- Research Article
- Open Access
The role of the community health delivery system in the health and well-being of justice-involved women: a narrative review
Health & Justice volume 7, Article number: 12 (2019)
Over seven million imprisoned and jailed women are released into the community each year and many are ill-equipped to meet the challenges of re-integration. Upon release into their community, women are faced with uncertain barriers and challenges using community services to improve their health and well-being and reuniting with families. Few studies have identified and described the barriers of the community health delivery system (CHDS)- a complex set of social, justice, and healthcare organizations that provide community services aimed to improve the health and well-being (i.e. safety, health, the success of integration, and life satisfaction) of justice-involved women. We conducted a narrative review of peer-reviewed and gray literature to identify and describe the CHDS and the CHDS service delivery.
Peer-reviewed and gray literature (n = 82) describing the CHDS organizations’ missions, incentives, goals, and services were coded in three domains, justice, social, and healthcare, to examine their service delivery to justice-involved women and their efforts to improve the health and well-being of justice-involved women.
We found that the CHDS is fragmented, identified gaps in knowledge about the CHDS that serves justice-involved women, and offer recommendations to reduce fragmentation and integrate service delivery aimed to improve the health and well-being of justice-involved women.
Women made up 7% of the total prison population at year-end 2017 (Bronson & Carson, 2017). The number of women incarcerated for more than 1 year increased by more than 700 prisoners in 2016 (Shinkfield & Graffam, 2009; Springer, 2010). In the United States, more than 11 million people are released from jails and prisons each year (Shinkfield & Graffam, 2009; Wolff, 2005). Women constitute nearly 16% of the correctional facilities population, with more than 75,000 in state prisons, close to 10,000 are in federal facilities, and 64,000 are in U.S. jails (Freudenberg, Daniels, Crum, Perkins, & Richie, 2008; Shinkfield & Graffam, 2009). Additionally, over one million women are under care custody and control (i.e. parole and probation) of correctional agencies (Freudenberg et al., 2008; Kajstura, 2019; Shinkfield & Graffam, 2009). About two-thirds of the incarcerated women will be under care custody and released into their communities, thus over 2 million women will reintegrate into their communities to continue to care for themselves and their families (Freudenberg et al., 2008; Shinkfield & Graffam, 2009).
Recent research has called for a special focus on how best to serve justice-involved women upon returning to their communities, the majority of whom will do so within days, weeks, or months of incarceration (La Vigne, Davies, Palmer, & Halberstadt, 2008). Upon returning to the community, justice-involved women will face significant barriers in obtaining housing, greater difficulty in obtaining and sustaining employment, less family support, and more substance abuse than men (La Vigne et al., 2008). They suffer from sexual abuse and mental illness and their experiences in the justice system may have led to re-traumatization (La Vigne et al., 2008). Additionally, many jails and prisons fail to provide women with basic hygiene and reproductive health needs adding additional burden on women during reintegration. (Visher, La Vigne, & Castro, 2003). Many justice-involved women return to low-income communities, where there are limited services and resources available to assist women in the re-integration process while meeting the requirements of probation and parole (Sprague, Scanlon, & Pantalone, 2017). Community re-integration is complex, as the women require a substantial number of social, justice, and healthcare services. In the first year after release, 35% of female prisoners were re-arrested and 14 per 100 women paroled return to jail because they fail to meet parole requirements (Alper, Durose, & Markman, 2018; Kaeble, 2018). Thus, justice-involved women must meet requirements which include regular meetings with their parole officer, stable housing, employment, and avoiding drugs and alcohol (Freudenberg et al., 2008; La Vigne et al., 2008; Richie, 2007; Visher et al., 2003) leaving them heavily dependent upon the community health delivery system (CHDS), which we define as a complex set of social, justice, and healthcare organizations that provide community services aimed to improve the health and well-being (i.e. safety, health, success of integration, and life satisfaction) of justice-involved women of justice-involved women. The CHDS is a complex system that lack of coordination to improve the health and well-being of justice-involved women.
Women face many barriers utilizing the CHDS due to a limited understanding of the provision of services, fragmented services, and accessibility (Freudenberg et al., 2008; La Vigne et al., 2008; Visher et al., 2003). The barriers faced by justice-involved women are compounded with the social stigma of having a criminal record, sexual abuse, higher rates of sexually transmitted diseases, and often minority status; therefore, women’s needs are often unmet and unknown by the CHDS (Glaze, 2009; Richie, 2007; Visher et al., 2003). The CHDS agencies vary widely in their missions, goals, and operations to improve the health and well-being of justice-involved women (Glaze, 2009; Richie, 2007; Visher et al., 2003). Identifying and defining the CHDS and understanding the role it plays in improving the health and well-being of justice-involved women is a vital step in improving CHDS services and programs delivery and population health.
The purpose of this narrative review is (1) identify the CHDS organizations, (2) summarize what is known about the CHDS, (3) understand the CHDS services that influence the health and well-being of justice-involved women, and (4) identify unanswered questions and the need for additional research. The system is referred to as the CHDS because they provide a complex set of social, justice, and health care services and activities that collectively increase the chances of successful integration in the community, reduce recidivism, and improve health and well-being. The CHDS organizations are not interdependent of each other. For this reason, the review reflects the systems-thinking lens that captures the ability to understand individual organizations and interconnections that influence the health and well-being of justice-involved women (Rosenblatt, 1993). The systems-thinking lens focuses on the interconnected set of elements and interconnections that are organized to achieve a function or purpose (Rosenblatt, 1993). While most re-entry research has solely focused on linkage to mental health and substance abuse treatment, housing, education, and employment, limited attention has been focused on the comprehensive system to address the cyclical problem (i.e. women cycle in and out of jail due to poverty and the inability to meet the obligations of their parole and probation) that women struggle to deal with due to justice-involvement (Freudenberg et al., 2008; Glaze, 2009; La Vigne et al., 2008; Richie, 2007; Rosenblatt, 1993; Shinkfield & Graffam, 2009; Visher et al., 2003; Wolff, 2005). Therefore, this article presents findings from a narrative literature review focused on the diverse CHDS agencies and services recognizing that most research focuses on individual health care linkages and there is limited knowledge of the CHDS as a whole.
