Getting started in jail, prison, and legal system research.

Extensive health inequities exist for persons with criminal-legal involvement in the USA. Researchers, both novice and experienced, are critical in documenting these inequities and implementing programs that address the many health and social problems of this population. However, working with currently or formerly incarcerated persons brings new challenges to researchers that may have not been previously considered as necessary. Because incarcerated persons were systemically exploited by biomedical researchers until reform following the Civil Rights Movement, resulting in their designation as a vulnerable population in the Code of Federal Regulations, enhanced protections are necessary in implementing contemporary research involving incarcerated persons. These enhanced protections can delay or prolong the regulatory approval process, particularly to the novice carceral system researcher, which may discourage some from engaging with this important population. Drawing on the many years of experience working with incarcerated persons accumulated by the Sexual Health Empowerment (S)HE Team at the University of Kansas Medical Center (KUMC), this article offers some concrete steps toward getting started in this work.

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

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

A Systematic Evaluation of Barriers and Facilitators to the Provision of Services for Justice-Involved Women.

The community health delivery system (CHDS) are vital agencies to the success of integration and the provision of services to improve the health and well-being of justice-involved women. Many agencies face barriers and challenges in providing services to vulnerable populations, such as justice-involved women, and, as a result, often offer individual rather than coordinator care. Thus, it is necessary to explore CHDS systemic barriers and challenges to identify opportunities for coordinated care. We conducted semi-structured interviews with 26 CHDS directors or designees to identify systemic barriers and challenges, organizational processes, experiences with vulnerable populations, services and programs, and care coordination and perceived women's barriers and challenges to the provision of services including decision-making processes and access. Qualitative analyses were used to construct thematic descriptions in five areas: (1) mental health as an unmet need, (2) financial constraints, (3) limited organizational capacity, (4) implicit bias, and (5) minimal cultural support of vulnerable populations.

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

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

Validating self-reported cervical cancer screening among women leaving jails.

BACKGROUND: Despite women with criminal justice involvement reporting routine Papanicolaou (Pap) testing, significant disparities in cervical cancer outcomes exist when compared to women without criminal justice involvement. A possible reason for the discrepancy is that this group of women may be misreporting Pap testing. The objective of this study was to validate self-reported cervical cancer screening among women leaving jails. METHODS: We used three methods to validate self-reported cervical cancer screening for women recently released from jail: 1) Medical record review; 2) Semi-structured interview; 3) Pap test knowledge survey. After validating women's self-reported Pap tests with a review of their medical records, we scored interviews for Pap test recall, and used Pap test knowledge survey scores to compare scores between women who accurately reported Pap tests vs. those who did not. RESULTS: Sixty-one percent (N = 14/23) self-reported cervical cancer screenings were accurate per medical record review. Comparing participants who did and did not accurately self-report a Pap test, we found a significant difference in Pap test recall scores (1.90 vs. 0.00, t = 3.87, p < .01) and Pap test knowledge scores (13.50 vs. 12.13, t = 2.42, p < .05). CONCLUSION: Self-report of cervical cancer screening was more likely to be accurate if a woman's Pap test knowledge was high. Clinicians might take extra care in describing screening and distinguishing between Pap tests and pelvic exams to support the cervical health of women with lower knowledge.

Retention Strategies in Working With Justice-Involved Women.

Research-based findings with vulnerable populations are strengthened by strong retention rates at the time of postintervention data collection. Women in the criminal justice system face a variety of gender-specific challenges including histories of childhood and adult sexual and physical abuse, substance abuse, untreated mental health problems, and chronic housing insecurity that can hinder follow-up of a research sample. The authors highlight a variety of retention strategies that they successfully used in their work with women following incarceration in local county jails.

Feminism and Bourdieusian Social Theory in a Sexual Health Empowerment Project with Incarcerated and Recently Released Women.

Theory is often downplayed or omitted in the research and scholarly literature around public health interventions in carceral settings. Our Sexual Health Empowerment (SHE) project was an education intervention and ethnographic study that aimed to reduce cervical cancer risk among women with histories of incarceration. In this article, we describe our application of concepts from feminist theory and bourdieusian social theory to the design, planning, and delivery of SHE. We outline how theory-driven practice both underscored and helped us meet challenges in implementation in three urban jails over a two-year period, 2014-2016. Our approach provides a model for others who wish to bring critical theory and research practice together in health interventions with populations that are marginalized in multiple ways.

Justice-involved women's preferences for an internet-based Sexual Health Empowerment curriculum.

PURPOSE: The purpose of this paper is to gain insight into justice-involved women's preferences for an internet-based Sexual Health Empowerment (SHE) curriculum. DESIGN/METHODOLOGY/APPROACH: The authors analyzed data from four focus groups conducted with 52 women in a minimum-security county jail in a Midwestern US city. FINDINGS: Women reported daily access to the internet while in the community and use of the internet for searching about health concerns. Four themes emerged in the discussion about preferences for an internet-based SHE curriculum, that it cover healthy sexual expression, how to access resources, video as an educational modality and a non-judgmental approach. PRACTICAL IMPLICATIONS: Justice-involved women are potentially reachable through internet-based health education. Their preferences for content and modality can be used to inform internet-based sexual health programming designed specifically for this population. Using this modality could offer easily disseminated, low-cost and consistent messaging about sexual health for a vulnerable group of women. ORIGINALITY/VALUE: Though internet-based health education programming has been widely utilized in the general population, less attention has been paid to if and how these programs could be utilized with a vulnerable group of women who move between the justice system and communities. This exploratory study begins to fill that gap.

Impact of a brief intervention on cervical health literacy: A waitlist control study with jailed women.

