A roadmap for cardiovascular care after release from incarceration: uses of a smartphone application

Pamela J Surkan; Lisa B Puglisi; Karim Butler; Nika Elmi; Wayne W Zachary

doi:10.1093/jamia/ocab079

A roadmap for cardiovascular care after release from incarceration: uses of a smartphone application

Surkan, Pamela J; Puglisi, Lisa B; Butler, Karim; Elmi, Nika; Zachary, Wayne W 2021-06-18 00:00:00 Abstract Objective Cardiovascular disease (CVD) and its risk factors disproportionately affect people returning from incarceration. These individuals face multiple barriers to obtaining care, which can impact CVD and risk factor management and may be mitigated through use of a smartphone application (app). Therefore, we explored the CVD-related needs of people released from incarceration and which app features would support these needs. Materials and Methods In 2019, we collected qualitative data through 7 focus groups with 76 returning citizens and 19 key informants through interviews and small group discussions in Baltimore, Maryland. Verbal data were audio-recorded, transcribed, and analyzed using inductive thematic coding with N-Vivo qualitative software. Results Returning citizens face multiple barriers when trying to engage in care and services related to cardiovascular health, including around medications and health insurance. Some major challenges were identifying trusted social services and making cardiovascular health a priority. Findings suggested that CVD risk factors could be more effectively addressed in combination with attending to other pressing needs related to employment, housing, behavioral health, and building trust. Participants suggested that a smartphone app would be most useful if it broadly addressed these issues by linking returning citizens to social services, including recommendations from peers, and facilitating access to healthcare. Discussion Returning citizens need broad support for societal reintegration. Addressing social issues would allow them to focus on cardiovascular health. Conclusion Given the challenges experienced after release from incarceration, an app focused on social and health-access issues may help returning citizens meet their CVD needs. mHealth, mobile application, cardiovascular disease, prison, jail, incarceration INTRODUCTION The population of persons returning from incarceration (henceforth termed returning citizens) is large, with over 600 000 returning citizens yearly since the 1990s.1,2 The incarcerated population is more economically disadvantaged than the overall population and in poorer health.3,4 Cardiovascular disease (CVD), the number 1 cause of death in the US,5 is also among the leading causes of mortality for people in jail6 and is a frequent cause of death after release.7 Cardiovascular risk factors, such as hypertension, are also more common among individuals with a history of incarceration.8–10 Acknowledging the critical need for interventions to improve cardiovascular health after release, the US National Heart Lung and Blood Institute held a 2017 workshop leading to recommendations for more research on cardiovascular health of returning citizen populations and new and innovative interventions to address these problems.4 Many smartphone applications (apps) have been created to improve chronic health conditions in the general population,11–14 including some that have shown efficacy for controlling cardiometabolic risk factors.15,16 None of these apps have focused on the needs of people who have been incarcerated. Moreover, there are reasons why these apps designed for a general population may not be accessible and may not align with the chronic health needs of returning citizens, despite their portability and convenience. Social Cognitive Theory asserts that individuals are nested within social environments that provide a context for their decisions and actions including health-related decisions, such as smoking, diet, and physical activity.17 For example, research on female returning citizens with substance use disorders found that mobile phones were a feasible way to deliver recovery support through access to their social networks.18 Such findings along with widespread penetration of smartphones in specific low-income subpopulations (eg, homeless youth),19–21 suggest app approaches may be effective, but also point out that their design and development must be rooted in an understanding of the social context of their users. Practically, the solution to this problem requires empirical data on the needs of returning citizens and constraints in their social environment. Given the complex situation around reentry, the aim of this study was to develop an understanding of the context returning citizens face and use this information to inform the design of a smartphone app to improve care of CVD and cardiovascular risk factors in this population. MATERIALS AND METHODS We used a community-engaged approach to guide the development of an app. In 2019, we collected qualitative data from returning citizens and key informants (KIs). The research team included students with graduate-level training in qualitative methods, 2 public health researchers with at least a decade of qualitative experience, an anthropologist, and 2 community health workers who work with returning citizens and have, themselves, been previously incarcerated. These community health workers were integrally involved in the project, bringing expertise about the experiences of formerly incarcerated individuals to the team, and shared in developing the research question as well as decisions about how to carry out the study. The research team also involved and received advice from 2 grassroots community organizations that support returning citizens in the reentry process. Data from returning citizens were collected through focus groups. Returning citizen inclusion criteria were 1) having returned