Due to the paucity of information on the CHDS to answer the research question, we conducted a narrative review of peer-reviewed and gray literature that discusses and describes the science and knowledge of community resources using the systems- thinking lens to identify and summarize what is known about the CHDS and enhance the understanding of the CHDS on the health and well-being of justice-involved women. The research questions used to identify the literature was “What are the community resources aimed to promote the health and well-being of justice-involved women?”. Which organizations provide the identified community resources? A number of PubMed, PsycINFO, and web of sci searches were performed, and additional websites were reviewed. To be confident the new evidence was not missed, two websites, OATD and ProQuest of dissertations, and current website review were conducted to review conference abstracts. To ensure that we identified relevant evidence from a variety of disciplines (e.g., criminal justice, public health, health care, social services, social work, and law and policy), we searched using mesh terms and databases described in Appendix 2. We identified 139 peer-reviewed and gray literature (i.e. unpublished research such as websites, conference abstracts, dissertations, and reports) published and updated between 1980 and 2017. We focused on literature between 1980 and 2017 because the number of women in United States prisons increased by 700% since 1980 and approximately 9 million women are released into the community each year, leading researchers to focus on the CHDS aimed to improve the health and well-being of justice-involved women (Morash, Kashy, Smith, & Cobbina, 2014; The Sentencing Project, 2017;). The primary focus of this review is to identify and understand the CHDS for justice-involved women (i.e. post-incarcerated, paroled, and probation), excluding other studies (i.e. qualitative and quantitative studies on incarcerated women) limited on post-release information. The review was restricted to studies related to community re-entry and community resources.
All peer-reviewed and gray literature (n = 82) were considered if they met the following criteria: (1) community reintegration for post-incarcerated women, (2) post-release interventions for incarcerated women, (3) parole and probation for women, (4) community services for post-incarcerated women, and (5) healthcare for post-incarcerated women. Gray literature such as websites, conference abstracts, dissertations, and reports was included. Peer-reviewed and gray literature that did not meet these criteria were excluded.
The 82 peer-reviewed and gray literature were reviewed and coded using the three domains and subdomains. Domains were defined based on the literature’s objectives, keywords, and results. Literature was grouped into domains and counted.
Tables 2, 3 and 4 summarizes the literature included in the review and described in Appendix 3. The overarching conclusion from all the literature reviewed was that justice-involved women utilized several CHDS organizations in the following domains: 1) justice, 2) social, and 3) healthcare Appendix 1. The justice organizations are agencies that institute practices to uphold social control, deter and mitigate crime, and sanction those who violate the law while providing or referring women to health and social services to improve their health and well-being (Dias & da Silva Junior, 2016; State, County, Municipal Courts, 2017; Swavola, Riley, & Subramanian, 2016). The justice agencies included are parole and probation departments, police departments, and courts including court officials-judges, administrators, prosecutors, deputies, and public and private defenders, prison and jails. Social organizations are agencies that provide a range of public services to improve the health and well-being of justice-involved women, their families, and their communities (Colbert & Durand, 2016; Huebner, DeJong, & Cobbina, 2010; Parsons & Warner-Robbins, 2002; Swavola et al., 2016; Yamatani & Spjeldnes, 2011). The social service agencies included are housing and urban development, department of children and families, welfare, workforce, substance abuse treatment centers, mental health, food pantries, local health departments, Medicaid, and faith-based organizations. Healthcare organizations are public and private agencies that provide healthcare services to justice-involved women to prevent, alleviate, and cure illness and injuries (Colbert & Durand, 2016; Huebner et al., 2010; Parsons & Warner-Robbins, 2002; Swavola et al., 2016; Yamatani & Spjeldnes, 2011). Healthcare agencies included are substance use and mental health treatment, community health centers, and hospitals. The purpose of this narrative review is (1) identify these CHDS organizations, (2) summarize what is known about these CHDS, (3) understand the CHDS services that influence the health and well-being of justice-involved women, and (4) identify unanswered questions and the need for additional research.
Domain one: justice organizations
The community health delivery system should be established to encompass the agencies justice-involved women have initial and continuous contact with and to set conditions in which they must comply in order to gain successful re-entry into their communities. The justice organizations encompass a complex number of organizations and vary widely in service delivery, resources, missions, goals, and incentives. The four main components of the justice system that respond to crime and victimization in communities are (1) law enforcement, (2) the courts, (3) institutional corrections facilities (e.g., jails, prisons), and (4) community corrections programs (probation, parole). Although the organizations within this system are well known by name and the processes but the resources, missions, goals, and incentives geared to meet the unmet needs and expectations of justice-involved women are unknown (Bell, Perez, Goodman, & Dutton, 2011; Clear, 2007; Cobbina, Morash, Kashy, & Smith, 2014; Covington, 2001; Covington, 2007; Daly, 1987; Golder, Hall, & Logan, 2014; Judging Science, 1999; Lam & Harcourt, 2003; Morash et al., 2014; Opsal, 2009; Petersilia, 2001; Schram, Koons-Witt, Williams, & McShane, 2006; Smith & Visher, 1981; The Sentencing Project, 2007; Women in the Criminal Justice System: Briefing Sheets, 2007; Zeoli, Rivera, Sullivan, & Kubiak, 2013). The unknown relationships, services, and programs highlight the needs to identify justice system organizations and understand their service delivery, resources, missions, goals, and incentives.
