Health-care utilisation among women involved with the criminal justice system: a systematic review and meta-analysis of population-based observational studies Open Access

Criminal justice involvement, which refers to any formal contact with the criminal justice system (CJS), including arrest, community supervision, probation, parole or incarceration, has been identified as a significant contributor to poor health and health-care underutilisation (Binswanger et al., 2011; Emerson et al., 2022). Women involved with the CJS represent a vulnerable group, typically presenting with complex health-care needs spanning physical, mental and reproductive health conditions, alongside harmful and chronic use of alcohol and illicit substances (Kinner and Young, 2018; McLeod et al., 2025). These health challenges are frequently compounded by intersecting social and structural disadvantages, including intergenerational trauma, childhood adversity, histories of abuse and socio-economic disadvantage (Green et al., 2016; Sapkota et al., 2022). Such disadvantages are associated with both offending behaviour and accumulation of unmet health needs (DeHart et al., 2013; Lambdin et al., 2018; Lynch et al., 2017), making health-care utilisation a critical area of study for addressing health inequities or disparities in this population.

Research on health-care utilisation in this population is growing, but most studies focus narrowly on health-care service use in prison or immediately after release (Agbaria et al., 2024; Bui et al., 2019). Many women enter prison with multiple and often unmanaged health conditions, as pre-prison life is commonly characterised by instability, poor access to care and competing survival priorities (Alves et al., 2015; Butsang et al., 2023). For some, incarceration could serve as a “window of opportunity” to address their health issues (Sapkota et al., 2022; Woodall and Freeman, 2020). However, the quality of prison health care varies considerably, with overcrowding and limited resources creating significant gaps between demand and service capacity (Plugge et al., 2006; Watson et al., 2004). As a result, women may face long waiting times for appointments and, in some cases, leave prison without receiving necessary screening or treatment (Bui et al., 2019).

The transition from prison to community represents a period of heightened vulnerability. Women re-entering the community must often prioritise urgent needs such as securing housing, finding jobs and reuniting with family/children, which can impede their health-care engagement. Despite significant health needs, many do not seek treatment or engage with services during this transition (Agbaria et al., 2024). Some women avoid health care altogether because of discrimination, negative past experiences or practical barriers such as transport and cost (Agbaria et al., 2024). This can disrupt treatment continuity, leading to deteriorating health and well-being (Binswanger et al., 2011; Frank et al., 2023).

Importantly, women’s contact with the CJS is not limited to incarceration. Many women cycle repeatedly through arrests, probation, parole and community-based supervision. Associated experiences, such as meeting court orders, childcare disruptions and stigma, can cause stress and trauma and lead to further challenges (Council on Criminal Justice, 2024). Evidence shows that recently arrested women have higher mental health needs and increased hospitalisation and emergency department use compared to those not recently arrested (Nowotny et al., 2019). Similarly, women on probation frequently use both emergency and routine health-care services (Lorvick et al., 2022; Lorvick et al., 2023).

The substantial health burden among justice-involved women (Australian Institute of Health and Welfare, 2023; Council on Criminal Justice, 2024), combined with the complexity of their health-care utilisation, highlights the need to understand the factors shaping service use. Andersen’s Behavioural Model of Health Service Use (Andersen, 1995) provides a simple, yet useful, conceptual framework to categorise influences into predisposing, enabling and need-related factors. Predisposing factors include demographic characteristics such as age, gender and social structure. Enabling factors encompass resources that are likely to promote the use of health-care services, including health insurance, income and access to care. Need-related factors refer to those that increase the vulnerability or perceived need for health services, including the presence of diagnosed health conditions or self-rated health status. While this model has been widely applied in general populations and adapted for incarcerated groups (Nowotny, 2017), its application across the broader spectrum of CJS involvement remains limited.

While there is a substantial body of literature describing the health needs of incarcerated women, relatively few studies have examined health-care utilisation patterns across different stages of women’s CJS involvement. Existing reviews have notable limitations. For example, one systematic review explored primary health-care use among women transitioning from prison into the community, highlighting barriers such as logistical challenges, stigma and fragmented care (Agbaria et al., 2024). However, this review focused solely on post-release primary health-care use, excluding other service types and not providing pooled prevalence estimates (Agbaria et al., 2024). Another review examined health-care access among incarcerated and recently released women in rural areas, concluding that women in rural prisons experience a general lack of health-care options and availability, and those returning to communities face significant access barriers (Heggie et al., 2025). However, this review examined access, which does not always represent utilisation and also did not report prevalence estimates for health-care use during and after prison. Overall, prevalence data are often restricted to a single period (incarceration or post-release) and to specific service types, leaving significant gaps in understanding. Although the publication of primary studies in this area has seen considerable growth in recent years, to our knowledge, no review has synthesised patterns of health-care utilisation across multiple health-care service types and different stages of CJS involvement.

