Davidson S Principle And Practice Of Medicine(v1.0) APK
Maybell Hughs
There is a growing body of evidence demonstrating the effectiveness of peer-led services in supporting community reintegration for people released from prison. This study aims to document the guiding principle of a peer-led service for people released from prison, from the perspective of peer mentors.
Six themes were constructed to reflect the guiding principles of UTGSS staff. This includes four central themes: 1) Offering hope; 2) Building respectful relationships; 3) Providing consistent support; 4) Meeting people where they are at. Two connected themes are also reported: 1) Relying on shared experience, which participants reported serves as the foundation for practicing these guiding principles and 2) Bridging connections to services, which reflects the outcome of practicing these guiding principles.
People who have been incarcerated face a number of barriers transitioning from prison back to community [1,2,3]. These are driven in part by the significant interruptions to community, health system, family, and peer networks of support posed by periods of incarceration [3, 4]. Upon return to community, the most immediate needs facing this population are income and social support to obtain basic needs, including access to food, clothing, and safe and stable housing [5, 6]. Alongside these immediate basic needs, are significant service needs to address the disproportionately high rates of chronic physical health problems faced by people who have been incarcerated, often coupled with the need for health system support to address mental health and or substance use needs [7, 8].
People who have been incarcerated face social and structural stigma when seeking health and social services. For example, negative and stigmatizing beliefs about people with histories of incarceration and/or substance use and mental health needs can create barriers to securing employment and accessing care and support in social assistance, criminal-legal, and health care settings [3, 9,10,11]. These experiences of stigma are known to be further compounded for people with particular identities, including Indigenous ancestry, who are overrepresented in the criminal legal system in Canada. Anti-Indigenous racism has been identified as systemic in Canadian health and carceral systems and system-level efforts are required to transform health care culture, policies and practices to move toward health equity and reconciliation [12]. This systemic stigma discourages health and social service engagement, leaving people unsupported and at further risk of adverse outcomes following release, such as unmet housing and financial needs and limited opportunities for employment, return to incarceration, and significant preventable morbidity and mortality [13,14,15]. As such, eliminating barriers to services access is critical to promoting positive post-release outcomes.
There is a growing body of evidence demonstrating the effectiveness of peer-led services in supporting community reintegration, helping people to navigate the many complex barriers and challenges faced in this period of transition [16,17,18,19]. For example, a pilot randomized controlled trial in the United States tested a peer-led support intervention which provided social, emotional, and logistical support to people released from prison to promote health care engagement. People who received the intervention were significantly more likely to access substance use treatment and mental health services, to live in permanent housing, and had a lower recidivism rate than people who did not have access to the peer support services [4]. The evidence supporting these programs builds on decades of evidence from peer-led services in other settings, for example, among people living with HIV, people who use substances and access harm reduction services, and people with chronic diseases such as diabetes, whereby peer support builds a sense of trust which can support readiness to engage in services [20,21,22,23,24].
In BC, Unlocking the Gates Services Society (UTGSS) (a not-for profit organization) has been operating a peer-led mentorship program since 2011, offering release planning and community reintegration support for people released from prison. UTGSS is not a direct service provider, but instead is a peer-led organization, whose peer mentors work to connect people released from prison to services in the community, in a client centered way. This includes ensuring access to basic human needs following release, including food, clothing, and shelter. UTGSS has been able to meet significant need, reaching more than 1000 people in 2022 alone.
Qualitative research can best be understood when considering the ontological approach guiding the inquiry. In the present study, the objective was to develop internal documentation of UTGSS principles, practiced by UTGSS Staff in their work connecting clients to services post-release. These principles can best be understood as efforts to understand the questions, assumptions, beliefs, and biases researchers bring to their inquiry. The first author (HP), who led data collection and analysis engaged in memoing regarding reflexivity to reflect on how her position, prior experiences, assumptions, and beliefs might have influence on the results [31]. The first author was an outsider, with no lived experience of incarceration, and approached the research question with a level of naivete not held by other team members, including the UTGSS Program Manager (PY) and Executive Director (MK). The research team, and in particular the first author who led data collection acknowledged her interactions with participants as an inherent part of the research process, where findings are derived from co-construction of knowledge. This is in line with constructivist epistemology, whereby it is understood that research findings are inevitably a construction of our own understanding of the world rather than a purely objective perception of reality [32, 33].
Participants of the present study are UTGSS staff. UTGSS is a peer-led organization that supports people leaving provincial and federal prisons across British Columbia. Importantly, contact to engage in release planning is initiated while people are still incarcerated. UTGSS provide immediate practical assistance (e.g., meeting people at the gate and providing transportation when they are released; support with acquiring clothing, housing), emotional support (e.g., accompanying clients to medical appointments and court proceedings) and facilitate clients in attaining longer term personal goals (e.g., employment) and other needs (e.g., access health and social services) post-release.
The UTGSS Executive Director (MK) and Program Manager (PY) (co-authors) supported recruitment of participants via their network of staff to take part in interviews and/or focus groups. The interview guide was developed in collaboration with MK and PY and included questions about staff motivations for engaging in the work, day-to-day activities, and the key values and principles used to guide their work with UTGSS clients. The interview was trialled with ED and Program Manager before bringing it to the rest of the UTGSS staff, and thus MK and PY served as study participants, in addition to serving as co-authors. As UTGSS staff with significant institutional knowledge, MK and PY have critical insights to offer as to the guiding principles practiced by staff.
Participants described a shared understanding of clients, through language, challenges, and feelings that they experienced in their transition back to community. They described that the experience of incarceration and return to community cannot be taught, and a true understanding can only be brought by someone who had also lived through the same experience. For example, Simon described:
Participants noted a vulnerability in clients during the period of return to community. Reciprocating the same vulnerability by openly sharing personal experiences was an important approach to building connections with clients, relying on shared, collective experiences. For example, Kent described that in opening up, and sharing his own experience with clients early in their relationships, he was able to develop stronger communication and a sense of trust:
The shared experience motivated staff to support UTGSS clients, with the aim of making the process of navigating service access easier than it had been for themselves. Staff frequently reflected on their own struggles faced during their transition back to community and were able to use these experiences to identify important points of intervention, where they could target supports to avoid similar negative experiences for their clients. For example, Yelena said:
Given these challenges to community reintegration, peer mentors described the process of re-engaging in community as non-linear, with clients often being met with setbacks. Having consistent contact with UTGSS staff, to provide reassurance through these difficult times was described as critical to supporting clients in remaining hopeful about the future. Neil described that some clients often need this sense of encouragement and, when it comes from someone who has overcome the same challenges, it is all the more meaningful:
Another core principle described by UTGSS staff was building respectful relationships. Three approaches were consistently discussed in this regard: 1) treating clients how you want to be treated; 2) being honest; and 3) being a friend.
Foundational to building respect among UTGSS staff was treating clients how they wanted to be treated. This experience required reflection on their own feelings and experiences at the time of release, including recalling encounters with health and social service providers, whether negative or positive. For example, one participant reflected on their own experiences in health care following release, feeling unsafe, and unable to discuss their drug use with their doctor due to feeling they were being judged about ongoing use. Health care visits were recognized as interactions with vast power imbalances between patients and providers and having a peer accompany clients to their visits was seen as a way of minimizing this imbalance. In these discussions, participants emphasized the stigma and discrimination facing people released from prison, and that their interactions were intended to meet each person with respect, regardless of their current situation. Ellen elaborated:
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