The literature revealed that the initial point of contact in determining the future health and well-being of justice-involved women are courts (Bell et al., 2011; Clear, 2007; Covington, 2001; Covington, 2007; Daly, 1987; Judging Science, 1999; Lam & Harcourt, 2003; Morash et al., 2014; Opsal, 2009; Schram et al., 2006; The Sentencing Project, 2007; Women in the Criminal Justice System: Briefing Sheets, 2007; Zeoli et al., 2013). There are many different types of courts at the federal, state, county, and municipal levels. Our review revealed the vital courts for justice-involved women are the municipal and county courts that determine the terms and conditions of both parole and probation since almost 60% of women are convicted of non-violent crimes (i.e. drug and property) and re-enter their communities within days or months after their conviction (Bell et al., 2011; Judging Science, 1999; The Sentencing Project, 2007; Women in the Criminal Justice System: Briefing Sheets, 2007). The municipal court hears most justice-involved women cases because the majority of women are convicted of non-violent crimes (Bell et al., 2011; Women in the Criminal Justice System: Briefing Sheets, 2007). In 2014, the rate of women convicted of non-violent drug crimes were 210.7 and 364.7 for property crimes (Carson, 2018). Women convicted of assault crimes encounter the county court, which hears two different types of cases, civil and criminal. In 2014, the rate of women convicted of assault crimes were 188.5 (Carson, 2018). The goal of the municipal and county courts are to determine whether the women accused of the crime are guilty and determine the punishment for the crime which also includes substance and drug abuse treatment (Bell et al., 2011; Daly, 1987; Judging Science, 1999; The Sentencing Project, 2007; Women in the Criminal Justice System: Briefing Sheets, 2007). Additionally, approximately 60% of justice-involved women are mothers and therefore, encounter family court at the same time they encounter municipal or county court (Bell et al., 2011; National Resource Center on Justice Involved Women, 2016; Women in the Criminal Justice System: Briefing Sheets, 2007). The family court decides the degree to which parents will have physical and legal custody of, or parenting time (also termed visitation) with, the child and whether they regain custody after criminal justice involvement (Salem, Nyamathi, Idemundia, Slaughter, & Ames, 2013). Although justice-involved women encounter at least two of the justice organizations at the same time, the limited knowledge of the organizations’ missions, incentives, and goals may become interwoven with the direct and collateral consequences-homelessness, drug and sexual abuse, mental health, inability to seek health care, lack of health insurance, and unemployment, of justice-involvement directly linked to their criminal activity (Smith & Visher, 1981).
Community corrections programs
Most justice-involved women are released “conditionally” or sentenced based on conditional provisions of parole or probation (Covington, 2007; Kruttschnitt, 2010; Petersilia, 2001). The parole population continues to grow, increasing by 0.5%, from 870,500 persons at year-end 2015 to 874,800 at year-end 2016 (Kaeble, 2018). In 2016, over 1.1 million women were supervised in the community under care custody- (probation or parole)- (Shinkfield & Graffam, 2009; Wolff, 2005). In 2016, 25% of justice-involved women were on parole and assigned a parole officer that supervises their ability to adhere to the terms and conditions of their conditional parole or probation (Cobbina et al., 2014; Golder et al., 2014; Kaeble, 2018; Kruttschnitt, 2010). Parole is a period of conditional supervised release in the community followed by state or federal prison (Kaeble, 2018). The mission of the parole office is to promote public safety and strive for justice and fairness while assuring the terms and conditions ordered by the court are followed to prevent recidivism (Kruttschnitt, 2010; The United States Department of Justice, 2018). These terms include but are not limited to living within state and county lines, meeting regularly with a parole officer, submitting to random drug and alcohol testing, and providing proof of residence and employment (Cobbina et al., 2014; Kruttschnitt, 2010). Unlike parole that is granted after an offender serves a portion of their prison sentence, probation may be granted as an alternative to a jail sentence or a combined sentence involving incarceration followed by a period of community supervision (Cobbina et al., 2014; Golder et al., 2014; Kaeble, 2018; Kruttschnitt, 2010). The justice-involved women on probation may live freely in the community but must abide by certain conditions of probation for a period of time and regularly report to a probation officer (Cobbina et al., 2014). The general conditions of probation are similar to those of parole living where directed, participating in court required services and programs including mental and substance abuse treatment, submitting to random drug or alcohol test, housing, and maintaining employment (Cobbina et al., 2014; Kruttschnitt, 2010).
Law enforcement and community policing
The increase in justice-involved women can be linked to changes in law enforcement practices targeting minority neighborhoods (National Resource Center on Justice Involved Women, 2016). The criminal justice process starts at the point of contact with a law enforcement officer and once released on parole or on community supervision, women have daily contact with law enforcement. However, limited research has focused on the larger population of women who have not been incarcerated and are not on probation or parole but had previous justice-involvement (Cobbina et al., 2014; Covington, 2007). These justice-involved women have daily contact with law enforcement officers because these individuals patrol the communities in which they work, live, and play (Covington, 2007). Law enforcement has a mission to protect and safeguard the lives and property of the people they serve (Covington, 2007; Morash et al., 2014). Some law enforcement departments have set up diversion programs, designed to refer justice-involved women whose behavior may indicate trauma, substance abuse, or mental health to treatment (Worden & McLean, 2018). Law Enforcement Assisted Diversion is an approach used by law enforcement to redirect low-level offenders engaged in drug or prostitution activity to community-based services, instead of jail and prosecution (Worden & McLean, 2018). In 2013, over 2700 communities had implemented crisis and non-crisis intervention teams, which involve specially trained officers and mental health professional responding to crises together or law enforcement assessments and direct referrals to community treatment and services. These approaches often help make treatment more accessible and avert the short and long-term disruption to women’s lives from short stays in jail and the collateral consequences of a conviction. However, the approach lacks the ability to connect women to other vital services that improve their health and well-being, such as housing, health care, and employment.
