Introduction

During 2020, approximately 1,215,800 people were incarcerated within correctional institutions in the United States, and 549,600 people were released back to the community [1]. Despite the high volume of people released each year, there is a notable lack of reentry support services to help reentrants access essential healthcare, secure housing and employment, and access essential social support services upon release [2–4]. If these essential needs remain unaddressed, reentrants are placed at a higher risk for experiencing poor physical, mental, and social health outcomes that can ultimately serve as catalysts for re-incarceration and pre-mature death [5–8].

The carceral environment in U.S. correctional institutions is exceedingly stressful and provides minimal opportunities for people to achieve and sustain their health. The majority of U.S. prisons are overcrowded, giving rise to high rates of interpersonal violence [9, 10], infectious disease transmission [6, 11–13], and mortality due to the poor quality of healthcare available in these densely populated institutions [14, 15]. Many people who are incarcerated report experiencing healthcare-induced trauma from the poor quality care they received in prisons and jails, leading to their severe fear of experiencing serious illness and death, as well as deep mistrust of healthcare providers and medical institutions as a whole [16]. These feelings of intense mistrust from adverse healthcare experiences continue into reentry, contributing to poor health outcomes post-release.

The reentry period presents a crucial opportunity for intervention, with reentry support services spanning the domains of healthcare, housing, employment, and social support proving to be especially beneficial for returning citizens as they navigate unfamiliar systems post-release, helping them achieve better health [17, 18]. Ensuring that formerly incarcerated individuals have the resources and support needed to overcome unfulfilled social determinants of health post-release can mitigate the range of inequalities that justice involved individuals face.

We examined the barriers and facilitators to health during reentry in the context of Miami-Dade County, where a sizeable proportion of Florida’s 26,420 reentrants are released each year [19]. Florida has the third largest prison population and ranks 10^th in imprisonment rates [20]. There are over 350,000 people under correctional supervision, with a 4:1 Black to White imprisonment ratio [21]. Miami is also the “epicenter” of the US housing crisis [22] and continues to face a high prevalence and incidence of HIV [23], with Florida being one of 12 states that has not expanded Medicaid. It is within this context that we conducted semi-structured interviews with people recently released from prison to Miami and Miami-area professionals who provide reentry support services, helping us gain insight into the process of community re-integration.

Materials and methods

The data reported in this paper were collected as part of a larger community needs and resource assessment project. In local communities, there are often a myriad of agency programs and services designed to meet the needs of specific populations that typically must meet specific criteria often resulting in fragmented and disconnected services at the community-level [24]. Additionally, many communities lack a shared knowledge and vision of the resources necessary to support different groups. Asset mapping is a community based participatory research approach originally designed as an asset-based community development (ABCD) strategy for community building and community capacity building [24, 25]. The World Health Organization (WHO) has recognized asset-based approaches to health as critical for supporting overall population health and in reducing health disparities. Using informational telephone interviews, we identified 171 community assets and providers in Miami Dade County that were able to serve the needs of formerly incarcerated individuals during reentry. These assets were mapped using an interactive platform. We then optimized the map by conducting online surveys with a subset of the community assets. We simultaneously conducted semi-structured interviews with community stakeholders, including recent reentrants and people who provide services to people during reentry. The purpose of key informant interviews is to collect information from a wide range of people who have firsthand knowledge about the community of interest [26]. We determined that a small sample size would be sufficient since interviews will be narrowly focused and participants will have high levels of expertise [27]. We strategically identified persons for initial interviews based on local knowledge and then used a snowball sampling technique to recruit additional participants [28].

While both groups are important community stakeholders for reentry, we use specific terms to differentiate the samples for reader clarity. We use terms like “reentrants” and “formerly incarcerated” to describe the former, and terms like “professionals” to describe the latter given the inclusion criteria (see below). Professionals encompassed a range of perspectives representing different sectors, including physicians, judges, nonprofit leaders, and support group facilitators. It is important to note that these are not mutually exclusive categories but determined which interview guide [S1 and S2 Appendices] was used during the interview. For example, one participant was formerly incarcerated and provided services to people during reentry and was interviewed following the professional interview guide.