This systematic review and meta-analysis aim to synthesise quantitative empirical evidence on health-care service utilisation among CJS-involved women and explore factors associated with service use. This paper will explore the following research questions:

Given the over-representation of CJS-involved women with complex health needs and the documented barriers to health-care access, a nuanced understanding of health-care utilisation across different CJS contexts is essential. Such knowledge is critical to informing the design of targeted interventions and policy reforms aimed at reducing health inequities and improving public health outcomes.

This systematic review was registered at the International Prospective Register of Systematic Reviews (PROSPERO; ID: CRD420251000483) and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines (Moher et al., 2015). The PRISMA checklist is provided in Supplemental Table S1.

A systematic search of the electronic databases MEDLINE, PsycINFO, Embase, Scopus, ProQuest One Academic and Criminal Justice Abstracts was performed to identify peer-reviewed articles published in English between 2015 and 2025. The initial search was conducted on 14 January 2025 and updated on 6 August 2025. Key search terms included (“healthcare use” or “health utilisation” or “healthcare services”) AND (“women or females or mothers”) AND (“prison or jail or convicts or offenders”). The search terms and search strategy for each database are provided in Supplemental Table S2. We also screened Google Scholar (up to 15 pages) for any new articles not identified in the initial search. Finally, the reference lists of the included articles were screened to identify additional literature that may meet eligibility criteria.

This review included studies that reported quantitative findings on any type of health-care service use by adult women (18 years and older) with CJS involvement. Studies including mixed gender samples were only eligible if disaggregated data for women were provided. Studies involving juveniles (<18 years) or those not providing disaggregated data for adult women were excluded. Only full-text articles published in English were considered. Studies that evaluated the impact of an intervention, program or policy on health-care utilisation were included only if baseline findings were reported and only baseline data were used in the meta-analysis. Narrative reviews, opinion papers and qualitative studies without quantitative data on health-care utilisation were excluded.

The study selection process was conducted with Covidence, a Cochrane-endorsed software package for conducting systematic reviews (Veritas Health Innovation, 2025). ZH performed the initial database search in January 2025 and imported identified records into Covidence. After removing duplicates and irrelevant records, two reviewers (DS and ZH) independently screened titles and abstracts, as well as full texts. Any discrepancies were resolved in consultation with a third reviewer (SD, TRM and JR). Of 106 articles included at the full-text stage from the initial search, the Kappa inter-rater agreement (α = 0.73) indicated substantial agreement (Landis and Koch, 1977). Data extraction was conducted using a Microsoft Excel spreadsheet, which included fields for author(s), title, year of publication, study setting and design, data collection methods/sources, sample size and characteristics, timeframe, type and prevalence of health-care utilisation and associated factors. DS and ZH independently extracted data for 20% of the studies (n = 10) and cross-checked each other’s work to ensure consistency in data extraction. The remaining studies were divided between the reviewers, with each cross-checking the other’s data extraction as needed. Discrepancies were resolved through discussion, involving other reviewers when necessary. When BB updated the search in August 2025, the same screening and data extraction procedures were followed. We identified eight new articles from the updated search.

In the context of this paper, health-care utilisation was defined as the use of any health-care services by women who had experienced contact with the CJS. We examined the different types of health-care services reported across studies and grouped them into mutually exclusive categories based on how service use was described in each article (Supplemental Table S3).

Of 42 eligible studies, 39 were conducted among currently and formerly incarcerated women, while three focused on women with other forms of CJS contact. Three studies that used measures other than proportions to report on health-care utilisation (e.g. mean and rates of visits) were not included in the meta-analysis (Supplementary Table S6). For the purposes of the meta-analysis, we only included studies conducted among ever-incarcerated women that reported proportions of health-care use, to maximise methodological consistency and ensure reliability of pooled estimates.

If three or more articles reported on proportions of health-care utilisation, then a proportional meta-analysis was conducted to calculate the pooled prevalence estimates. If a single article reported multiple outcomes for the same time point related to the same type of health-care utilisation, then we selected the most comprehensive outcome, typically the bigger sample size and higher estimate. However, if an article reported on the same type of health-care service utilisation at different times, then we included all estimates and identified the article using letters (e.g. “a” and “b”) after the year of publication. We conducted separate meta-analyses by service type to maintain the independence of effect sizes.