from 1 year or more of prison, or ≥6 months of jail, within the last 5 years, 2) residing in Baltimore, Maryland on a planned permanent basis, and 3) having cardiovascular disease or at least 1 of the following CVD risk factors: being a smoker, overweight/obese, having type 2 diabetes or metabolic syndrome, or hypertension. For the returning citizen focus groups, we also allowed family or close friends of a returning citizen who had actively supported him/her within the last 2 years. In practice, many participants also met both criteria for inclusion, as a returning citizen and as a family/friend to another returning citizen. Recruitment was led by a field coordinator who was a community health worker with extensive ties to community organizations that serve returning citizens. Recruitment was done via snowball sampling based on his networks and affiliations with organizations working with this population. Upon arriving at the focus group, eligibility criteria were confirmed, as returning citizens filled out a sign-in sheet indicating whether they had a CVD diagnosis and which risk factors for CVD they had. Participants were asked to first list problems that they had related to CVD (or that they discuss to help someone with CVD) as well as barriers experienced in caring for these problems since returning to the community. The items on both lists were written on a poster visible to the group, as a basis for continued discussion. Key informants were people who worked in a professional capacity with returning citizens and met the following criteria: be a worker (paid or unpaid) in a governmental, nongovernmental, faith-based, or medical organization that seeks to support or provide healthcare services to returning citizens in the city of Baltimore, MD, and/or a corrections organization that provides oversight to those returning persons and that also actively works full or part-time with returning citizens. Using snowball sampling, we identified initial seeds who suggested others who would be knowledgeable about working with returning citizens through contacts of our team members and organizations supporting returning citizens. Additional key informants were then recruited from referrals made by key informants in focus groups or interviews. Data from key informants were collected through in-depth interviews or small group discussions until saturation was reached (ie, no new ideas were being obtained with additional data collection). Semi-structured guides were used to capture information on the needs and problems faced by returning citizens that could be addressed by an app as well as what returning citizens or service providers deemed desirable on such an app. Separate guides were used for returning citizens and family members versus for key informants (See Supplementary Material). Verbal data from focus groups and interviews were audio-recorded, transcribed verbatim, anonymized, and analyzed primarily using inductive thematic coding. We followed analytic steps that included: data familiarization, generating initial codes, creating themes, reviewing the themes, defining and naming them, followed by write-up.22 We used N-Vivo qualitative data analysis software (QSR International, Melbourne, Australia) for data management. Data collection was approved by the Western and Johns Hopkins Bloomberg School of Public Health Institutional Review Boards. Participants provided oral informed consent that specified that deidentified data could be shared for research purposes. RESULTS Seven community focus groups included a total of 76 returning citizens. Participants were approximately equal in gender (55% male) and were predominantly African American (82%). Seventy-four percent reported having smartphones, though often older or secondhand devices. Data were collected from 19 key informants through 3 small-group discussions and 7 in-depth interviews (Table 1). Table 1. Demographic makeup of participants and data collection event Data collection type/event . Gender . Race . Ethnicity . Returning Citizen Data . Total N . Male . Female . African American . White . Other/Unknown . Hispanic (1) . Focus group 1 15 15 0 15 0 0 0 Focus group 2 18 0 18 13 4 1 1 Focus group 3 9 9 0 9 0 0 0 Focus group 4 10 0 10 8 1 1 0 Focus group 5 12 12 0 11 1 0 0 Focus group 6 6 0 6 5 1 0 1 Focus group 7 6 6 0 0 5 1 0 Subtotals 76 42 34 61 12 3 2 Key Informant Data Small group 1 5 2 3 3 1 1 0 Small group 2 5 5 0 5 0 0 0 Small group 3 2 1 1 2 0 0 0 In-depth interview (2) 7 5 1 3 3 1 0 Subtotals 19 13 5 13 4 2 0 TOTALS 95 55 39 74 16 5 2 Data collection type/event . Gender . Race . Ethnicity . Returning Citizen Data . Total N . Male . Female . African American . White . Other/Unknown . Hispanic (1) . Focus group 1 15 15 0 15 0 0 0 Focus group 2 18 0 18 13 4 1 1 Focus group 3 9 9 0 9 0 0 0 Focus group 4 10 0 10 8 1 1 0 Focus group 5 12 12 0 11 1 0 0 Focus group 6 6 0 6 5 1 0 1 Focus group 7 6 6 0 0 5 1 0 Subtotals 76 42 34 61 12 3 2 Key Informant Data Small group 1 5 2 3 3 1 1 0 Small group 2 5 5 0 5 0 0 0 Small group 3 2 1 1 2 0 0 0 In-depth interview (2) 7 5 1 3 3 1 0 Subtotals 19 13 5 13 4 2 0 TOTALS 95 55 39 74 16 5 2 Open in new tab Table 1. Demographic makeup of participants and data collection event Data collection type/event . Gender . Race . Ethnicity . Returning Citizen Data . Total N . Male . Female . African American . White . Other/Unknown . Hispanic (1) . Focus group 1 15 15 0 15 0 0 0 Focus group 2 18 0 18 13 4 1 1 Focus group 3 9 9 0 9 0 0 0 Focus group 4 10 0 10 8 1 1 0 Focus group 5 12 12 0 11 1 0 0 Focus group 6 6 0 6 5 1 0 1 Focus group 7 6 6 0 0 5 1 0 Subtotals 76 42 34 61 12 3 2 Key Informant Data Small group 1 5 2 3 3 1 1 0 Small group 2 5 5 0 5 0 0 0 Small group 3 2 1 1 2 0 0 0 In-depth interview (2) 7 5 1 3 3 1 0 Subtotals 19 13 5 13 4 2 0 TOTALS 95 55 39 74 16 5 2 Data collection type/event . Gender . Race . Ethnicity . Returning