Jails are confinement facilities operated under the authority of a sheriff, police chief, city or county administrator that primarily hold incarcerated person including women who are charged with committing a criminal offense or awaiting the resolution of their cases for short-term periods (Covington, 2001; Petersilia, 2001; Smith & Visher, 1981). In 2016, jails housed over 113,000 women awaiting trial, sentencing, or transfer to prison; parole or probation violators, and those sentenced to less than one year (Kajstura & Marigeon, 2015; Zeng, 2019). Due to the short-term stays of women in jails, limited research has focused on the post-release and the impact on the health and well-being (Covington, 2001; Petersilia, 2001; Smith & Visher, 1981). As a result, jails experience a high turnover and affect a far greater swath of the population (Kajstura, 2019). About one-fifth of justice-involved women often cycle in and out of jails, not because they commit a new crime, but rather they break rules of their parole and probation such as failing a drug test or missing a scheduled appointment (Kajstura, 2019). The high turnover and shorter stays make screening and health care challenging for the unique needs (i.e. reproductive care, sexually transmitted diseases, family planning, and sexual and drug abuse) of this population (Kajstura, 2019). Reversing the cycling in and out of jails can be difficult addressing the unmet unique needs of this population (Kajstura & Marigeon, 2015).
Prisons are facilities in which women are confined and denied the authority of the state for many years (Petersilia, 2001). In 2016, women made up 7% of the total national prison population. From 2015 to 2016, the number of women sentenced to more than 1 year in state or federal prison increased by 700; the rise in the number of women in prison can be traced to changes in the state and national drug policies (Carson, 2018). Changes in law enforcement practices and post-conviction barriers to reentry uniquely affect women (Lam & Harcourt, 2003; Petersilia, 2001; Smith & Visher, 1981). Women prisoners are vulnerable and it is, therefore, necessary to pay particular attention to preventing, monitoring, and treating women-specific health problems, while in prison and upon release (Ramirez, 2016; Willging, Nicdao, Trott, & Kellett, 2015) of the one-quarter of women released from prison fail within 6 months (i.e., have an arrest for a new crime), one-third fail within a year and two-thirds fail five years after release (Willging et al., 2015). Not all prison provide eligible women with trauma treatment, pregnancy programs, and other needed health care services. Prisons often fail to meet the basic and complex needs of women by limiting and charging women for basic needs such as menstrual and feminine products, soap, toothpaste, toothbrushes, and shampoo (Huebner et al., 2010; Smith & Visher, 1981). The inability of the prison to meet the women’s basic and health care needs has negative implications on the health and well-being of the 21% of women released from prison in 2016 (Alper et al., 2018). Prisons lack coordination with community health providers needed to continue care for women upon their release. Recent literature on the impact of imprisonment has attempted to estimate the impact of imprisonment on post-release experiences and circumstances (Bell et al., 2011; Clark, Dolan, & Farabee, 2017; Dias & da Silva Junior, 2016; Glaze, 2009; Morash et al., 2014; O’Brien, 2007; Shinkfield & Graffam, 2009) but is limited in the prison’s role to coordinate with community organizations to ensure smooth transitions and successful reintegration for women.
Domain two: social service organizations
The complexities of re-establishing life after criminal involvement include securing housing, formal identification, finding a job, and re-applying for other social services (Department of Children and Family, 2009; Kruttschnitt, 2010). Additionally, the majority of justice-involved women have children and because the children have needs of their own, women must have contact with social service agencies that have conflicting or otherwise incompatible goals and values than some social services (McCarty, Falk, Aussenberg, & Carpenter, 2012; Smith & Visher, 1981).
Several social service agencies also have stake and interest in the preventive recidivism and can be valuable in efforts to provide vital service and program to a vulnerable population (Jason, Salina, & Ram, 2016; Salem et al., 2013). These agencies are housing and urban development, department of children and families, welfare, workforce, substance abuse treatment centers, mental health, food pantries, health departments, Medicaid, and faith-based organizations. The Department of Housing and Urban Development (HUD), children and family services, welfare, and workforce operate under multiple authorities and missions to provide a variety of resources, while their missions and incentives are very different these agencies aim to provide safe and affordable services and are often considered second chance services for vulnerable populations (Braithwaite, Treadwell, & Arriola, 2008; Jason et al., 2016).
Decent and affordable housing is critical to the well-being of women released from jail or prison. Without safe and stable housing, justice-involved women are directly in the path of violence, sex work, drugs, and other high-risk life choices (Department of Children and Family, 2009; Jason et al., 2016). Research suggests housing is the most important social service for these populations as housing determines whether justice-involved women have access to other social services (Dekeseredy, Alvi, & Tomaszewski, 2003). While some justice-involved women live with family upon release or while on probation, some may not have a family willing to house them (Jason et al., 2016). As a result, justice-involved women are almost 10 times more likely to be homeless than the general public (Jason et al., 2016.; Dekeseredy et al., 2003; Department of Children and Family, 2009). The Department of Housing and Urban Development (HUD) is working to strengthen the housing market for all persons and provides justice-involved women hope for safe and affordable housing (Jason et al., 2016). Despite HUD’s mission to increase the availability of affordable, decent, and accessible housing for all residents, justice-involved women are three times more likely to spend years on the housing authority waiting list than the general public and often rejected by a string of property owners based on a prior conviction and are ineligible based on U.S. housing policies (Jason et al., 2016).
