Health Education Initiatives for People Who Have Experienced Prison: A Narrative Review

Due to the selectiveness of criminal systems and the context of social vulnerability, there is a high prevalence of health problems among individuals with a history of incarceration. When there is an insufficient level of health care, prior clinical conditions can worsen, and health education can be a response to this problem. Health education is a process of building health knowledge that is intended to facilitate thematic appropriation by the population that enables people to access, understand, and use health-related information for health improvement. In the context of criminal justice, health education can contribute to the successful transition of people who have experienced prison from their custody to the community setting. This study aimed to identify, synthesize, and critically evaluate peer-reviewed evidence concerning health education initiatives developed during or after incarceration aimed at people released from prison. A narrative review methodology was used to analyze 19 studies about health education interventions for prisoners or people who were arrested. Initiatives were identified in five countries, which showed differences in approaches, with motivational interviewing and group sessions standing out in the studies. All of them were grouped into the following themes: HIV and other sexually transmitted infections, alcohol, opioids and other substances, tuberculosis, and women’s health. We have not performed a quality assessment of the studies included (using checklists such as PRISMA, AMSTAR, or SANRA) as this study is a narrative review and was not intended to be a systematic review or meta-analysis. This review has the potential impact of informing future health education initiatives and policies for individuals transitioning from prison.


Introduction
By improving people's access to health information and their ability to use it in personally meaningful ways, health literacy is crucial to autonomy and health promotion.Studies reveal that limited health literacy skills in people in conflict with the law serve to intensify experiences of disenfranchisement, isolation, and shame [1,2]; in this context, health literacy is recognized as a type of intervention for health promotion [3].The aspect of literacy gains relevance and priority in the context of criminal justice, as autonomy in making informed decisions is fundamental for what international literature calls a "successful transition from custody to the community", which demands engagement in access to health services [4,5].
Health literacy refers to the ability of the public to access, understand, communicate, and use health-related information in a way that promotes and maintains health [6].The concept of literacy or health literacy has gained prominence in public health as it enables innovation in individual care.The World Health Organization (WHO) defines literacy as "a set of cognitive and social skills, as well as an understanding and use of information that promotes and maintains good health" [7].
The effects of incarceration on individual health are well known, but the release also has long-term effects and constitutes a high concentration of risks.People who have been arrested are 12 times more likely than the general population to die within the first two weeks of release from any cause [8,9], as well as having disproportionately higher rates of hepatitis C [10].
In this context, overdose is the most common cause of death after release from prison [11], and psychostimulants are the most common substance involved in such deaths [12].
In addition to pre-existing social vulnerability to incarceration, this population is also affected by several social determinants of health, including unemployment, histories of intra-family and community violence, abuse of legal and illicit drugs [13,14], and low educational attainment.As most incarcerated individuals often return to their communities, healthcare delivery during incarceration plays a substantial role in the health of communities at all levels [8].
Sustainable Development Goal (SDG) 3 aims to ensure healthy lives and promote well-being for all at all ages, particularly for vulnerable populations, including people who have experienced prison.As such, it is imperative to develop coordinated health programs across correctional and community programs [9,15,16] to support the successful re-entry of these people who have experienced prison into their communities.Thus, health education can be a viable approach at the point of transition to the community or even after liberation.
It is, therefore, essential that health education is provided to help people recognize the importance of health care in other spheres of life that are involved in the transition to a community.As a result of knowledge of how to make informed decisions, as well as access to health services, people who return to social life will experience greater well-being, which will positively affect their employment, family, and personal relationships in the future.
Therefore, this narrative literature review aims to identify, synthesize, and critically evaluate the scientific evidence on health education initiatives aimed at adults who are about to or recently released from prison.