Citizen Data . Total N . Male . Female . African American . White . Other/Unknown . Hispanic (1) . Focus group 1 15 15 0 15 0 0 0 Focus group 2 18 0 18 13 4 1 1 Focus group 3 9 9 0 9 0 0 0 Focus group 4 10 0 10 8 1 1 0 Focus group 5 12 12 0 11 1 0 0 Focus group 6 6 0 6 5 1 0 1 Focus group 7 6 6 0 0 5 1 0 Subtotals 76 42 34 61 12 3 2 Key Informant Data Small group 1 5 2 3 3 1 1 0 Small group 2 5 5 0 5 0 0 0 Small group 3 2 1 1 2 0 0 0 In-depth interview (2) 7 5 1 3 3 1 0 Subtotals 19 13 5 13 4 2 0 TOTALS 95 55 39 74 16 5 2 Open in new tab All data were collected between March and August 2019. Participants were asked if they identified as Hispanic or not (independently of their racial identification). In 1 in-depth interview conducted by phone, gender and ethnicity were not recorded. Challenges to cardiovascular health and app functions to address them Most returning citizens cited existing CVD diagnoses or a range of risk factors, including prior heart attacks and stroke, high blood pressure, diabetes and diabetes complications (amputations), smoking and obesity, and other possibly CVD-related symptoms (eg, shortness of breath, chest pains). They described awareness of the need to deal with these problems as well as barriers that prevented them from doing so. Barriers reflected 5 themes: problems related to health insurance; problems finding and accessing healthcare resources; the complexity of treatment and self-management plans; knowledge/information gaps; and distrust in healthcare and broader social institutions. Table 2 summarizes the barriers/needs identified in the analysis and potential app functionality derived to meet these needs. Table 2. Specific cardiovascular health support needs and corresponding app functionality from returning citizen participants Problem themes/subthemes from returning citizens . Corresponding app functionality suggested by returning citizens . Health insurance Poor/no insurance Limited understanding of coverage App gives user access to data on that user’s insurance benefits and coverage Finding and accessing healthcare Aids to find or gain access to health resources Can’t find resources for medications, healthcare providers Transportation is difficult and expensive App offers users ability to communicate with returning citizen peers to find health resources chance to use telemedicine, tele-triage, tele-diagnosis consults healthy food and nutritional information walking/public transportation maps of health resources and calculators that give user estimates of time and cost of travel to a health resource Barriers to keeping focus on health during reentry Aids to support health management Difficulty keeping track of healthcare needs and appointments Difficulty keeping track of health history Few opportunities for exercise Involvement in pleasurable activities inaccessible while “inside” App offers users automated checklists of how to complete specific tasks and reminders to follow up on scheduled tasks (eg, appointments) access to personal health record and supports access to providers’ patient portals a way to find others to join with them in exercise/physical activity Overcoming knowledge and information gaps Includes learning and information finding tools Lack of knowledge of medications and their intended effects and side effects CVD, related conditions, and risk factors how healthcare and social safety-net services are organized, and how to find and utilize them App offers users information on medical procedures, medication indications, contra-indications, interactions access and learning tools public-transit maps and help-finding mechanisms Lack of trust in health care, social, or penal system Reviews and comments from other returning citizens Expectations based on negative past experiences as returning citizens Openness to using experiences of other returning citizens to guide what to trust App allows and displays crowd-sourced reviews of healthcare (and other) resources entered by other returning citizen users of the app Problem themes/subthemes from returning citizens . Corresponding app functionality suggested by returning citizens . Health insurance Poor/no insurance Limited understanding of coverage App gives user access to data on that user’s insurance benefits and coverage Finding and accessing healthcare Aids to find or gain access to health resources Can’t find resources for medications, healthcare providers Transportation is difficult and expensive App offers users ability to communicate with returning citizen peers to find health resources chance to use telemedicine, tele-triage, tele-diagnosis consults healthy food and nutritional information walking/public transportation maps of health resources and calculators that give user estimates of time and cost of travel to a health resource Barriers to keeping focus on health during reentry Aids to support health management Difficulty keeping track of healthcare needs and appointments Difficulty keeping track of health history Few opportunities for exercise Involvement in pleasurable activities inaccessible while “inside” App offers users automated checklists of how to complete specific tasks and reminders to follow up on scheduled tasks (eg, appointments) access to personal health record and supports access to providers’ patient portals a way to find others to join with them in exercise/physical activity Overcoming knowledge and information gaps Includes learning and information finding tools Lack of knowledge of medications and their intended effects and side effects CVD, related conditions, and risk factors how healthcare and social safety-net services are organized, and how to find and utilize them App offers users information on medical procedures, medication indications, contra-indications, interactions access and learning tools public-transit maps and help-finding mechanisms Lack of trust in health care, social, or penal