Department of Children and Family Services
The Department of Children and Family (DCF) is vital to justice-involved women regaining custody of their children. The goal of the DCF is creating a safe and stable environment for children and reunite children with their parents (Clark et al., 2017; Warners-Robbins & Parsons, 2010). In 2016, 1 in 8 incarcerated parents lost their parental rights regardless of the seriousness of their offenses (Hager & Flagg, 2018). Women prisoners’ children are five times more likely than male prisoners children to be placed in foster care (Hager & Flagg, 2018). It is difficult for justice-involved women to advocate for their children during this time and even harder reuniting with them upon release or after probation (Warners-Robbins & Parsons, 2010). Most women who give birth while incarcerated have to hand over their baby to a family member or friends (Warners-Robbins & Parsons, 2010). However, if no one can help, the baby goes to DCF. Reuniting with your children often requires working closely with a DCF casework and adhering to supervised visitation with children (Warners-Robbins & Parsons, 2010). Although women complete the requirements within a few months, they may wait for years to be reunited with their children (Warners-Robbins & Parsons, 2010). It has been acknowledged that women who do not have a good rapport with DCF or additional help from other local organizations are less likely to be reunited with their children (O’Brien, 2007; Warners-Robbins & Parsons, 2010). Yet, little is known about relations between DCF and justice-involved women’s health and well-being due to the lack of matched child protective services and incarceration and post-incarceration data (Berger et al., 2016). A better understanding of this relationship can improve services directed to families interacting with DCF and the criminal justice systems.
Temporary assistance for needy families
Justice-involved women, like other women and parents in the community, need money and employment to support their families and be a part of mainstream society (Holtfreter & Morash, 2003; Sprague et al., 2017). Unlike many social services organizations, Temporary Assistance for Needy Families (TANF) and workforce have coordinated efforts wherein TANF is a substitutional income program that assists women in their transition to the workforce and workforce identifies employment opportunities (Holtfreter & Morash, 2003; Sprague et al., 2017). TANF and Food Stamps assist justice-involved women with cash assistance and food during their transition into the workforce (Holtfreter & Morash, 2003; Sprague et al., 2017). However, TANF is the most difficult program to access—it entails lengthy application processes and upfront work activities that create barriers for justice-involved women (Berger, Cancian, Cuesta, & Noyes, 2016; Holtfreter & Morash, 2003; Huebner et al., 2010). Numerous federal laws have imposed a lifetime ban on welfare services such as TANF and food stamps regardless of efforts of rehabilitation efforts (Holtfreter & Morash, 2003). Although some states have opted out of the ban, many states require drug tests thus justice-involved women have difficulties complying with the work requirements of these programs, which often leads them to discontinue court-ordered programs and other social service requirements (Holtfreter & Morash, 2003). As a result, women may be required to choose between meeting the requirements of their parole and probation or doing what is required to receive these services. These barriers serve as deterrents for accessing TANF and limit women’s ability to use other social services, meet the obligations of their parole and probation, live stable lives, and improve their health and well-being.
Medicaid is the largest single payer of direct medical services for vulnerable populations (DiPietro & Klingenmaier, 2013; Enard & Ganelin, 2013; Hirsch, 1994; Richie, 2007). Medicaid agencies aim to provide health and long-term care insurance to vulnerable populations (DiPietro & Klingenmaier, 2013). Despite this intention, many states have failed to expand Medicaid to ensure this vulnerable population receives Medicaid upon their release (DiPietro & Klingenmaier, 2013; Enard & Ganelin, 2013; Hirsch, 1994). Although research shows that providing individuals with access to the needed health care services upon release reduces the likelihood of recidivism, 19 states terminate rather than suspend or reclassify Medicaid for women entering the justice system (DiPietro & Klingenmaier, 2013; Enard & Ganelin, 2013; Hirsch, 1994). Suspending and prescreening justice-involved women who are eligible to receive Medicaid services will allow women to gain quicker access to mental health treatment, prescribed medicines, and other needed care upon release as well as reduce paperwork for the state (Richie, 2007). The termination of Medicaid benefits creates barriers to the receipt of health care upon release (DiPietro & Klingenmaier, 2013; Enard & Ganelin, 2013; Hirsch, 1994). Upon release, many women lack the needed documentation (i.e. identification and physical address) to obtain Medicaid and have limited transportation to make required Medicaid and doctor appointments and therefore forego their healthcare needs (Richie, 2007). Although Medicaid offers transportation services and mileage reimbursement, justice-involved women may have limited knowledge of services that could reduce the barriers to seeking healthcare (DiPietro & Klingenmaier, 2013).
Members of the faith-based community seek to live out their religious and spiritual faith through various activities to make their communities safer places to live (Huebner et al., 2010; Parsons & Warner-Robbins, 2002). Spiritual teams and individuals within these organizations participate in efforts that focus on breaking the cycle of crime and incarceration to improve the quality of their neighborhoods (Huebner et al., 2010; Parsons & Warner-Robbins, 2002; Swavola et al., 2016). To that end, they have found creative ways to respond to the unmet needs of justice-involved women in their communities (Huebner et al., 2010; Swavola et al., 2016). Not only do they build relationships with women prior to their release from jail or prison, but they also work closely with parole and probation officers to assist women with unmet needs post-release (Colbert, Sekula, FAU- Zoucha, Zoucha, & Cohen, 2013; Huebner et al., 2010). Faith communities have provided various aftercare ministries that include showers, food pantries, shelters, financial assistance, and referrals to other services and resources (Colbert et al., 2013; Huebner et al., 2010). Faith-based communities earn justice-involved women’s trust because of the work done with the women prior to their release from jail or prison and with parole and probation officers to meet justice-involved women unmet needs (Huebner et al., 2010; Swavola et al., 2016). However, a limitation of the faith-based organization’s services is the requirement to participate in prayer and religious activities as a stipulation of assistance, which justice-involved women are often forced to comply with (Huebner et al., 2010). Another limitation is that these faith-based services are not guaranteed services – they are voluntary, highly community specific, and individualized (Huebner et al., 2010; Parsons & Warner-Robbins, 2002; Swavola et al., 2016).