Materials and Methods
This narrative review was guided by the following question: "What are the existing health education initiatives developed for adults (adults over the age of 18) recently released from prison or about to be released?".Typically, narrative literature reviews present a more open theme without a rigid methodology and are used with an exploratory objective to identify studies produced on a particular topic without rigorous assessment of the methodology and quality of the studies.
The following question has been formulated using the PICo strategy: (P: patient or problem; I: intervention; Co: context).In the context of this narrative review, a patient (P) is a person who has experienced prison and who has already been released or who is in the process of transitioning back into society; (I) refers to the health education intervention, which in the context of the present study varied from focus group discussions and motivational interviews to traditional educational programs (lectures, readings, dramatizations, and group discussions with didactic content); and context (Co) refers to life prison experience [17].
The search was carried out in seven (07) electronic databases: PubMed, Embase, CINAHL, Socindex, Scopus, Web of Science, and the Virtual Health Library (VHL/LILACS), using the descriptors: ("Post-release" OR "post-release" OR "Post-Incarceration" OR "Post Incarceration" OR "after incarceration*" OR "Post-Carceral" OR "Post Carceral" OR "after release" OR "Ex-prisoner*") and ("Health Education" OR Education*), as well as other derivations associated with search terms according to the search criteria for each database.Publications in English, Portuguese, and Spanish were included.
The inclusion criteria for the selected articles were primary studies using qualitative and/or quantitative mixed or theoretical methods, retrieved without limitation on the year of publication.On the other hand, articles without open access or literature review, course completion works, editorials, study protocols, or descriptions of work not yet implemented were adopted as exclusion criteria.Two independent reviewers (PQB and CAV) performed the narrative review, and the researchers' disagreements over whether an article should be included in the review were resolved by mutual agreement.

Search Results
In total, 1462 studies were initially identified.First, duplicate works were excluded (n = 484).The titles of the remaining 978 articles were reviewed using the inclusion criteria.In this second stage, 950 articles were excluded, 934 of these because they dealt with other topics, 10 because they referred to review studies, and 6 because they addressed interventions in the context of juvenile justice.
Thus, as a final step, 35 studies were read in full, but 16 of them did not meet the inclusion criteria and were excluded for the reasons set out below in the flowchart of the search strategy (Figure 1).The process of inclusion and exclusion of articles took place between February and August 2023.

Studies Characterization
The following data refer to the general characteristics of selected studies.This review included 19 studies in total.We classified the studies according to authors, year of publication, country, theme and moment of intervention, sample (participants), objectives, methods, and main findings (Table 1).
The oldest study publication included in this review dates back to 1997 (5.2%).Five studies were published between 2001 and 2008 (26.3%), seven studies were published between 2014 and 2018 (42.1%), and six between 2019 and 2022 (31.5%).Regarding the country of origin, the majority (13 studies) were developed in the United States (68.4%), two in Australia (10.5%), two in Cuba (10.5%), and the rest are equally distributed (5.2% in each) from Brazil and South Africa.
Finally, it is relevant to highlight that five works (5) were focused on women's health, approaching topics such as reproductive health, cervical cancer, and HIV risk reduction.A more detailed synthesis of the selected studies' content can be found in Table 1.

Studies Characterization
The following data refer to the general characteristics of selected studies.This review included 19 studies in total.We classified the studies according to authors, year of publication, country, theme and moment of intervention, sample (participants), objectives, methods, and main findings (Table 1).
The oldest study publication included in this review dates back to 1997 (5.2%).Five studies were published between 2001 and 2008 (26.3%), seven studies were published between 2014 and 2018 (42.1%), and six between 2019 and 2022 (31.5%).Regarding the country of origin, the majority (13 studies) were developed in the United States (68.4%), two in Australia (10.5%), two in Cuba (10.5%), and the rest are equally distributed (5.2% in each) from Brazil and South Africa.
Of the total number of studies selected (n = 19), the majority were quantitative studies (12), others were qualitative (2), and the rest were classified with a mixed methodological approach, quantitative and qualitative (5).Regarding the health interventions described   During the first two months after release, there were eight "boosting" sessions, the first being four days after release.
By learning about HIV rates among women prisoners, participants gained a better understanding of how HIV affects children, families, and communities.As a result of this knowledge, followed by training to achieve social support, self-efficacy can be enhanced.