system Reviews and comments from other returning citizens Expectations based on negative past experiences as returning citizens Openness to using experiences of other returning citizens to guide what to trust App allows and displays crowd-sourced reviews of healthcare (and other) resources entered by other returning citizen users of the app Open in new tab Table 2. Specific cardiovascular health support needs and corresponding app functionality from returning citizen participants Problem themes/subthemes from returning citizens . Corresponding app functionality suggested by returning citizens . Health insurance Poor/no insurance Limited understanding of coverage App gives user access to data on that user’s insurance benefits and coverage Finding and accessing healthcare Aids to find or gain access to health resources Can’t find resources for medications, healthcare providers Transportation is difficult and expensive App offers users ability to communicate with returning citizen peers to find health resources chance to use telemedicine, tele-triage, tele-diagnosis consults healthy food and nutritional information walking/public transportation maps of health resources and calculators that give user estimates of time and cost of travel to a health resource Barriers to keeping focus on health during reentry Aids to support health management Difficulty keeping track of healthcare needs and appointments Difficulty keeping track of health history Few opportunities for exercise Involvement in pleasurable activities inaccessible while “inside” App offers users automated checklists of how to complete specific tasks and reminders to follow up on scheduled tasks (eg, appointments) access to personal health record and supports access to providers’ patient portals a way to find others to join with them in exercise/physical activity Overcoming knowledge and information gaps Includes learning and information finding tools Lack of knowledge of medications and their intended effects and side effects CVD, related conditions, and risk factors how healthcare and social safety-net services are organized, and how to find and utilize them App offers users information on medical procedures, medication indications, contra-indications, interactions access and learning tools public-transit maps and help-finding mechanisms Lack of trust in health care, social, or penal system Reviews and comments from other returning citizens Expectations based on negative past experiences as returning citizens Openness to using experiences of other returning citizens to guide what to trust App allows and displays crowd-sourced reviews of healthcare (and other) resources entered by other returning citizen users of the app Problem themes/subthemes from returning citizens . Corresponding app functionality suggested by returning citizens . Health insurance Poor/no insurance Limited understanding of coverage App gives user access to data on that user’s insurance benefits and coverage Finding and accessing healthcare Aids to find or gain access to health resources Can’t find resources for medications, healthcare providers Transportation is difficult and expensive App offers users ability to communicate with returning citizen peers to find health resources chance to use telemedicine, tele-triage, tele-diagnosis consults healthy food and nutritional information walking/public transportation maps of health resources and calculators that give user estimates of time and cost of travel to a health resource Barriers to keeping focus on health during reentry Aids to support health management Difficulty keeping track of healthcare needs and appointments Difficulty keeping track of health history Few opportunities for exercise Involvement in pleasurable activities inaccessible while “inside” App offers users automated checklists of how to complete specific tasks and reminders to follow up on scheduled tasks (eg, appointments) access to personal health record and supports access to providers’ patient portals a way to find others to join with them in exercise/physical activity Overcoming knowledge and information gaps Includes learning and information finding tools Lack of knowledge of medications and their intended effects and side effects CVD, related conditions, and risk factors how healthcare and social safety-net services are organized, and how to find and utilize them App offers users information on medical procedures, medication indications, contra-indications, interactions access and learning tools public-transit maps and help-finding mechanisms Lack of trust in health care, social, or penal system Reviews and comments from other returning citizens Expectations based on negative past experiences as returning citizens Openness to using experiences of other returning citizens to guide what to trust App allows and displays crowd-sourced reviews of healthcare (and other) resources entered by other returning citizen users of the app Open in new tab Table 3 provides direct quotes exemplifying each of these themes referenced below. Table 3. Specific cardiovascular health support needs and corresponding app functionality Quote # . Typea . Quotation . Theme: Health insurance 1 RC “I’ve had problems getting medication that I need, because they assigned me to Lantus. That’s an insulin… And the insurance that I got…they don’t want to pay for it.” 2 RC “Your primary care physician does not carry that insurance no more. Every time you go see your primary care, you still got that insurance, it’s a bill on you.” 3 RC “Because some insurances cover certain things that other insurance don’t cover… So, whatever it is, the insurance got to—when you get signed up with insurance, you got a list of everything it covers.” Theme: Finding and accessing healthcare 4 RC “… a list of who does and who don’t. You know what I’m saying? Because then instead of running to the emergency room I can go there, like a 24-hour hotline… because say I had a problem with my teeth, I can get a direct line to a dentist, you know like a non-profit…” 5 RC “I had to see my parole officer. So, I’m all the way up there at Walbatch, but then I had appointment all the way over there on Fleet Street going towards O’Donnell Heights and I had to travel all the way over there from Walbatch to over there to back over here to be back at group [therapy] at a certain time, and it just can be overwhelming sometimes.” 