Local health departments
Local health departments (LHD) are the backbone of the local public health system with a mission and goal to improve health, wellness, safety, and quality of life in the community (Huebner et al., 2010; Nargiso, Kuo, Zlotnick, & Johnson, 2014; Parsons & Warner-Robbins, 2002; Smith & Visher, 1981). LHDs help create and maintain conditions in communities that support healthier choices, lead efforts to prevent and reduce chronic illnesses, and protect children and families from infectious diseases (Nargiso et al., 2014; Parsons & Warner-Robbins, 2002; Smith & Visher, 1981). They play a central role in providing essential public health services in communities (Abbott, Magin, Lujic, & Hu, 2017). As a part of their role and mission, they provide health promotion programs and services to vulnerable populations such as justice-involved women (Abbott, Magin, Lujic, & Hu, 2017). Justice-involved women are more likely to suffer from chronic and communicable diseases like HIV, Hepatitis C, and sexually transmitted infections than women in the general population (Kelly, Hunter, Daily, & Ramaswamy, 2017). In addition, they require pre-and post-natal and family planning services because they are at high risk for unintended pregnancies and substance abuse upon release (Kelly et al., 2017). These services are often obtained at an LHD due to their ability to provide services at no or little cost (Kelly et al., 2017). Not only do LHDs provide services to justice-involved women but they also provide services to their children such as women, infant, and children services, immunizations, and physicals (Abbott, Magin, & Davison, 2017).
Community re-integration programs
Community reentry programs have been proven to help reduce recidivism rates and improve the health and well-being (i.e. safety, success of integration, and referrals and linkage to social and health services) of justice-involved women (Bloom, 2006; Eggers, Munoz, Sciulli, & Crist, 2006; Rich et al., 2001; Richie, Freudenberg, & Page, 2001). Many justice-involved women have difficulty integrating into the community and meeting the conditions of parole due to their limited ability to find a job, adequate housing, and attain photo identification (Richie et al., 2001). Some re-entry programs provide the opportunity for inmates to gain basic living skills on how to successfully transition back into the community after release (Help for Felons, 2017). Re-entry programs offer a comprehensive list of services such as short-term housing, food, clothing, job assistance (i.e. placement, training, and career development), medical and dental care, substance abuse treatment, and mental health services (Richie et al., 2001). Forty-six states have community re-entry programs that vary from faith-based programs to comprehensive community re-entry programs that provide education on the department of corrections, job training and placement, and family reunification (Help for Felons, 2017; TheLlion Heart Foundation, 2018). For example, a well-documented New York reentry program, Health Link, is designed to assist drug-using jailed women in New York City to return to their communities, reduce drug use and HIV risk behavior, and avoid rearrests by working directly with women in the jail and after release and by addressing the community conditions that hamper successful reintegration. (Richie et al., 2001). Re-entry programs are broadly defined as organizations that serve individuals released from the criminal justice system into the community thus may vary in services and resources limiting their ability to provide a comprehensive approach that may improve the health and well-being of justice-involved women (Richie et al., 2001). The development of programs that engage women in navigating the CHDS through referrals and work directly with other CHDS agencies may help women change the conditions of their lives by reducing drug use, improving their health, avoiding dangerous relations, and improving their well-being.
Domain three: healthcare organizations
Two weeks following release, women prisoners are at a 12 fold increased risk of death, which highlights the need for timely linkages to medical care and preventive services during community reentry (Kelly et al., 2017). However, for women leaving prison or jail, there are roadblocks that reduce or eliminate the ability to seek or continue needed services such as alcohol and drug treatment and other healthcare treatment to successfully reintegrate into their communities (Kelly et al., 2017; Rogers, 2015). Recent studies have shown that justice-involved women have a myriad of health issues compounded by unique circumstances in the re-entry into their communities (Abbott, Magin, & Davison, 2017; Erin & Ost, 2007). Additionally, justice-involved women are less likely to receive routine care (i.e. well-women exams and screenings) and may not seek health care treatment because of barriers such as the lack of health coverage, cost, limited knowledge of the health system, and the demands to meet the obligations of probation, parole, and family (Abbott, Magin, & Davison, 2017; Erin & Ost, 2007). These barriers often lead to the increased use of the hospital’s emergency departments (ED) for chronic and minor health care (Bandara, Huskamp, & Riedel, 2015). However, substance abuse and mental health treatment and community health centers (CHC) particularly safety-net clinics remove the financial barrier to seeking health care (Hirsch, 1994; Richie, 2007). Despite the availability of free health care services in multiple communities, women face competing priorities such as housing, finding employment, re-establishing relationships, and attending regular parole meetings, which may delay the receipt of medical care (Abbott, Magin, & Davison, 2017; Kelly et al., 2017); Ryan, Pagel, & Smali, 2016).
Substance use and mental health
Drug and alcohol problems and critical mental health issues have reached epidemic proportions for justice-involved women (Jason et al., 2016; Lyons, 2010; Nargiso et al., 2014; Sprague et al., 2017). Documented underlying behaviors that cause women to have justice involvement is a history of substance abuse and mental illness (Lyons, 2010; Nargiso et al., 2014). An estimated 80% of individuals released from prison in the United States each year have a substance use disorder, or chronic medical or psychiatric condition (Guyer, Serafi, Bachrach, & Gould, 2019). In 2012, 65.8% of women prisoners and 67.9% of women in jails reported a history of mental health problems (Bronson & Berzosky, 2017). Many individuals utilize substances to cope with mental illness or physical health, which often creates the co-occurrence of substance abuse with persisting mental health problems (Lyons, 2010; Nargiso et al., 2014). Although both substance abuse and mental health treatments are vital to the recovery of women with a history of drug abuse, justice-involved women are often referred to only substance abuse treatment (Jason et al., 2016; Lyons, 2010;Nargiso et al., 2014 ; Roth et al., 2012). The central mission of substance abuse treatment centers is to help individuals with substance abuse and underlying mental health needs in order to improve lives (Nargiso et al., 2014). Effective substance abuse programs work with clients to broaden their range of response to various types of behaviors and needs, enhancing their coping and decision-making skills with an empowerment model to help women achieve self-sufficiency (Jason et al., 2016; Lyons, 2010). In addition, effective therapeutic approaches are multidimensional and deal with specific women’s health and well-being, including chemical dependency, domestic violence, sexual abuse, pregnancy and parenting, relationships, and gender bias (Nargiso et al., 2014; Roth et al., 2012). Though substance abuse treatment is most often provided to justice-involved women, the barriers to receiving treatment and care from both substance and mental health treatment services are often ignored (Lyons, 2010; Roth et al., 2012). The receipt of both substance and mental health treatment services has the potential to reduce recidivism.
