The health needs and healthcare experiences of women leaving prison

This thesis examines healthcare access for women in contact with the criminal justice system, as experienced both in prison and in the community, with a particular focus on primary health care. There were two main research objectives. The first was to examine the healthcare needs of women leaving prison and their experiences in accessing health care. The second was to examine continuity of care across the interface between prison and community-based health services, in particular, general practitioner (GP) care. Three distinct studies were undertaken: a retrospective medical record review of the health records of women in prison, a qualitative study using pre- and post-release interviews and a scoping review of published literature reporting on qualitative research with prisoners. For the first study, prison health records from 231 periods of incarceration of women released between 2013 and 2014 from prisons in New South Wales (NSW), Australia, were reviewed. Data were collected in predefined categories relating to healthcare delivery in prison, health information transfer and continuity of care arrangements across the interface between prison and community health services. Qualitative data relevant to these themes were also collected. The review showed that most women in prison had multiple contacts with healthcare providers and, at release, most women required ongoing management for substance misuse and mental and physical health problems. Hearing health was often not recorded despite a third of records being of women from an Aboriginal and Torres Strait Islander background, a high risk group for ear problems. Health management plans generated in prison were not always completed before release. Reasons for this included custodial factors and waiting times for appointments. Except for women with certain priority health conditions, continuity of care arrangements and health information transfer appeared to occur infrequently outside formal transitional programs. For the second study, 69 semi-structured interviews were conducted with 40 women while they were in prison and with 29 of these women after their release in 2014 and 2015. Inductive thematic analysis was undertaken. Most of these women had histories of substance misuse. Women perceived that they were not considered legitimate patients because of their drug use histories, and this impeded their access to health care. For women in transition between prison and community, health care could be experienced as ‘medical homelessness’ in which women felt caught in a perpetual state of waiting and exclusion during cycles of prison- and community-based care. Their healthcare experiences were characterised by ineffectual attempts to access care, transient relationships with healthcare providers, disrupted medical management and a fear that stigma would prevent access to health care, even in the event of serious illness. Women perceived that GPs lacked interest in their wellbeing beyond physical ailments and needed more skills in substance misuse management. Women often chose not to disclose their prison health care due to fear of differential treatment, decreasing the value of health care initiated in prison due to lack of follow up in the community. For the third study, a scoping review of methods used in qualitative interview and focus group research with prisoners published between 2005 and 2017 was undertaken. The review aimed to investigate considerations when conducting ethical and rigorous research in prison settings, with a focus on recruitment, sampling and data collection. Strategies used by researchers to manage coercion risk, informed consent, recruitment, sampling, confidentiality, privacy and working with prison-based intermediaries were identified, and key considerations highlighted. The findings presented in this thesis provide new information to support the changes needed in order to release healthier, well-supported people into the community and to provide community-based care which meets the needs of people leaving prison. Promoting the confidence of healthcare providers to manage people who have a history of substance misuse, facilitating timely care in prison and supporting continuity of care at release will increase access to health care for those in contact with the criminal justice system