two bus tickets as compensation for participation.

We transcribed data verbatim from the focus groups. We used NVivo software to conduct an inductive qualitative content analysis [45], meaning that we reviewed data to identify emerging themes rather than using data to test a specific theory. Three researchers (Jessica Jurgutis, Catherine Hu, and Fiona Kouyoumdjian) participated in coding. Two people reviewed each transcript for themes, and we developed and revised the coding framework iteratively as we coded the data. Our coding tree included seven themes: (1) experiences in custody, with subthemes challenging environment in jail, health care in jail, and differences between jail and the community, (2) thoughts and feelings regarding experiences in custody, (3) challenges on release, with subthemes housing, ongoing criminal justice system involvement, employment, broken social bonds, health care needs, cycle of crime, pleas deals and impact, and taking care of basic needs, (4) thoughts and feelings regarding challenges on release, (5) barriers and facilitators of success on release, with subthemes barriers to success, facilitators of success, and opportunities to support success, (6) thoughts and feelings regarding barriers and facilitators of success on release, and (7) value and importance of health, with subthemes in jail and after release. We used the thematic analysis to form a set of conclusions about our research question.

We did not return transcripts to participants for comment or correction, and participants did not provide feedback on the findings.

The study protocol was approved by the Hamilton Integrated Research Ethics Board.

Results

We conducted three focus groups with a total of 18 participants. Participants were adults between the ages of 20 and 69; we did not collect data on race, gender, length of time spent in custody, or whether participants were on probation or parole in the community.

In this report, we focus on focus group content about barriers, facilitators, and opportunities for health. We placed additional emphasis during analysis on the feelings that participants expressed as a means to better understand issues that resonated among participants, and to acknowledge participants’ emotional experiences.

Discussion

In this qualitative study, participants described diverse and complex health needs on release from a provincial correctional facility. They had challenges finding good medical care, housing, and employment, and accessing ongoing treatment. They encountered discrimination related to their criminal record in accessing health care services, housing, and employment. Participants described how incarceration and the post-release period substantially impacted their health, and many felt lost, stigmatized, demoralized, and overwhelmed on release. Access to health care, social services, and social relationships supported participants’ health, and made them feel lucky and cared for. They identified the need for better discharge planning and for information on health issues and community resources while in custody, and access to a clinic at the time of release.

Our finding that mental health, substance use, and pain management were major concerns for people on release from custody is consistent with other research [20,21,25,28,46]. Similarly, other studies have also identified stigma and discrimination [17,19–21,26,28], competing priorities such as housing and employment [17–23], lacking access to health care and other services [17,21,22,25,26], and lack of continuity of care on release [17,21,22,24,25,40,47] as barriers to health on release. Several studies corroborate our findings regarding facilitators of health on release, including support from family and friends, access to social services, convenient and accessible health services including for opioid agonist treatment such as methadone, and service providers [17,19,23,26,40]. Other studies also identified facilitators not discussed in the current study, such as support from parole officers and motivation to care for their children among people who were parents [19,23].

This study has several potential limitations. We did not achieve saturation. We concluded the study after conducting three focus groups, as we had spent the funds that were available for this pilot study, and if we had conducted more groups we would not have been able to compensate additional participants or pay research staff. While our study findings may not be generalizable to all people who experience incarceration in provincial correctional facilities, we expect that the results would be relevant for a large proportion of people who experience incarceration, especially given the high prevalence of mental illness, substance use disorders, and precarious housing and homelessness in this population [1,48,49]. We did not collect data on the length of time people spent in custody or on whether participants were supervised through the correctional system after release, and these factors may be relevant to experiences of health and health care on release. There was limited ability to apply an intersectional lens in our analysis due to the small sample size and lack of formal data collection on race, gender, or other factors of potential interest. Given that women, people who are gender non-conforming, people of colour, and Indigenous persons have unique health experiences shaped by structural determinants of health during and after incarceration and more generally, being able to capture these experiences may be an area of priority in future research on health experiences in the transition between the jail and the community [18,50,51].

Study strengths are that we included people who may be more likely to have health needs after release from custody, namely people with mental illness, people with substance use disorders, and people who were homeless or precariously housed. This study provides contemporary data from the Canadian context, as one of a limited number of qualitative studies conducted in Canada on health needs on release [24,40,41], and one of only two such studies conducted since 2010 [24]. The findings demonstrate that even in the context of universal health insurance, recent primary care reform to enhance access and quality [52], bolstered treatment and harm reduction programs for people who use illicit drugs in the context of the opioid overdose crisis [42], and the implementation of innovative court models such as drug and mental health courts, people who experience imprisonment continue to face major challenges to health and continuity of health care at the time of release.

Dealing with physical and mental impacts of time in custody and urgent needs such as finding housing and employment, people post-release may need to work harder than the average person in the general population to try to meet their health care needs, and given issues of health care access and quality, they may be less likely to be able to meet their needs. Recognizing this unique set of barriers to health at the time of release may lead to reframing how we consider obligations for the State and for health care and social services to attend to the needs of this population at this vulnerable time; a greater focus on health at this transition may redress the harms of incarceration and support people as they work to improve their health, which could improve both health and health equity. Population-level opportunities include enhancing integration of prison and community health care services, consistent with the principles articulated in the World Health Organization’s Moscow Declaration [53], and explicitly including a focus on people who experience imprisonment in the development of social and health services [54].

In addition, we suggest a focus on individual-level strategies to improve health on release, which should be developed in collaboration with people with lived experience and with evaluation of acceptability, accessibility, and effectiveness. Building on evidence from transitional programs [30–36], concrete solutions may include comprehensive and patient-focused discharge planning before release from jail, the provision of information in jail and in the community on health issues and community-based services, and enhancement of programs to link people in custody with services in the community, including primary care. After release, emphasis should be placed on supports that have the capacity to adapt and respond to people’s changing circumstances and needs, including harm reduction and substance use disorder treatment programs such as opioid agonist treatment programs. Other broader strategies to support health after release may include initiatives to protect people from discrimination in health care, housing, and employment due to criminal record, linking people with peer support networks and other sources of social support after release, and continuing efforts to improve access to and quality of health care within the jail. Supporting people building networks of health care, services, and supports may be key to assisting people’s health, continuity of care, and reintegration into the community.

Supporting information