Community health care centers
Correctional facilities provide health care for justice-involved women while in jail or prison (Abbott, Magin, & Davison, 2017; Rogers, 2015). However, there is little to no coordination between the correctional facilities’ health care services and community health centers (Abbott, Magin, & Davison, 2017; Rogers, 2015). Community health centers are well positioned to provide preventive and follow-up health care to justice-involved women (Abbott, Magin, & Davison, 2017; Rogers, 2015). CHCs have a mission to provide high-quality, accessible medical, dental and behavioral health services to individuals and families at an affordable cost or free (Rogers, 2015). The CHC is less likely to meet the needs of vulnerable populations due to limited knowledge about the provision of services and lack of coordination with correctional facilities (Rogers, 2015).
The ED serves as an entry point for inpatient admissions and is a common setting for acute care (Bandara et al., 2015). Several studies have reported that women with a history of incarceration were more likely to have poor health outcomes and use EDs as a regular source of care (Bandara et al., 2015). A recent study found that justice-involved women had a higher proportion of frequent ED visits (27.2% vs 9.4%) than women with no criminal justice contact (Bandara et al., 2015). A history of incarceration among women has been associated with a higher prevalence of infectious diseases, chronic diseases, and a higher risk of death (Bandara et al., 2015; Bracken, Hilliard, McCuller, & Harawa, 2015; Erin & Ost, 2007). The poor health of justice-involved women has led to the overutilization of emergency rooms resulting in limited primary care engagement (Bandara et al., 2015). Research suggests that primary care engagement improves the health and well-being of justice-involved women and has a positive association with stable housing and satisfaction of housing (Bracken et al., 2015). ED physicians do not provide follow-up service or have the staff on hand to deal with these multiple health conditions: substance abuse, physical and sexual abuse, and mental health (Bandara et al., 2015). Justice-involved women that utilize ED as usual source of care often have an untreated or undiagnosed medical condition, which in some cases can lead to continuing risky behaviors that may threaten their health and well-being (Erin & Ost, 2007).
Over the past 30 years, America has expanded the use of prisons and jails and increased criminal punishment for women (Morash et al., 2014; Smith & Visher, 1981). The expansion of punishment penetrates deeply into the fabrics of women’s lives inside and outside correctional institutions (Visher & Travis, 2003; Morash et al., 2014; Smith & Visher, 1981). For example, justice-involved women are forced to navigate a complex community health delivery system, including justice, social, and healthcare organizations, to meet the requirements of their parole and probation and reintegrate into their community. The requirements of parole and probation are often aligned with the priorities of obtaining housing, employment, substance abuse treatment, and required appointments with probation and parole officers (Bridgman, 2002; Broner, Lang, & Behler, 2009; Dekeseredy et al., 2003; Department of Children and Family, 2009; Jason et al., 2016; Kruttschnitt, 2010; Kurlychek, Brame, & Bushway, 2006; Metraux & Culhane, 2004; Salem et al., 2013; Walter, Viglione, & Tillyer, 2017; Why Punish the Children?, 1993). Although many CHDS organization directors and staff do not feel they have a role in improving the health and well-being of justice-involved women, navigating the CHDS often creates barriers to seeking needed health care and leads to missed opportunities to redirect women toward healthier, stable, and more productive lives in the community (Rogers, 2015). Yet little is known about the comprehensive CHDS justice-involved women must navigate to reintegrate into their communities. Limited research has focused on identifying and understanding the CHDS and its impact on the health and well-being of justice-involved women.
Although the CHDS for justice-involved women has been identified in our review, the identification of the organizations is only the first step to identifying the gaps and uncertainties in the programs and services for justice-involved women. Our review suggests that the CHDS is a complex fragmented system made up of individual organizations that have limited alignment in missions and independent practices that spawn inefficient allocation of resources for justice-involved women. The review also suggests that the remaining uncertainties that justice-involved women confront daily in their attempt to navigate the CHDS are unknown (Morash et al., 2014; Rogers, 2015; Smith & Visher, 1981). Additionally, the gaps in the provision of CHDS services and programs for justice-involved women is also unknown. Expanding the research to focus on the integration of the CHDS and its barriers and facilitators for justice-involved women will require several key approaches to research.