We examined random effects by using the generalised linear mixed models, which have smaller biases and better performance than other methods (Lin et al., 2021). The proportion of health-care utilisation in each article was logit-transformed to stabilise the variances of the prevalence estimates (Schwarzer et al., 2019). A random-effects model was chosen because of the anticipated heterogeneity in the data. The extent of heterogeneity across articles not because of chance was assessed using I² and the Cochrane’s Q tests (Barker et al., 2021).

Subgroup analyses were performed if five or more observations were available (Supplementary Table S6). These analyses were based on the types of health-care services accessed and the timing of utilisation (e.g. pre-prison, in prison and post-release). When the timing of health-care use was unclear, we used the timeframe reported in the paper (e.g. past 6 months, past 12 months and ever) and grouped them as “ever” for the subgroup analyses. Additional subgroup analyses explored if the pooled prevalence rates varied by study characteristics, including study setting (e.g. high- and middle-income group; World Bank, 2024), sample size (e.g. < 100, 100–499, 500–999 and ≥ 1,000) and publication year (2015–2019 and 2020–2025). Publication bias was not assessed because of the lack of a suitable publication bias assessment tool in a single-arm meta-analysis, with a small number of included studies (Barker et al., 2021). All analyses were performed using the “meta” package in R (version 4.2.2; R Core Team, 2021).

For studies reporting factors associated with health-care utilisation, findings were synthesised under the three categories of Andersen’s Behavioural Model of Health Services Use (Andersen, 1995; Supplementary Table S7).

The quality of the included studies was assessed using the National Institute of Health Quality Assessment Tool for Observational Cohort and Cross-sectional Studies (Supplemental Table S4). Articles from the initial search were appraised by ZH, and those from the updated search were assessed by BB. DS reviewed all assessments to ensure consistency. Any discrepancies were resolved through discussion among the authors until consensus was reached. Studies were rated as Good, Fair or Poor. A “Good” study was considered to have the least risk of bias, “Fair” indicated susceptible to some bias, and “Poor” indicated a high risk of bias.

A total of 6,606 articles were extracted during the database searches (Figure 1). After removing duplicates and screening titles and abstracts, the full text of 115 articles was reviewed. Of these, 55 met the inclusion criteria. A further five papers were identified by manually searching the reference lists of the eligible articles and past reviews. In total, 60 articles were included in the review, drawn from 42 independent studies.

The basic characteristics of the included studies are summarised in Supplemental Table S5. Most studies were conducted in the USA (n = 23, 32 articles), with additional studies from Australia (n = 4, 9 articles), Canada (n = 4, 6 articles), Brazil (n = 3, 4 articles) and the UK (n = 2, 3 articles). Overall, the majority were undertaken in high-income countries (n = 38), with the remaining four conducted in middle-income countries (Figure 2).

Of 42 studies, 39 examined currently and/or formerly incarcerated women, one focused on women on probation (Lorvick et al., 2022; Lorvick et al., 2023), one on women on probation and parole (Lorvick et al., 2015) and one on recently arrested women (Nowotny et al., 2019). Only a few studies focused on women with specific characteristics. For example, five studies were conducted among women living with HIV, five among women with mental illness or substance use disorders, one among First Nations women in Australia and two among women aged 50 years and older.

More than half of the studies had cross-sectional designs (n = 25), and only six were conducted longitudinally. The most used data collection methods were administrative health and correctional records (n = 13), interviews (n = 10) and surveys (n = 9). Five studies used a combination of interviews/surveys and administrative data. Sample sizes ranged from 7 to 13,739 participants, with the total sample size being 58,028 CJS-involved women.

Of the 60 papers included in the review, 32 were rated as “Good quality” and 28 as “Fair”. As all studies included in the meta-analysis were assessed as either “Good” or “Fair” quality, subgroup analyses based on quality ratings were not conducted.

A total of 33 studies were included in this group, yielding 85 observations for the meta-analysis. Because of heterogeneity in the types of health-care services assessed, we conducted separate meta-analyses for each service type to estimate pooled prevalence rates.