Semi-structured interviews allowed for consistent topics to be addressed across all interviews, yet the interviewer had the freedom to probe for more details that were unique to each participant’s experience. A priori, our research interest was in assessing the health and health related needs of people within the context of reentry to Miami Dade County from a diverse group of stakeholders. In both our participant interviews and in our analysis, the term “holistic reentry programs” is used to describe reentry programs that address all social determinants of health by providing opportunities for housing, job training/employment, healthcare access, educational training, and community involvement.

In our initial study design, we aimed to conduct 8 to 10 interviews with each group of participants (n = 16–20 total). Data collection occurred during the height of the COVID-19 pandemic (summer 2020), which made recruitment challenging, resulting in a smaller sample size than planned. However, determining sample size a priori in qualitative research is considered inherently problematic [29]. And despite the controversies over the use of saturation in qualitative research [30–32], we think that no new themes would be identified by conducting more interviews. Inclusion criteria for formerly incarcerated participants was that participants must (1) be an adult aged 18 years or older who was released from an adult prison to Miami Dade County within the past year, (2) speak and understand English; and (3) currently reside in Miami Dade County. Inclusion criteria for professional participants included (1) be an adult aged 18 years or older, (2) work in Miami Dade County, (3) speak and understand English, and (4) have primary job responsibilities working with or providing services to formerly incarcerated adults for at least one year (e.g., judges, parole officers, substance use counselors, reentry housing staff, etc.). Given that interviews were conducted virtually and remotely, potential participants were also assessed for their capacity to conduct the interviews through either phone call or video call. We recruited participants through referrals from community organizations and subsequent snowball sampling. Interviewers assessed the capacity of respondents to provide their informed consent and ensured that respondents understood the nature of the research, study goals, risks, and benefits before they could participate in the study. All study protocols were approved by the University Institutional Review Board at University of Miami and informed written and verbal consent was obtained from all participants included in this study.

In total, 12 participants were interviewed: 5 formerly incarcerated persons and 7 professionals. A.B. (a sociology doctoral candidate and woman of color) conducted interviews with formerly incarcerated participants and M.K. (a medical student and woman of color) conducted interviews with professionals from June 2020 through August 2020, with interviews ranging from 45 minutes to 1 hour. Each participant was interviewed at one time point, and they were not contacted for elaboration or clarification purposes. S.M. (an undergraduate pre-med student at the time of data collection and woman of color) collected additional asset mapping data that is not reported in this manuscript. All three research assistants received extensive training from the project principal investigator (K.M.N., a white woman faculty member). Formerly incarcerated respondents were compensated $30 for their time, and professionals were not compensated because providing feedback for community organizations and initiatives was inclusive of their primary job responsibilities. Study procedures were approved by the Institutional Review Board at [University] and verbal consent was obtained from each participant. We followed the consolidated criteria for reporting qualitative studies (COREQ; [33].

We transcribed interviews verbatim and used NVivo software to conduct qualitative analysis using the general inductive approach [34]. This analytic theory uses data as a mechanism for revealing the main themes that are reflected in the respondent interviews by providing a straightforward approach for deriving findings in the context of focused research questions. Three researchers from our team participated in the coding process, with one researcher coding all respondent interviews through an iterative process (S.M.), and two others reviewing the coding framework to ensure the validity of the identified codes and themes (A.B. and M.K.). As the greater themes emerged, participants’ narratives were used to explain the theme in the language that was used by participants.

Results

Discussion

We identified several social and structural barriers and facilitators to health during reentry. Access to housing, employment, and food are three important social determinants of health and were identified as barriers to health during reentry. Affordable housing is a major problem in Miami and restrictions on low-income housing and shelters make it even more difficult for returning citizens to find safe and stable housing. Moreover, there are over 1,000 collateral consequences of a criminal conviction in Florida, including 20 related to housing, 76 related to education, and 745 related to employment [36]. For example, Florida statute allows for people convicted of offenses “detrimental to other residents” to be evicted from mobile park homes [37]. This makes access to employment difficult as well due to legal discrimination against people with a criminal conviction. Without a stable income, access to health and nutritious food is difficult. Participants identified empowerment and social support and addressing trauma as potential facilitators to positive health post-release. Participants described how learning more about the inequities of the criminal legal system and learning to no longer be ashamed of their “felon” status was empowering for them. Unaddressed trauma was identified as a major issue, either trauma experienced prior to or during incarceration, and receiving trauma-informed counseling better positioned people to deal with day-to-day challenges.