Jailed women are four-five times more likely to have had cervical cancer compared to women without criminal justice histories. Previous research has shown that an important contributor to cervical cancer risk, and perhaps lack of follow-up, is incarcerated women's low health literacy about broader reproductive health issues. Little work has been done to address this disparity. Thus, the objective of this study was to test the effectiveness of an intervention to improve incarcerated women's cervical health literacy and ultimately address cervical cancer disparities. Using a waitlist control design, we compared changes in cervical health literacy (knowledge, beliefs, self-efficacy, and confidence for screening and follow-up) among 188 incarcerated women who completed a 10-hour intervention between 2014 and 2016 in three Kansas City jails. We used bivariate tests and multivariate analyses that controlled for baseline cervical health literacy level and key covariates. Women in the intervention group showed significant gains in seven out of eight cervical health literacy domains (all p < 0.01), whereas the control group only improved in one domain (p < 0.01). When controlling for covariates, the intervention group had less barriers, perceptions of seriousness, susceptibility to disease, and increased self-efficacy for cervical health screening and follow-up, compared to the control group (all p < 0.05). A brief intervention is an effective way to improve jailed women's cervical health literacy, but should be provided alongside systemic efforts that expand access to correctional preventive health services, including the human papillomavirus vaccine, community-based cancer screenings, and health insurance after women leave jails and transition back to communities.

Corrigendum to "Impact of a brief intervention on cervical health literacy: A waitlist control study with jailed women" [Prev. Med. Rep. 6 (2017) 314-321].

[This corrects the article DOI: 10.1016/j.pmedr.2017.04.003.].

Adapting an HIV Risk Reduction Curriculum: Processes and Outcomes.

Becoming a Responsible Teen (BART) is a community-based, HIV risk reduction curriculum shown to increase safer sex behaviors among African American adolescents. However, BART does not address common barriers to sexual health care access, which may limit program efficacy. We used a community-engaged adaptation process to maximize program relevance and health outcomes by incorporating a broad ecological perspective. Adolescent and staff advisory boards at a community-based organization recommended modifications (e.g., delete references to Kwanzaa, update language, localize incentives) and supported inclusion of critical on-site health services, such as sexually transmitted infection testing and condom provision. We conducted a trial of adapted BART (one session/week for 8 weeks) with 36 adolescents at two community organizations (mean age = 15.5 years, 52% female; 61% reported previous sexual intercourse). Most received on-site sexually transmitted infection testing (61%) and condoms (70%). Adolescents demonstrated significant improvements in self-efficacy for safer sexual practices (p < .02), AIDS risk knowledge (p < .001), condom knowledge (p < .001), and condom attitudes (p < .04). Adolescents and staff were satisfied with the revised curriculum and found on-site services acceptable. Based on improvements in constructs influencing behavior and the successful delivery of services essential for optimal health, future studies to assess efficacy and sustainability of the adapted curriculum appear warranted.

Accessing General and Sexual Healthcare: Experiences of Urban Youth.

Urban adolescents face many barriers to health care that contribute to health disparities in rates of sexually transmitted infections (STIs) and unintended pregnancy. Designing interventions to increase access to health care is a complex process that requires understanding the perspectives of adolescents. We conducted six focus groups to explore the attitudes and beliefs about general and sexual health care access as well as barriers to care among urban, economically disadvantaged adolescents. Participants first completed a written survey assessing health behaviors, health care utilization, and demographics. The discussion guide was based on the Theory of Planned Behavior and its constructs: attitudes, subjective norms, and perceived behavioral control. Transcripts of group discussions were analyzed using directed content analysis with triangulation and consensus to resolve differences. Fifty youth participated (mean age 15.5 years; 64% female; 90% African American). Many (23%) reported missed health care in the previous year. About half (53%) reported previous sexual intercourse; of these, 35% reported no previous sexual health care. Youth valued adults as important referents for accessing care as well as multiple factors that increased comfort such as good communication skills, and an established relationship. However, many reported mistrust of physicians and identified barriers to accessing care including fear and lack of time. Most felt that accessing sexual health care was more difficult than general care. These findings could inform future interventions to improve access to care and care-seeking behaviors among disadvantaged youth.

Views on human papillomavirus vaccination: a mixed-methods study of urban youth.

While the human papillomavirus (HPV) vaccine has potential to protect against the majority of HPV-associated cancers, vaccination rates in the United States remain low. Racial/ethnic and economic disparities exist for HPV vaccination completion rates. We conducted a mixed-methods study using the theory of planned behavior framework to explore attitudes and beliefs about HPV vaccination among urban, economically disadvantaged adolescents. Fifty adolescents aged 14-18 years were recruited from community-based organizations to complete a written survey and participate in a focus group. The mean age was 15.5 ± 1.3 years; 98 % were African American or mixed race; 64 % were female; 52 % reported previous sexual intercourse; 40 % reported receipt of ≥1 HPV vaccine dose. The knowledge deficit about the HPV vaccine was profound and seemed slightly greater among males. Mothers, fathers and grandmothers were mentioned as important referents for HPV vaccination, but peers and romantic partners were not. Common barriers to vaccination were lack of awareness, anticipated side effects (i.e., pain), and concerns about vaccine safety. Characteristics associated with ≥1 vaccine dose were: having heard of the HPV vaccine versus not (65 vs. 20 %, p = 0.002) and agreeing with the statement "Most people I know would think HPV vaccine is good for your health" versus not (67 vs. 27 %, p = 0.007). Our work indicates a profound lack of awareness about HPV vaccination as well as the important influence of parents among urban, economically-disadvantaged youth. Awareness of these attitudes and beliefs can assist providers and health officials by informing specific interventions to increase vaccine uptake.