Figure 3 illustrates the use of emergency department (Ed.) services, GP visits, general health services use and hospitalisation. General health-care use was highest at 73.0% (95% CI: 49.0, 88.0%, n = 7), followed by GP services, with nearly seven in ten women reporting at least one visit (67.0%; 95% CI [55.0, 77.0], n = 6). More than half of women with a history of incarceration accessed emergency health care at some point (53%; 95% CI [30.0, 75.0], n = 6). In contrast, hospitalisation was relatively uncommon, with 24.0% of women having ever been hospitalised (95% CI [16.0, 35.0], n = 8). Substantial heterogeneity was observed across all analyses (I² = 90.5%–98.3%).

Figure 4 displays pooled prevalence rates of health-care utilisation for mental health-related health care, including services for substance use. Overall, 31.0% (95% CI [22.0, 41.0], n = 19) of women used unspecified/general mental health services. The cumulative proportion of women receiving services from a psychiatrist was 51.0% (95% CI [34.0, 67.0], n = 4), while only 15.0% of women engaged in SUD treatment services (95% CI [5.0, 38.0%], n = 6). Heterogeneity across articles remained substantial (I² = 94.2%–98.2%).

As shown in Figure 5, utilisation rates varied across preventive, reproductive and unspecified health-care services, as well as services for Sexually Transmitted Infections/Blood Borne Viruses (STIs/BBVs). Use of unspecified health-care services was high, accounting for 73.0%, followed by preventive services (64.0%; 95% CI [38.0, 84.0], n = 7). Just over six in ten women reported using services for STIs/BBVs (62.0%; 95% CI [41.0, 80.0], n = 8), while reproductive health-care use was reported by 55.0% (95% CI [21.0, 85.0], n = 7). Considerable heterogeneity was present across all analyses (I² = 97.4%–99.8%).

Finally, Figure 6 highlights health-care utilisation among women with specific health or demographic characteristics who experienced incarceration. Among currently/formerly incarcerated women living with HIV, 58.0% accessed some form of health care (95% CI [40.0, 74.0], n = 9), though heterogeneity was high (I² = 95.2%). In contrast, less than half of women with mental illness and substance use disorders (MISUDs) used any health-care services (40.0%; 95% CI [30.0, 50.0]; n = 16; I² = 95.1%). Utilisation among older incarcerated women was notably lowest, with only one in four accessing health-care services (25.0%; 95% CI [19.0, 32.0], n = 3; I² = 77.9%).

Subgroup analyses using Cochrane’s Q Test revealed several statistically significant differences in health-care utilisation across the incarceration timeline (Supplemental Table S6). The proportion of Ed. utilisation varied markedly by timing (Q (3) = 140.80, p < 0.01, n = 6). Specifically, post-release use was at 66.0% (95% CI [49.0, 79.0], n = 2), while pre-prison use was highest at 70.0% (95% CI [64.0, 76.0], n = 2). Only one article each examined ever Ed. use and use during incarceration.

A similar pattern was found for GP visits, with significant differences across the incarceration timeline (Q (2) = 66.26, p < 0.01, n = 6). Pre-prison GP visits had a pooled prevalence of 51.0% (95% CI [39.0, 64.0], n = 2), whereas in-prison GP visits were more common at 69.0% (95% CI [62.0, 74.0], n = 3). Only one article reported on post-release GP visits.

Mental health (MH) service use also differed significantly across timeframes (Q (3) = 73.75, p < 0.01, n = 19). Post-release MH service use was relatively low at 13.0% (95% CI [7.0, 24.0], n = 3). Pre-prison MH service use was higher (28.0%; 95% CI [25.0, 31.0], n = 2), increasing to 32.0% (95% CI [22.0, 43.0], n = 12) during incarceration. Ever use of MH service use had the highest prevalence at 68.0% (95% CI [60.0, 76.0], n = 2).

Hospitalisation rates also differed significantly across incarceration timelines (Q (3) = 35.59, p < 0.01, n = 8). The pooled prevalence increased from 16.0% (95% CI [6.0, 33.0], n = 3) pre-prison to 19.0% (95% CI [15.0, 23.0], n = 2) during incarceration, with ever use reaching 40.0% (95% CI [34.0, 47.0], n = 3). Only one study reported hospitalisation post-release.

Reproductive health service use varied significantly by timing (Q (2) = 10.51, p < 0.05, n = 7). In-prison utilisation was relatively low, with a pooled prevalence of 19.0% (95% CI [2.0, 69.0], n = 3), while ever use was considerably higher at 86.0% (95% CI [69.0, 95.0], n = 3). Only one study reported on pre-prison reproductive health-care use. STIs/BBVs screening or treatment services also showed significant variation across time (Q (2) = 142.81, p < 0.01, n = 8). In-prison utilisation had a pooled prevalence of 62.0% (95% CI [38.0, 82.0], n = 5) compared with 82.0% (95% CI [80.0, 83.0], n = 2) for ever use, with only one study reporting pre-prison use.