6 RC “So, if I could go on an app or something and talk with someone and deal with somebody, it’d be a lot better… It’d be like a doctor online.” An RC described an app could help with 7 RC “Resources, like, for transportation—like mobility and stuff like that. Like cabs… [The transit authority] has a lot of services that people don’t know about.” Theme: Complexity of treatment and Self-management Plans 8 RC “You could really keep track of your health on that 1 thing. Am I doing this? Did I do this? Did I do this today? Checklists, a tool. That would be good.” 9 RC “The app almost feels like it could be like a reminder… ‘Did you check this? Did you do that? Take your meds’ or just [provide] the regular contact.” 10 RC “I have all my [medical] information on the phone. So, when I go to my primary care doctor, if she doesn’t have the information, I can pull it up and show her.” Theme: Gaps in Knowledge and Information 11 RC “I had 2 back surgeries… I have to look up everything that I get because if they give me a dirty urine, I could get thrown off the [substance treatment] program.” 12 RC “What I like to do is, whenever I get a medication, I’d like to look it up and see what it’s interactive with.” 13 RC “You go to the section with diabetes and it’ll break it down to you just what diabetes is, what the medicine [is], ‘This is what the side effects is, this is what you should be eating, this is what you shouldn’t be eating.” 14 RC “There are a number of reentry programs here and some people may or may not know about that. But if you had that listed on the app, that might be easier for them to pinpoint…’” Theme: Lack of trust in health care, social, or penal system 15 RC “You get choice in your choice of doctor, but you got to also check the doctors. You got to learn something about the doctors, their history. So, you got to get some history about the doctor, because all doctors are not good doctors.” 16 RC “[We would like] actual statements from the people [that reflect] how we feel about the services.” 17 RC “[When you] come back to the community, they might send you to somewhere that ain’t fitting for you. But you got to deal with it until you find out there’s the resources updated.” Quote # . Typea . Quotation . Theme: Health insurance 1 RC “I’ve had problems getting medication that I need, because they assigned me to Lantus. That’s an insulin… And the insurance that I got…they don’t want to pay for it.” 2 RC “Your primary care physician does not carry that insurance no more. Every time you go see your primary care, you still got that insurance, it’s a bill on you.” 3 RC “Because some insurances cover certain things that other insurance don’t cover… So, whatever it is, the insurance got to—when you get signed up with insurance, you got a list of everything it covers.” Theme: Finding and accessing healthcare 4 RC “… a list of who does and who don’t. You know what I’m saying? Because then instead of running to the emergency room I can go there, like a 24-hour hotline… because say I had a problem with my teeth, I can get a direct line to a dentist, you know like a non-profit…” 5 RC “I had to see my parole officer. So, I’m all the way up there at Walbatch, but then I had appointment all the way over there on Fleet Street going towards O’Donnell Heights and I had to travel all the way over there from Walbatch to over there to back over here to be back at group [therapy] at a certain time, and it just can be overwhelming sometimes.” 6 RC “So, if I could go on an app or something and talk with someone and deal with somebody, it’d be a lot better… It’d be like a doctor online.” An RC described an app could help with 7 RC “Resources, like, for transportation—like mobility and stuff like that. Like cabs… [The transit authority] has a lot of services that people don’t know about.” Theme: Complexity of treatment and Self-management Plans 8 RC “You could really keep track of your health on that 1 thing. Am I doing this? Did I do this? Did I do this today? Checklists, a tool. That would be good.” 9 RC “The app almost feels like it could be like a reminder… ‘Did you check this? Did you do that? Take your meds’ or just [provide] the regular contact.” 10 RC “I have all my [medical] information on the phone. So, when I go to my primary care doctor, if she doesn’t have the information, I can pull it up and show her.” Theme: Gaps in Knowledge and Information 11 RC “I had 2 back surgeries… I have to look up everything that I get because if they give me a dirty urine, I could get thrown off the [substance treatment] program.” 12 RC “What I like to do is, whenever I get a medication, I’d like to look it up and see what it’s interactive with.” 13 RC “You go to the section with diabetes and it’ll break it down to you just what diabetes is, what the medicine [is], ‘This is what the side effects is, this is what you should be eating, this is what you shouldn’t be eating.” 14 RC “There are a number of reentry programs here and some people may or may not know about that. But if you had that listed on the app, that might be easier for them to pinpoint…’” Theme: Lack of trust in health care, social, or penal system 15 RC “You get choice in your choice of doctor, but you got to also check the doctors. You got to learn something about the doctors, their history. So, you got to get some history about the doctor, because all doctors are not good doctors.” 