People leaving prison have high rates of chronic illness and other conditions. Within Miami, three challenges with accessing medical care following release from prison were identified. First, participants discussed difficulties with accessing their medical records from the DOC and their frustration with having to “start over” on known diagnoses. Related, Florida is one of 12 states that are not Medicaid expansion states. Therefore, access to health coverage is difficult especially for returning citizens. The healthcare safety nets that do exist in the community were described as so bureaucratic that most people “give up.” Participants also noted that there was a lack of coordinated continuity of care, which can be especially harmful for people living with HIV and other chronic illnesses. Finally, formerly incarcerated participants described how the healthcare that they received in prison was of such poor quality that they were concerned about negative long-term health impacts. This concern was compounded by their inability to access medical care in the community.

Based on accounts from both groups of participants, it is clear that a holistic approach to reentry that addresses the social determinants of health is necessary. We have several recommendations for improving services. First, developing reentry resource guides that span holistic continuums of care (e.g. behavioral health services, primary care, support groups, safe housing programs, and job training programs) can support both reentrants seeking essential services and professionals who would like to present reentrants with opportunities for case management and linkage to care [38, 39]. Having a publicly accessible database of resources [40] that offers quality care that is affordable and non-discriminatory towards justice involved individuals [41–43] can counteract barriers that exist in reentry, ultimately breaking the silos that exist in the current reentry service landscape.

Second, developing holistic reentry support programs that offer educational programming and reentry support services that begin in correctional institutions pre-release and continue throughout the reentry period can support the transition back to civil society. Supplementing pre-release educational programming with linkage to essential services [44] and community providers post-release can heighten service utilization during reentry. Third, expanding the eligibility criteria of essential governmental aid programs such as Medicaid [45, 46] and Section 8 HUD Housing [47–49] to include coverage for justice involved individuals can help them secure affordable healthcare and housing upon release. Twelve states in the US, including Florida, have yet to expand Medicaid eligibility to include low-income adults without dependent children [50]. States that have expanded Medicaid eligibility to this population have cited increases in outpatient care utilization for chronic and preventable diseases [52], increases in the use of preventative health screenings and services [51], increases in outpatient substance use disorder treatment for reentrants three months post release [52], and reduced financial strain for patients seeking care [51]. Wisconsin’s Department of corrections implemented prerelease Medicaid enrollment assistance, which increased Medicaid enrollment one month post release by 25% for those who completed applications in prison pre-release [53].

While this study was successful in examining the health and health related needs of reentrants from a diverse stakeholder population, there were numerous potential limitations. Our study inclusion criteria was limited to individuals who re-entered into Miami-Dade County, so while the results are valid in characterizing the obstacles experienced by returning citizens in the reentry period, they are not generalizable to the experiences of reentrants in other regions or states with different social and political contexts. Another potential limitation is that many reentrants were incarcerated and released during the COVID-19 pandemic, so their experiences both in prison and during reentry may reflect additional barriers that are more severe than those experienced by reentrants in existing literature from the pre-COVID-19 pandemic era. We did not collect data on the duration of incarceration for each of the formerly incarcerated respondents, and this may have impacted the health status and healthcare needs of respondents upon release, as more severe health outcomes may exist among those who have been incarcerated for a longer period. Among our study’s strengths, the most robust is that we included diverse perspectives among our respondent sample to achieve a more holistic understanding of the reentry period, with respondents encompassing formerly incarcerated individuals, judges, substance use support group leaders, harm reduction specialists, and reentry program leaders who serve diverse populations of returning citizens. We believe this research can better inform future reentry programs, reentry support services, and correctional health system reform to better address the health and health related needs of returning citizens within the South Florida region.

Conclusion

This study provides a foundation for examining the healthcare needs of reentrants to Miami, and offers insight about the social and structural barriers that prevent them from fulfilling the social determinants of health post-release. By conducting in-depth interviews and examining the perspectives of both reentrants and professionals, we provide a holistic overview of the long-term consequences of incarceration on reentrant health. This information can be used to inform future attempts to support reentrants returning to Miami as they work to re-integrate and address their healthcare needs following incarceration. Based on participant data, it is clear that improving the health and wellbeing of justice impacted and other marginalized people in Miami can be achieved by addressing community health needs [54], established health inequities [55, 56] and long-standing structural inequalities [57–59]. Engaging in these public health efforts will have the added benefit of reducing reliance on the carceral system to address social problems [60].

Supporting information