Substance use treatment differed significantly across the timeline (Q (2) = 33.23, p < 0.01, n = 6). In-prison utilisation was reported at 18.0% (95% CI [6.0, 44.0], n = 4). Unspecified health-care use also varied significantly by timing (Q (2) = 9.25, p < 0.01, n = 6), with pre-prison use at 62.0% (95% CI [29.0, 87.0], n = 4). In contrast, no statistically significant differences were found for preventive health services (Q (2) = 1.74, p > 0.05, n = 7) or for physical/general health services (Q (2) = 1.20, p > 0.05, n = 7).

When stratified by country income level, overall health-care utilisation among women who experienced incarceration was significantly higher in articles from middle-income countries (83.0%, 95% CI [72.0, 90.0], n = 8) compared with those from high-income countries (44.0%, 95% CI 36.0, 52.0], n = 76; Q (1) = 25.27, p < 0.01). No significant differences were observed across subgroups by publication year (Q (1) = 0.01, p > 0.05) or sample size (Q (1) = 7.61, p > 0.05).

Examination of health-care service use among ever-incarcerated women with HIV at any timeframe revealed a statistically significant difference by service type (Q (8) = 10.64, p < 0.05). Ed. use and STIs/BBVs services had the highest pooled prevalence, each at 62.0% (Ed. use: 95% CI [57.0, 67.0], n = 2; STIs/BBVs: 95% CI [36.0, 83.0], n = 4). Substance use treatment had a lower pooled prevalence of 28.0% (95% CI [11.0, 56.0], n = 2), while unspecified health care was reported in only one article (Supplemental Table S6).

Sample size was also a significant moderator (Q (8) = 8.06, p < 0.05), with studies enrolling fewer than 100 participants showing a higher pooled prevalence of health-care use (74.0%, 95% CI [58.0, 85.0], n = 5), compared with those recruiting between 100 and 499 participants (38.0%, 95% CI [23.0, 57.0], n = 4). Subgroup analyses by timing of any health-care utilisation (Q (6) = 1.93, p > 0.05) and publication year (Q (9) = 3.78, p > 0.05) were not statistically significant.

Among ever-incarcerated women with MISUDs, the proportion of health-care utilisation significantly varied by service type (Q (5) = 107.24, p < 0.01, n = 14) as shown in Supplemental Table S6. Use of mental health professionals was most common, with a pooled prevalence of 59.0% (95% CI [37.0, 68.0], n = 4), followed by physical or general health services at 37.0% (95% CI [24.0, 51.0], n = 2). Ed. visits, psychiatrist consultations and substance use treatment services were each reported in only one study. No significant differences were observed by publication year (Q (1) = 2.09, p > 0.05, n = 13).

This section summarises the key factors associated with health-care utilisation (n = 33), organised under three conceptual categories – predisposing, enabling and need factors – based on Andersen’s Behavioural Model for Health Services Use (Supplemental Table S7).

Predisposing factors such as sex, age, ethnicity, housing, education and social roles influence health-care use in varied ways. A total of 14 articles examined health-care utilisation by sex, demonstrating notable but inconsistent sex differences across service types. Several studies found that ever-incarcerated women were more likely than men to use hospital or Ed. services (Edwards et al., 2024; Norris et al., 2021; Puing et al., 2020; Ramaswamy et al., 2015) or general health care services (Bebbington et al., 2017; Jakobowitz et al., 2017; Norris et al., 2021). Most studies reported that ever-incarcerated women were more likely to use mental health services, HIV or STI treatment and screening services; however, some studies found the opposite association (Beckwith et al., 2017; Burgess-Proctor et al., 2024; Harmon et al., 2020).

Age patterns were mixed, with older ever-incarcerated women being less likely to use hospital or Ed. care (da Silva et al., 2017), yet more likely to seek mental health and general health-care services (Emerson et al., 2022; Timko et al., 2019).

Ethnic disparities persisted across service types, with women of colour often reporting lower utilisation of mental health, general health-care and STI services (Hicks et al., 2023; Kerr et al., 2023; Timko et al., 2019; Vaughn et al., 2024), but in some instances, higher rates of hospitalisation or Ed. use and cervical cancer screening (Kelly et al., 2018; Salyer et al., 2022).