16 RC “[We would like] actual statements from the people [that reflect] how we feel about the services.” 17 RC “[When you] come back to the community, they might send you to somewhere that ain’t fitting for you. But you got to deal with it until you find out there’s the resources updated.” a Participant type. Abbreviations: RC, returning citizen; KI, key informant. Open in new tab Table 3. Specific cardiovascular health support needs and corresponding app functionality Quote # . Typea . Quotation . Theme: Health insurance 1 RC “I’ve had problems getting medication that I need, because they assigned me to Lantus. That’s an insulin… And the insurance that I got…they don’t want to pay for it.” 2 RC “Your primary care physician does not carry that insurance no more. Every time you go see your primary care, you still got that insurance, it’s a bill on you.” 3 RC “Because some insurances cover certain things that other insurance don’t cover… So, whatever it is, the insurance got to—when you get signed up with insurance, you got a list of everything it covers.” Theme: Finding and accessing healthcare 4 RC “… a list of who does and who don’t. You know what I’m saying? Because then instead of running to the emergency room I can go there, like a 24-hour hotline… because say I had a problem with my teeth, I can get a direct line to a dentist, you know like a non-profit…” 5 RC “I had to see my parole officer. So, I’m all the way up there at Walbatch, but then I had appointment all the way over there on Fleet Street going towards O’Donnell Heights and I had to travel all the way over there from Walbatch to over there to back over here to be back at group [therapy] at a certain time, and it just can be overwhelming sometimes.” 6 RC “So, if I could go on an app or something and talk with someone and deal with somebody, it’d be a lot better… It’d be like a doctor online.” An RC described an app could help with 7 RC “Resources, like, for transportation—like mobility and stuff like that. Like cabs… [The transit authority] has a lot of services that people don’t know about.” Theme: Complexity of treatment and Self-management Plans 8 RC “You could really keep track of your health on that 1 thing. Am I doing this? Did I do this? Did I do this today? Checklists, a tool. That would be good.” 9 RC “The app almost feels like it could be like a reminder… ‘Did you check this? Did you do that? Take your meds’ or just [provide] the regular contact.” 10 RC “I have all my [medical] information on the phone. So, when I go to my primary care doctor, if she doesn’t have the information, I can pull it up and show her.” Theme: Gaps in Knowledge and Information 11 RC “I had 2 back surgeries… I have to look up everything that I get because if they give me a dirty urine, I could get thrown off the [substance treatment] program.” 12 RC “What I like to do is, whenever I get a medication, I’d like to look it up and see what it’s interactive with.” 13 RC “You go to the section with diabetes and it’ll break it down to you just what diabetes is, what the medicine [is], ‘This is what the side effects is, this is what you should be eating, this is what you shouldn’t be eating.” 14 RC “There are a number of reentry programs here and some people may or may not know about that. But if you had that listed on the app, that might be easier for them to pinpoint…’” Theme: Lack of trust in health care, social, or penal system 15 RC “You get choice in your choice of doctor, but you got to also check the doctors. You got to learn something about the doctors, their history. So, you got to get some history about the doctor, because all doctors are not good doctors.” 16 RC “[We would like] actual statements from the people [that reflect] how we feel about the services.” 17 RC “[When you] come back to the community, they might send you to somewhere that ain’t fitting for you. But you got to deal with it until you find out there’s the resources updated.” Quote # . Typea . Quotation . Theme: Health insurance 1 RC “I’ve had problems getting medication that I need, because they assigned me to Lantus. That’s an insulin… And the insurance that I got…they don’t want to pay for it.” 2 RC “Your primary care physician does not carry that insurance no more. Every time you go see your primary care, you still got that insurance, it’s a bill on you.” 3 RC “Because some insurances cover certain things that other insurance don’t cover… So, whatever it is, the insurance got to—when you get signed up with insurance, you got a list of everything it covers.” Theme: Finding and accessing healthcare 4 RC “… a list of who does and who don’t. You know what I’m saying? Because then instead of running to the emergency room I can go there, like a 24-hour hotline… because say I had a problem with my teeth, I can get a direct line to a dentist, you know like a non-profit…” 5 RC “I had to see my parole officer. So, I’m all the way up there at Walbatch, but then I had appointment all the way over there on Fleet Street going towards O’Donnell Heights and I had to travel all the way over there from Walbatch to over there to back over here to be back at group [therapy] at a certain time, and it just can be overwhelming sometimes.” 6 RC “So, if I could go on an app or something and talk with someone and deal with somebody, it’d be a lot better… It’d be like a doctor online.” An RC described an app could help with 7 RC “Resources, like, for transportation—like mobility and stuff like that. Like cabs… [The transit authority] has a lot of services that people don’t know about.” Theme: Complexity of treatment and Self-management Plans 8 RC “You could really keep track of your health on that 1 thing. Am I doing this? Did I do this? Did I do this today? Checklists, a tool. That would be good.” 9 RC “The app almost feels like it could be like a reminder… ‘Did you check this? Did you do that? Take your meds’ or just [provide] the regular contact.” 