An Examination of Three Transitional Events in the Substance Misuse Trajectories of Women With Criminal Legal System Involvement

Research has consistently demonstrated that criminal legal system (CLS)-involved women are distinct from men in initiation and course of drug use, with important differences on biological, environmental, and sociocultural levels. Thus, the unique pathways and transitions into and out of drug use for women with CLS involvement are critical to consider from a research perspective, but also from a need to develop and support evidence-based, women-centered services in correctional contexts. This dissertation project uses a three-paper format to investigate three aims: (1) to understand CLS-involved women’s initiations to injection drug use and their experiences providing injection initiation assistance (IIA) to others; (2) to explore unique correlates of CLS-involved women’s experiences with overdose and overdose reversal, including relationships between overdose and traumatic stress; and (3) to examine community reentry and recurrences of drug use post-incarceration for women who have completed corrections-based substance use treatment services. This project utilizes secondary data from two studies. Aim 1 includes cross-sectional data from the Women’s Intervention to Stop HIV/HCV, conducted with women incarcerated in rural Appalachia. Aims 2 and 3 use data from the Criminal Justice Kentucky Treatment Outcome Study (CJKTOS), a longitudinal state-funded evaluation of corrections-based substance use treatment in Kentucky. Aim 2 is conducted using baseline CJKTOS data collected from women at treatment entry, describing their experiences during the 12 months prior to incarceration. Aim 3 uses a mixed-methods analysis of follow-up CJKTOS data collected from a stratified random sample of women who graduated from corrections-based treatment, 12 months after their release to the community. Collectively, findings from the three papers contribute to a complex portrait of factors that are associated with CLS-involved women’s risk of substance misuse-related harm. Specifically, findings from Aim 1 suggest that women who exhibit trajectories of drug use characterized by faster transitions and more severe patterns, and who are more enmeshed in social networks of others who use drugs, are more likely to have provided IIA. Results from Aim 2 indicate that witnessing and/or experiencing overdose is common among treatment-seeking incarcerated women and independently associated with mental health issues, although knowledge of where to obtain naloxone is also related to lower odds of meeting PTSD criteria among women who have witnessed overdose. Finally, findings from Aim 3 show that, across factors at all social ecological levels, employment demonstrates the strongest relationship to abstinence from drug use after release from incarceration. However, women’s qualitative appraisals of risk and protective factors emphasized internal/individual qualities (e.g., motivation), complex relational influences, and environmental triggers as critical for recovery. The use of multilevel theoretical models to guide selection of variables across all three papers emphasizes the need to frame substance misuse transitions not just from an individual-level perspective, but also from interpersonal, community, and intersectional standpoints. Implications for prevention, intervention, and recovery support services for CLS-involved women are also discussed, as well as the value of comparing quantitative findings alongside women’s subjective understanding of events

An Exploratory Study of Syringe Exchange Program Awareness and Perceptions in Kentucky

Research has documented the myriad benefits to public and individual health provided by syringe exchange programs (SEPs), which allow persons who inject drugs access to sterile injection equipment. In 2015, Kentucky passed legislation that permitted public health departments to operate SEPs, but much remains unknown about knowledge and perceptions of the newly-implemented programs, particularly among individuals with histories of substance use. The present study therefore aimed to: 1) describe awareness of SEPs in Kentucky among participants of corrections-based substance abuse treatment programs, surveyed one year after their release into the community; 2) to determine if awareness of SEPs varies based on whether individuals live in counties with operational SEPs; 3) to describe perceptions of SEPs in Kentucky; and 4) to explore barriers and motivations for PWID to use SEPs. Results indicated that the majority of respondents had heard of SEPs in their area, and that individuals living in counties with operational SEPs were significantly more likely to correctly identify that an SEP existed. Analysis of qualitative data demonstrated that respondents were aware of SEPs’ provision of sterile equipment and their role in preventing injury and disease transmission. However, many respondents believed that concerns about confidentiality, specifically related to police or community surveillance, may act as barriers to SEP utilization. These findings suggest that additional outreach, particularly targeting fears of legal repercussions, could increase utilization and positive perceptions of SEPs in Kentucky

A Description of COVID-19 Lifestyle Restrictions Among a Sample of Rural Appalachian Women

Background: COVID-19 has led to swift federal and state response to control virus transmission, which has resulted in unprecedented lifestyle changes for U.S. citizens including social distancing and isolation. Understanding the impact of COVID-19 lifestyle restrictions and related behavioral risks is important, particularly among individuals who may be more vulnerable (such as rural women with a history of substance use living in Appalachia). Purpose: The overall purpose of this study was to better understand the perceptions of lifestyle changes due to COVID-19 restrictions among this vulnerable group. Methods: The study included a mixed methods survey with a convenience sample of rural women (n=33) recruited through a closed, private Facebook group. Results: Study findings indicated that COVID-19 restrictions related to limited social activities and interactions with family and friends had a significant impact on women. Implications: Findings suggest that social isolation may have a number of unintended consequences for rural women, and implications for rural health practitioners are discussed

Age of First Arrest, Sex, and Drug Use as Correlates of Adult Risk Behaviors Among Rural Women in Jails