Housing instability generally increased utilisation of acute care, mental health services and STIs/BBVs screening (Comartin et al., 2021; Satcher et al., 2023) but was associated with reduced engagement in preventive care (Salyer et al., 2022).

Lower educational attainment and having a male sexual partner were linked to reduced STIs screening (Kerr et al., 2023; Santana et al., 2021), while those who were ever pregnant were more likely to have STIs screening (Santana et al., 2021).

Enabling factors such as health insurance, public benefits and service availability played a critical role in facilitating health-care use. Two articles from the USA showed increased use of most services among those with health insurance (Salyer et al., 2022; Timko et al., 2019), although disparities remained – for example, Black women with insurance were less likely to access HIV treatment than White men (Vaughn et al., 2024). Other enablers, such as higher self-efficacy (Salyer et al., 2022), fewer perceived barriers (Kelly et al., 2018; Lorvick et al., 2022; Salyer et al., 2022), service accessibility (Kerr et al., 2023; Nowotny, 2016; Santana et al., 2021) and having a regular source of care (Lorvick et al., 2022; Salyer et al., 2022; Santana et al., 2021), were also associated with higher utilisation across multiple service categories. Prior engagement with SUD treatment services showed increased utilisation of HIV treatment services (Vaughn et al., 2024).

Need factors, reflecting individuals’ health conditions and perceived vulnerability, emerged as strong drivers of health-care use. Mental health disorders, chronic conditions and poor general health were associated with higher utilisation across hospital, mental health and reproductive services (Casey and Bentley, 2021; Janca et al., 2023; Lorvick et al., 2023; Nowotny et al., 2019; Satcher et al., 2023; Timko et al., 2019), though poor physical health was negatively associated with general health-care use in one study (Timko et al., 2019) . SUDs also had divergent effects. While Alves and colleagues (2022) and Walters and Magaletta (2015) reported increased use of acute, mental health and general health services among women using substances, others found lower utilisation of physical health care (Timko et al., 2019), preventive services (Salyer et al., 2022) and HIV treatment (Vaughn et al., 2024). Financial hardship was linked to lower engagement in preventive care and STIs screening (Lorvick et al., 2022; Santana et al., 2021).

Greater CJS-involvement, measured by violent offending, involvement in antisocial behaviours, longer sentences and repeated incarcerations, as well as experiencing childhood victimisation, were generally associated with increased health-care utilisation, particularly of mental health and preventive services (Casey and Bentley, 2021; da Silva et al., 2017; Kelly et al., 2018; Kerr et al., 2023; Nowotny, 2016; Qureshi et al., 2025; Santana et al., 2021; Walters and Magaletta, 2015). Compared to those with no CJS involvement, those with any type of CJS involvement (e.g. probation, parole or community supervision) were more likely to have increased hospitalisation (Nowotny et al., 2019) or STI screening (Lorvick et al., 2015) but less use of preventive care (Lorvick et al., 2022).

This paper aimed to synthesise quantitative evidence on health-care service utilisation among women across different stages of their criminal justice involvement. However, only three eligible studies focused on justice-involved women who were not currently incarcerated (i.e. probation and parole), which were precluded from meta-analysis. Consequently, the existing evidence presented here provides the first comprehensive synthesis of literature on health-care utilisation among women with a history of incarceration. Across 85 estimates pooled from studies conducted among incarcerated women, we found that health-care utilisation varied substantially across service types and stages of incarceration. We also pooled 25 estimates from studies conducted among subgroups of women (e.g. CJS-involved women with HIV, mental illness, or older women), which further revealed variations in health-care use. Health-care utilisation was shaped by multiple factors, which were grouped as predisposing, enabling and need factors based on Andersen’s Behavioural Model of Health Service Use.

Attesting to the diverse nature of health-care services and their variability in different countries, the studies used multiple outcome measures to define health-care utilisation. Overall, primary care services (general health care or GP visits) were the most used services by women experiencing incarceration, while overnight hospitalisation, mental health services and SUD treatment were less frequently used. More than half of women in these studies utilised preventive health care, screening and/or treatment services for STIs/BBVs and reproductive health care. The significant variability in service types used may be because of contextual differences in service delivery and accessibility or reflect the prioritisation of acute needs over preventive care – a pattern consistently observed in marginalised populations (Banham et al., 2019; Johnson et al., 2012).