10 RC “I have all my [medical] information on the phone. So, when I go to my primary care doctor, if she doesn’t have the information, I can pull it up and show her.” Theme: Gaps in Knowledge and Information 11 RC “I had 2 back surgeries… I have to look up everything that I get because if they give me a dirty urine, I could get thrown off the [substance treatment] program.” 12 RC “What I like to do is, whenever I get a medication, I’d like to look it up and see what it’s interactive with.” 13 RC “You go to the section with diabetes and it’ll break it down to you just what diabetes is, what the medicine [is], ‘This is what the side effects is, this is what you should be eating, this is what you shouldn’t be eating.” 14 RC “There are a number of reentry programs here and some people may or may not know about that. But if you had that listed on the app, that might be easier for them to pinpoint…’” Theme: Lack of trust in health care, social, or penal system 15 RC “You get choice in your choice of doctor, but you got to also check the doctors. You got to learn something about the doctors, their history. So, you got to get some history about the doctor, because all doctors are not good doctors.” 16 RC “[We would like] actual statements from the people [that reflect] how we feel about the services.” 17 RC “[When you] come back to the community, they might send you to somewhere that ain’t fitting for you. But you got to deal with it until you find out there’s the resources updated.” a Participant type. Abbreviations: RC, returning citizen; KI, key informant. Open in new tab Health insurance Returning citizens described having reduced access to health insurance if unemployed and many discussed being insured by subsidized low-income public insurance which provided limited coverage and required out-of-pocket expenses (Table 3, Quote 1). They also noted that providers often change which insurance they accept, leaving the patient with unaffordable fees. One participant described finding a primary care provider only to realize soon afterward that the provider no longer accepted their insurance (Table 3, Quote 2). Returning citizens also described problems understanding what coverage their insurance provided, leading to situations where they could not find a provider who would accept them. Participants offered few specific ways in which an app could help, though 1 suggested the app could serve as a resource for insurance information, to make clear what their insurance would and wouldn’t cover (Table 3, Quote 3). Finding and accessing healthcare Separate from insurance, returning citizens noted difficulties finding healthcare resources to deal with acute problems, both as a challenge on its own and in conjunction with finding a way of paying for these resources (See Table 3, Quote 4 for an example regarding care for a toothache). Returning citizens frequently reported that logistics, particularly transportation, were practical barriers to successfully seeking and receiving healthcare. Since most lacked cars, transportation to healthcare services had to be accessed through public transit. But for anything other than simple primary care, they reported that dealing with a problem often required multiple trips to various locations. This required knowledge of the public transit options and time and energy to reach these locations (Table 3, quote 5), a problem that could further be complicated by limited locations being served by public transit. The expense and physical grind of traveling everywhere on foot or by public transit was exacerbated by a poor knowledge of geography, transit, and support options after time spent incarcerated and away from the community. Returning citizens suggested app functions that related to finding healthcare resources. Several returning citizens envisioned uses of telemedicine (including tele-triage and tele-diagnosis) in an app (Table 3, Quote 6). A returning citizen envisioned an app that could help in finding healthcare resources and educate users about what transportation services are available (Table 3, Quote 7). Complexity of treatment and self-management plans Returning citizens reported having simultaneous issues around multiple medications, disease self-monitoring (eg, glucose testing for diabetes), multiple healthcare appointments, and remembering to engage in exercise. These combined needs resulted in many things to keep track of and complex schedules, which were difficult to manage. Many participants perceived that reminders, calendars, and checklists would be helpful app functions (Table 3, Quotes 8 and 9). Separately, the disjointed nature of access to the health system that many returning citizens described was seen as a source of challenges with maintaining a consistent medical history. Several returning citizens thought some form of access to their records via the app was important, and 1 talked about already trying to do that by saving information to share with the doctor on the smartphone (Table 3, Quote 10). Gaps in knowledge and information Numerous returning citizens expressed concern over the number of prescribed medications, lacking understanding of what each was for and of possible side-effects and medication interactions. This appeared to lead them to distrust and potentially discontinue/not start some medications. An example of this lack of information was reported as not knowing which medications could impact urine tests for substance-abuse programs and, therefore, lead to the person being denied treatment (Table 3, Quote 11). A common suggestion was that the app should provide some functionality to identify effects, interactions, and contraindications of medications and analogous information for procedures (Table 3, Quote 12). Other returning citizens expressed similar desires to understand CVD in relation to comorbidities (Table 3, Quote 13). Finally, multiple