Incarcerated women frequently report initiation of substance use and sexual encounters at an early age, and often engage in high-risk drug use and sexual behaviors as adults. This study examined the timing of first sex, drug use, and arrest, as well as their unique influences on specific risky behaviors in adulthood, among a high-risk population of rural women recruited from jails. Ages of initiation were all positively and significantly correlated, and each independently increased the likelihood of several risky behaviors in adulthood. Implications are discussed for screening, intervention, and treatment targeting high-risk women and girls in rural areas, particularly within criminal justice settings

Rural Re-entry and Opioid Use: Identifying Health-Related Predictors of Relapse Among Formerly Incarcerated Women in Appalachia

Introduction: Despite improved knowledge of the health care needs of formerly incarcerated women, there exists a gap regarding the relationship between health, health care access, and relapse among rural women returning to the community during the opioid epidemic. Purpose: With an emphasis on health care access, this study examined health-related factors associated with opioid relapse among women reentering the community in rural Appalachia. Methods: As part of a larger study, 400 rural women reporting a history of substance use were recruited from three Appalachian jails in Kentucky. Analyses focused on participants reporting a history of illicit opioid use prior to incarceration, who had also completed follow-up interviews at 6- and 12-months post-release from jail. Results: Fifty-five percent of participants reported relapse to opioids during the 12-month follow-up period. Compared to those who did not use opioids during this time, women who relapsed reported poorer mental and physical health, as well as encountered more barriers to needed health services. They were also more likely to report a usual source of care. Multivariate regression analyses reveal that, even when controlling for other known correlates of opioid use and relapse to any non-opioid drug during the follow-up period, the number of barriers to health service utilization was a significant predictor of opioid relapse. Implications: Stakeholders should address the complex reentry needs of women who use opioids in rural Appalachia. This includes examining innovative approaches to reduce extensive barriers to quality health care utilization, such as implementing telehealth for opioid use treatment

Staying Out: Reentry Protective Factors Among Rural Women Offenders

The current study examines protective factors for women who transition from county jails to rural Appalachian communities, areas with limited health and behavioral health services. The study included drug-using women recruited from three jails in rural Appalachia and followed-up at 12-months post-release. Analyses focused on differences between women who remained in the community and those who returned to custody, as well as a multivariate model to determine protective factors for reentry success. At the bivariate level, staying out of jail was associated with being older, having a job, not using drugs, stable housing, receiving health treatment, and having prosocial peers. In the multivariate model, the most robust predictors of staying out of jail were drug use abstinence, health care utilization, and prosocial peers. Most research on criminogenic needs associated with reentry success have focused on men, and most focused on reentry to urban communities where services and resources are more accessible. These findings have important implications for criminal justice systems to implement reentry programs for women offenders during the transition to the community

Partner Relationships and Injection Sharing Practices Among Rural Appalachian Women

Background—The role of relationships in initiating and maintaining women’s risk behaviors has been established. However, understanding factors that may underlie partner relationships and women’s risky drug use, particularly in rural contexts, is limited. This study is the first to examine the association between injecting partners and women’s risky injection practices as a function of relationship power perception. Methods—Female participants were recruited from three rural jails in the Appalachian region. Women were randomly selected, provided informed consent, and screened for study eligibility criteria. This cross-sectional analysis focuses on women who inject drugs (WWID) during the year before entering jail (n=199). Main findings—Approximately three-quarters (76%) reported having a recent main male sexual partner with a history of injection drug use (IDU). Although having a risky partner independently increased the likelihood of women reporting shared injection practices, perceptions of relationship power significantly moderated the effect on shared needle (AOR = 0.02 [0.003, 0.23]; p = .001) and shared works (AOR = 0.17 [0.03, 0.95]; p = .04) use. Conclusions—This interaction indicated that for WWID with a recent injecting male partner, greater perception of relationship power was associated with a decreased likelihood of shared injection practices. Implications for clinical assessment and intervention are discussed

Age of first arrest, sex, and drug use as correlates of adult risk behaviors among rural women in jails

Incarcerated women frequently report initiation of substance use and sexual encounters at an early age, and often engage in high-risk drug use and sexual behaviors as adults. Less is known, however, about the relationship between age of onset of these risk behaviors, as well as the timing of first arrest, and risky behaviors in adulthood. Objectives of the present study were to: 1) profile age of first arrest, age of first illicit drug use, and age of first sex in a sample of rural women drug users (N=400) recruited from jails and screened for high-risk behaviors; 2) to examine the relationships among the age of onset of these risk behaviors; and 3) to examine the unique contributions of these onset variables to adult high-risk drug use and high-risk sexual practices. Ages of initiation were all positively and significantly correlated at the bivariate level, indicating that onset of sex, illicit drug use, and arrest are related among high-risk rural women. In logistic regression models, each onset variable independently increased the likelihood of several specific adult risky substance-using or sexual behaviors; independent effects of demographic covariates were also noted. In describing rural women’s initiation of risky behaviors and involvement with the justice system and exploring associated differences in adult trajectories, this study has contributed to an understanding of the development of high-risk rural women. Implications are discussed for screening, intervention, and treatment targeting vulnerable women and girls in rural areas, particularly within criminal justice settings. Keywords: risk behaviors, rural, incarcerated, women, initiation, substance use, arrest, sexual behavio