Subgroup analyses revealed disparities aligned with known health inequities (Saunt et al., 2025; Unwin et al., 2020). Women with HIV used Ed. and STI services more often but had low uptake of substance use treatment, consistent with literature showing that competing health demands often shift focus from addiction to health treatment (Schultz et al., 2014). Similarly, women with MISUDs engaged with mental health professionals but had low utilisation of substance use treatment. Given their high co-occurrence (Kingston et al., 2017; Lai et al., 2015), it is possible that mental health professionals also treated substance use but recorded it as broader mental health treatment.

Despite the higher health burden found among older women generally (Boerma et al., 2016; Carmel, 2019), incarcerated older women showed low utilisation of health-care services. Examining reasons for underutilisation is beyond the scope of this review; however, this gap warrants further investigation, given the substantial age-related health needs of this vulnerable population (Emerson et al., 2022).

We also found variation in rates of health-care utilisation at different time points of women’s incarceration. Most assessments were made during women’s imprisonment, followed by pre-prison and post-release periods. Pre-prison, women relied heavily on Ed. services, reflecting unaddressed acute health needs and limited engagement with preventive or primary care. These findings align with existing literature highlighting that women may not seek health-care services before their incarceration, except during crisis (Ramaswamy et al., 2015). During incarceration, GP and preventive care use increased, likely because of mandatory screening programs, structural access or fewer logistical barriers within prison settings. These results support the assertion that for some women, incarceration may provide a period of stability and improved health-care access. Conversely, following release, utilisation of health-care services generally declined, pointing to critical gaps in continuity of care and reintegration in the community. These patterns highlight transitions into and out of prison as periods of heightened vulnerability requiring targeted interventions that ensure continual support and care (Binswanger et al., 2011; Frank et al., 2023). Because of the limited number of studies, we were not able to assess utilisation rates of different health-care services after release from prison. However, previous studies demonstrated women may have higher rates of acute service use post-release, often linked to resumption of alcohol or substance use, exposure to violence or deterioration of pre-existing conditions, while uptake of preventive and ongoing primary care remains low (Agbaria et al., 2024; Wang et al., 2013).

We conducted analyses based on the income category classification of countries where the studies were published. Notably, no studies from low-income countries were found. Service use was significantly higher in middle-income countries compared to high-income countries. While no general explanation for this result could be identified, the observed variability may be because of differences in study designs or population characteristics. Nevertheless, the finding reinforces the idea that health-care utilisation among women with incarceration histories is highly context-specific, requiring contextualised policy responses.

Our analysis revealed that factors influencing health-care utilisation among women with incarceration histories are diverse and sometimes inconsistent, depending on the service types examined. Enabling factors, such as insurance, service accessibility, access to regular care and perceived self-efficacy, consistently promoted utilisation across services. However, other factors, including gender, housing instability and SUDs, showed mixed or opposing associations. These findings suggest that to improve health-care utilisation, it is essential to ensure women’s access to health insurance and health services.

Underlying health conditions strongly predicted health-care use. Mental disorders, chronic illness and perceived poor health were need factors linked with higher service utilisation, especially of acute and mental health care. Interestingly, SUDs showed divergent effects, sometimes increasing women’s use of acute and mental health services, while also reducing their use of preventive and HIV care. These findings are consistent with past literature suggesting substance use can have differential effects regarding health-care utilisation among women (Barnett et al., 2021; Farhoudian et al., 2022). For some, especially for those who are pregnant or have children, substance use can be a motivator to seek health-care support. For others, it can act as a barrier to health-care engagement because of stigma and other competing challenges (Barnett et al., 2021; Farhoudian et al., 2022).

Greater justice involvement, including longer sentences, repeated incarceration, violent offending and victimisation histories, was generally associated with higher health-care utilisation, particularly for mental health and preventive services. This result contrasts with findings from studies conducted among women in the general population, where CJS involvement is often associated with limited access (Agbaria et al., 2024). However, as most studies included in this review were conducted among women who experienced incarceration, it is plausible that the observed high levels of health-care use may be because of court-ordered mandatory engagement with mental health programs or screening services within correctional facilities or post-release, which needs further investigation.

Our review highlights that ever-incarcerated women utilised different health service types at different rates. The consistently low post-release utilisation of most services compared to before and during incarceration underscores the urgent need to strengthen continuity of care during community re-entry. Bridging this gap will require coordinated release planning, linkages with community services and holistic wraparound support for women after release (e.g. securing housing, access to income support/welfare, safety planning against domestic and family violence, reunifying with children and access to training and employment). Identified barriers such as housing instability, risk of victimisation, unemployment, poor education and financial hardship not only shape health-care utilisation but also intersect with enabling factors such as health insurance, a regular source of care and service accessibility (Nowotny, 2017). To address health-care inequities, it is crucial to remove structural barriers while simultaneously strengthening enabling factors. The paucity of primary studies focusing on women who experience CJS contacts other than incarceration underscores an urgent need for further investigation. Such research is essential to determine whether varying forms of CJS contact differentially influence patterns of health-care utilisation.