Transition from Prison to the Community and Health Education Interventions
Most of the studies described in this review were developed in the context of the transition from prison to the community.As stated by previous authors [37], prisoner reentry includes many processes that begin before the individual is released from prison, as well as experiences at the moment of release and during the first few years in the community.Educational interventions allow the provision of new cognitive, social, and health education skills.Several authors have reported that good health in prison is associated with a reduced likelihood of recidivism [38].Thus, educational interventions and research involving prison health care generally recognize that incarceration is an opportunity (sometimes the first) for medical care [26,28], diagnosis, and treatment of illness.
Despite that, internationally, numerous challenges were reported in the criminal justice setting and the intersection with health care during and after prison, highlighting limited financial resources, the absence or underdevelopment of reintegration programs, and those focused on adaptation, especially for women [18], and the lack of knowledge or lack of control over the release date or even short lengths of stay [39]-factors that result in interventions that are sometimes briefer and more flexible [31].

Women's Health and Techniques for Health Education and Promotion
Nearly one-third of the studies included in this review focused on health education for women.Previous literature showed that women with criminal records are more likely to suffer from chronic diseases such as cancer, hypertension, heart disease, and diabetes [40], thus requiring more attention from academics and governments in the scenario of public health focused on prison health.Even though research on the general health of criminalized women is needed, it is limited and almost nonexistent [41,42].
Some authors argue that ideas relating to health promotion in prisons, especially in women's prisons, are in development.Such include a more participatory approach, using community development methods that can contribute to making women prisoners more health literate and more confident to look after their health and the health of their children (particularly babies born in prison) [42].
On the other hand, few studies indicate that women leaving prison prefer multimedia interactions [43].In contrast, other studies suggest that health information delivered via video is more likely to lead to a change in preventive behavior than traditional methods (pamphlets), especially for audiences with less health education [44].

Focus Group Discussions, Motivational Interviews, and Health Education Interventions
Focus group discussions and motivational interviews were used in some of the interventions reported by our review.In terms of the intervention technique, motivational interviews have shown to be suitable for incarcerated populations [45,46], as evidenced by research conducted on urban women involved in criminal justice, which indicated a reduction in risky sexual behaviors as well as drug abuse [46].
When it comes to substance abuse, in general, motivational interviewing is regarded as an effective tool for treating this health issue since more traditional treatment during and after incarceration may be limited by barriers to access, both inside and after prison [47].Although studies using a motivational interview approach for alcohol consumption education for prisoners were not included in the present review, part of the literature indicates that such an approach is more effective than educational interventions [48].It should be noted, however, that there is a low quality of literature on motivational interviewing on this topic due to the lack of measurements of motivation to change and duration of treatment, among other parameters [47].

Alcohol, Drug Abuse, and Health Education Interventions
Apart from alcohol consumption, some of the studies in this review dealt with issues linked to opioids and other substances.The association between substance use and crime is very common but complex [49].Opioid use disorder is a very common problem in prisons, which can be explained by drug criminalization and, therefore, by people's involvement and use of illegal drugs.An estimated one-third of criminal justice-involved individuals with substance use disorders receive treatment within 1 year of their release [50].
In this review, we observed that most of the interventions aimed at preventing substance abuse were led during imprisonment and that, in at least three of them [18,32,36], participants were followed up after release to determine the effects of the intervention.This is aligned with other authors who state that it is important to adapt the programs to the needs and individual characteristics of each offender in order to achieve a successful intervention [49].

Lack of Educational Interventions Linked to Noncommunicable Diseases
Even though people deprived of liberty have an increased risk of developing noncommunicable diseases by 1.2 to 1.8 times more often compared with the extramural community, and cardiovascular diseases are among the most common causes of death in prisons [51], especially hypertension and smoking [52,53], we observed a lack of educational interventions performed for this particular issue.
Tuberculosis is also a particular health concern in prison settings, and it often occurs at a tenfold higher rate in prisoners than in the general population [28].The impact of this on public health is often related to the interruption of treatment initiated in prison as a result of the release of prisoners.
As stated by previous authors [54], prison health policies that combine prevention and treatment measures via physical activities, healthier diet, and smoke-free prisons can contribute to supporting the sustainable development goal 3.4 of "reducing one-third of the incidents of premature mortality from noncommunicable diseases".Additionally, more research is needed to provide scientific-based evidence that can be used by stakeholders to improve ongoing prison health policies and strategies.