First, research is needed to identify opportunities to integrate CHDS services and programs. The growth of the incarcerated female population and health and human services funding cuts have contributed to the fragmentation of the CHDS by increasing workloads limiting the ability to meet justice-involved women needs with limited community resources, budgets, and evidence-based practices (Shinkfield & Graffam, 2009; Springer, 2010). Predictably, solo (i.e. parole and probation officers) or small single (i.e. faith-based organizations, re-integration programs, and substance abuse treatment centers) have dominated the landscape, with a variation in services, costs, referrals and follow-up, and low accountability. The limited research that identifies the justice organizations as contributors to justice-involved women health and well-being contributes to the CHDS fragmentation, thereby interposing an inherent disconnect between social and health care organizations interest and the interest of justice-involved women (Cobbina et al., 2014; Golder et al., 2014; Petersilia, 2001; Smith & Visher, 1981). The increasing incarceration rate, cycling, and the unique constellation of health and social problems of incarcerated women suggest that justice-involved women require services, programs, and care from multiple CHDS providers in multiple settings and accountability for seeking these services (Shinkfield & Graffam, 2009; Springer, 2010). The opposite of a fragmented CHDS is a coordinated, integrated CHDS similar to integrated healthcare and public health delivery system (Enthoven, 2009; Strange, 2009). The CHDS may improve the alignment of missions and practices by implementing a tracking system that can manage referrals or transitions and allows organizations to close-the-loop in the system. An integrated CHDS is an organized, coordinated, and collaborative system that (1) links various social services providers, (2) coordinated efforts with justice organizations, (3) is accountable for and has a system in place to manage and improve the health and well-being of justice-involved women (Enthoven, 2009; Strange, 2009).
Second, research is needed to identify the barriers and facilitators of each CHDS and the role they play in justice-involved women’s ability to seek preventive health care. Numerous known and unknown barriers and facilitators may hinder justice-involved women’s ability to seek needed care. Although it is well known that a large majority of justice-involved women have risky behaviors and receive health care while incarcerated, little is known about how to best engage justice-involved women in their health care within the context of re-entry and criminal justice supervision (i.e. parole and probation) (Covington, 2007; Erin & Ost, 2007; Freudenberg et al., 2008; Rogers, 2015; Rosenblatt, 1993). Justice-involved women are unlikely to seek the needed preventive sexual health care or practice healthy sexual behaviors often encouraged by primary care physicians because most seek their care in an ED (Cobbina et al., 2014; Covington, 2007; Institute of Medicine, 2002; Ramaswamy, Upadhyayula, Chan, Rhodes, & Leonardo, 2015). Identifying barriers and facilitators will not only enhance the women’s ability to seek needed health care but enhance the knowledge of CHDS providers and may lead to strategic approaches to eliminate barriers and enhance facilitators.
Third, research should focus on strengthening the CHDS and documenting the impact of the CHDS on the health and well-being of women. Due to limited state budgets and capacity in CHDS, many have limited resources to meet the needs of vulnerable populations (Broner et al., 2009; Dias & da Silva Junior, 2016; Richie, 2007). The CHDS need health promotion plans that target systematic and vulnerable population problems and resources to develop strategies to intervene and address problems (Celinska & Siegel, 2010; Cobbina et al., 2014; Covington, 2001; Erin & Ost, 2007; Ramaswamy et al., 2015; Rogers, 2015). The recommended approaches to strengthen the CHDS may improve its infrastructure and capacity to effectively meet the needs of justice-involved women through service provisions, integration of services, collaborations, and policies. Additionally, expanding the target-substance abuse and mental health of existing diversion programs to address the overall health and well-being of women may enhance the capacity of the CHDS to integrate services and programs (Rogers, 2015).
Fourth, research needs to focus on the CHDS policies and procedures and the role they play in creating barriers for justice-involved women to seek preventive health care. Policies are often the result of choice by autonomous decision makers at each phase of the justice system whose actions are based on their limited knowledge of the CHDS and its impact on the health and well-being of justice-involved women (Hirsch, 1994; Jason et al., 2016; Parsons & Warner-Robbins, 2002).
Finally, our review indicated that the current body of literature on CHDS for justice-involved women are limited and demonstrates the need to examine the system comprehensively (Rosenblatt, 1993: Judging science, 1999; Institute of Medicine, 2002). Although a full examination of the comprehensive CHDS for justice-involved women is beyond the scope of this review, our findings demonstrate that many CHDS organizations have services and programs for justice-involved women and may recognize their role in justice-involved women reintegrating into the community (Richie et al., 2001; Rogers, 2015; Shinkfield & Graffam, 2009). Thus, research should expand to examine the CHDS current role in reintegration and the integration of CHDS services and programs to ensure that justice-involved women receive needed resources and guidance after release. These efforts may make the difference between recidivism, successful transition to the community, and improving the health and well-being of justice-involved women.
The Institute of Medicine (IOM) recommended that closer collaboration and integration between governmental public health agencies and the health care delivery system may enhance the capacities of both to improve population health (Institute of Medicine., 2002). Our review represents the first literature review to identify the comprehensive CHDS that may collectively enhance the capacity of the CHDS to integrate services and programs for the purpose of reducing recidivism and improving justice-involved women’s health and well-being.
Some limitations of the review should be noted. First, our review does include a number of assessments of CHDS programs and services under development and not in peer-reviewed and gray literature. While we reviewed a number of conference abstracts in gray literature, additional literature on the CHDS may be underrepresented in both gray and peer-reviewed sources used in our review.
Despite the limitations, the results of our review help to fill the gap in the current literature by identifying CHDS organizations and pointing to targeted areas of future research to examine the programs, services, and impact of CHDS on the health and well-being of justice-involved women. Continued efforts toward documenting existing CHDS programs, understanding the mechanisms through which CHDS organizations improve the health and well-being of women, as well as increasing the integration of CHDS services and programs are an important means of strengthening the scientific knowledge base of health services research, programs, and policies.
Availability of data and materials
The submitted publication is a literature review and the data is available via many search engines and have been included in the Appendix.
Community Health Delivery System
Department of Child and Family Services
The Department of Housing and Urban Development
Institute of Medicine
Local Health Department
Temporary Assistance for Needy Families
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Smith, S.A., Mays, G.P., Collins, T.C. et al. The role of the community health delivery system in the health and well-being of justice-involved women: a narrative review. Health Justice 7, 12 (2019) doi:10.1186/s40352-019-0092-y
- Justice-involved women
- Community health delivery system
- Social services