As there were significant discrepancies across studies in terms of methodology and outcomes used, it is recommended that future studies standardise outcome measures and assessment approaches to reduce heterogeneity and improve comparability. Longitudinal research is particularly needed to track health-care use across incarceration trajectories, with a focus on post-release reintegration. Greater attention should be given to the intersecting effects of gender, race/ethnicity, age and social disadvantage on health-care utilisation. Filling these gaps will be essential to developing equitable, gender-responsive health systems for justice-involved women worldwide.

This review has several strengths. To our knowledge, this is the first systematic review and meta-analysis synthesising the use of health-care services among CJS-involved women. We applied a comprehensive search strategy without restricting service type or region. In addition, we used an established framework to systematically organise factors associated with health-care utilisation.

Despite these strengths, there are certain limitations to be acknowledged. Because of substantial heterogeneity in reported outcomes, we were unable to generate a single summary measure of health-care utilisation. No studies were identified from low-income countries, despite two-thirds of the global prison population residing in low- or middle-income countries (LMICs; Fair and Walmsley, 2022). This lack of studies from low-income countries limits the generalisability of our findings to resource-constrained contexts, where health-care access, policies and health needs may differ considerably. The evidence base is thus heavily skewed towards high-income contexts, particularly reflecting the USA health-care context, leaving major gaps in understanding the experiences of women in LMICs and other high-income countries. Furthermore, despite using comprehensive search terms, we identified only three studies that included women with justice contacts other than incarceration. Therefore, our findings primarily reflect health-care utilisation patterns among women who experienced incarceration. Finally, of 42 studies, 26 were cross-sectional, which restricted our ability to examine changes in health-care utilisation over time.

This comprehensive systematic review and meta-analysis examined health-care utilisation rates and patterns among ever-incarcerated women. We observed substantial variation across studies in both the types and timing of health-care services used. To synthesise findings, we grouped studies according to the type of health-care services used and calculated pooled proportions. Pooled analyses showed that unspecified and general health-care services were the most frequently used, whereas SUD treatment services were the least used. Incarcerated women with HIV had the highest health-care utilisation rates, particularly for Ed. use and STI screening. Subgroup analyses revealed differences in service use before, during and after incarceration, though few studies focused on the post-release period. Of the limited studies available, it was evident that health-care use was typically lower in the post-release period, highlighting the need to actively facilitate continuity in health-care access for women exiting prison.

Factors influencing health-care utilisation were mapped onto Andersen’s Behavioural Model for Health Services Use, highlighting the role of predisposing (e.g. sex, age, ethnicity, education and relationship status), enabling (e.g. health insurance, public benefits and service availability) and need-related (e.g. individuals’ health conditions and perceived vulnerability) factors. Most studies were cross-sectional, underscoring the need for longitudinal research. Greater attention to the intersecting effects of gender, race/ethnicity, age and social disadvantage on health-care utilisation is critical for informing health-care policy and interventions for women who have experienced incarceration.

The authors would like to thank Camille Hutchins for her support in the development of Figure 2 presented in the manuscript.

The supplementary material for this article can be found online.

This work was carried out as part of the Transforming Corrections to Transform Lives project (Transforming Corrections to Transform Lives Centrewww.transformingcorrections.com.au). The authors thank the Paul Ramsay Foundation for funding this project (grant number: 5090). Any opinions, findings or conclusions expressed in this manuscript are those of the authors and do not necessarily reflect the views of the Foundation.

Patients or the public were not involved in the design, conduct, reporting or dissemination plans of this study.

Diksha Sapkota: Conceptualisation, Formal analysis, Methodology, Visualisation, Writing – original draft; Zara Hurst: Literature Search, Formal analysis, Validation, Writing – Reviewing and editing; Brigitte Braddock: Literature Search, Validation, Writing – reviewing and editing; Janet Ransley: Funding acquisition, Writing – Review and editing; Tara Renae McGee: Funding acquisition, Writing – Review and editing; and Susan Dennison: Funding acquisition, Validation, Supervision, Writing – Review and editing.