HIV and Other Sexually Transmitted Infections
Several of the studies approached in this review included sexual health interventions initiated in prison and whose effects could be monitored or evaluated after release.The increase in the incidence of human immunodeficiency virus (HIV) infections in prisons has historically been another major health problem, which is why the prison environment is considered an important focus for prevention, screening, and referral to healthcare [55].It is for no other reason that this topic was the most discussed in studies.
We observed that most of the research conducted on sexual health education focused on HIV infections as the primary concern, and literature [43] has indicated that providing general education and case management services enhances retention in treatment.
A major challenge identified is the continuity of care initiated in prison, as post-release infections are extremely difficult to measure outside of carefully constructed, funded, and controlled research settings [44].Due to this, research supports the need to manage the transition from prison to society to facilitate the use of community resources, especially those associated with drug/alcohol treatment combined with sexual health care [46].Almost all of the studies included in this review described the group intervention approach as the main strategy for the prevention of risky sexual behaviors, using health education sessions in the form of lectures and presentations.Prison peer education was a crucial intervention strategy used to deliver health education, contributing to reducing behavioral risks in participants [44].
Nevertheless, the majority of studies addressing peer education interventions in prisons still lack adequate methodological quality.Authors argue, however, that prevention strategies that rely solely upon education may not be sufficient to reduce sexual risk among these populations and that behavioral interventions may result in more concrete habit changes [56], especially when considering the biomedical needs of women incarcerated who are HIV/AIDS-positive [57].

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The results of this narrative review should be interpreted with caution due to specific study limitations of the literature included, such as the small sample size of some of the quantitative studies (n < 100).

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We did not perform a quality assessment of the studies included (using checklists such as PRISMA, AMSTAR, or SANRA) as this study is a narrative review and was not intended to be a systematic review or meta-analysis.

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The limitation of the study language was a limitation in the present study.

Conclusions
In this review, we identified relevant health education initiatives around the world that target individuals undergoing the transition from prison to community life or recently released from prison.The implementation of educational interventions for prisoners through lectures, discussions, reading tasks, and group activities were critical aspects for achieving successful results.
As seen, educational interventions develop new cognitive, social, and educational skills that are essential for this public, not only due to the history of social vulnerability that generally identifies this population but also due to the fact that health care within a prison environment implies a reduced likelihood of repeating criminal behavior.When people received health education instructions following their release, they were more likely to initiate medication treatment in the first month following their release.Re-entry programs based on health education have the potential to reduce the risk of death due to opioid overdose in females.
This narrative review unveils the need for more research in health education interventions focused on people who are in prison or have experienced prison, aiming particularly at public health topics where gaps prevail (such as noncommunicable diseases).
Considering the implications for practice, this present work has the potential impact of informing future health education initiatives and public policies for individuals who have experienced prison, particularly those in the pre-release moment.In the context of criminal justice, implementing health education initiatives such as those discussed in this study will facilitate the development of possibilities for social reintegration through health, including facilitating the work of both justice and health professionals.

Figure 1 .
Figure 1.Flowchart of the search strategy and article selection phases.

Figure 1 .
Figure 1.Flowchart of the search strategy and article selection phases.

Table 1 . Characterization of selected studies. Authors, Year, and Place of Study Theme and Moment of Intervention Study Objectives Methods Main Results
The implementation of a successful re-entry program for the vulnerable female incarcerated population has the potential to reduce the risk of opioid overdose death and negative health outcomes post-release and provide an opportunity for adapting culture and starting other supportive re-entry type programs.