participants, particularly those who had returned to the community longer ago, had become aware that there were multiple community-level resources and programs intended to support returning citizens and their reentry. They felt that most returning citizens had little knowledge of them, especially of those most geographically accessible to them, and needed more information to support these resources. Lack of trust in healthcare institutions Participants often voiced uncertainty about the quality of healthcare resources. Such comments suggested widespread distrust of healthcare and social services (Table 3, Quote 15). Several returning citizens expressed a desire to have access to other returning citizens’ opinions when dealing with unfamiliar healthcare or social services (Table 3, Quote 16) and indicated that they would read reviews and be willing to register their opinions to help future returning citizens avoid inappropriate resources (Table 3, Quote 17). Thus, they felt distrust in unknown resources could be allayed by positive reviews from other returning citizens. This suggested a specific app functionality based on the concept of crowd-sourcing.23 Specifically, returning citizens wanted crowd-sourced reviews from other returning citizens in similar situations. Multiple concerns take priority over cardiovascular health Returning citizens faced a multiplicity of concerns, especially regarding reliable housing and employment, which they perceived as priorities compared to their health. Mental health and substance use disorders also distracted returning citizens from attending to CVD-related problems. Other distractions may have resulted from discrimination due to belonging to a stigmatized group or to multiple stigmatized groups (eg, being a person with mental illness or with a drug or alcohol use disorder, a racial/ethnic minority, low-income). Table 4 provides direct quotations from the data exemplifying how some of the broader issues discussed below related to multiple stigmas and challenges and how an app might address them. Table 4. Multiple concerns take priority over cardiovascular health suggesting the need for general solutions Quote # . Typea . Quotation . 1 KI “I would say way at the bottom… If they’re not in total distress, I think they'll put it at the bottom.” 2 KI “Typically, people are stressed by a number of other things, so they’re not sitting around thinking ‘Oh, I hope my health is doing better now.’” Housing and Jobs/Income 3 KI “The most common [needs] is housing, transportation, food, clothing and just the matter of general support.” 4 KI “Well, people don’t ordinarily attack healthcare when they come out of incarceration. That’s not the first priority. And I’ve dealt with so many people. The first priority is usually, ‘Where am I going to stay?’ and ‘I have to get a job because I’ve been in there 15 years. I’m leaving with $72.’” 5 RC “We going on to a year that I’ve been home. I’m sitting here fighting and sleeping from this girlfriend’s house to this mother house to this cousin house to this homeboy house…I’m still trying to do your program, duck the police because I got a hustle on the side a little bit to make some type of income. To still be able to abstain and hold on my end of the bargain that y’all asking me, do you feel that pain? That’s real.” 6 RC “Because when you just coming out of incarceration, a lot of companies, they not trying to hire you, but they got this [idea of] return to society, like you supposed—you just supposed to automatically return to society, like you never left.” 7 KI “So, the most common need we see is unstable housing … They return with a limited number or amount of income, and transitional housing is $20 a week. So, they can usually get by 2 or 3 weeks and after that we’re in alarm mode… The second thing I would say is medication and not being connected to a medical service… So, I get people in crisis who [are saying], ‘I need my medication. I have 2 days left and I don’t know where to go.’ That and, ‘I have nowhere to stay.’ Or ‘I don’t have the money for the transitional housing.’ Sometimes food is an issue, but more so the housing.” Substance Use and Mental Health 8 KI “People aren’t necessarily really healthy, right… I have so many people who are HIV-positive, and they’ll have been on super-hard street drugs. They’ll get somewhat clean or maybe totally clean for a while, and then they go to a doctor and are like ‘Whoa. I was better off using. I don’t want to know this stuff. I don’t want to deal with it.’… A lot of people are kind of fighting for survival…, and then to be like ‘Oh, about that heart and that cholesterol’— I think it’s just difficult for a lot of people just to keep their head above water.” 9 RC “Being educated and being smart enough to see the whole process but knowing that I’m counted among all the transgressors in the world. I've been to jail. I have mental health issues. I’ve had drug problems. I’m homeless.” Support and Guidance Needed to Navigate Reentry 10 KI “I just think about the whole transition process and that really it seems to me there is no process. I’ve heard these stories about this van dropping people off Wilkins Avenue, and I’m like, ‘Well, welcome to freedom.’” 11 KI “They should leave the jail with some type of package that involves your mental, physical, emotional, and financial health. Where to go and how to get there. Each area of life. And then let them go from there. You gotta give them some type of guidelines. ‘Cuz once you step outside of jail, if you don’t have a home to go to…. If you don’t give them some type of information, they end up right back in jail. They give up.” 12 KI “These are situations that have to be tailored. When they come out, they come out to nothing. And so much nothing until where they came from looks better than what they’d been released to. If you really want a solution, let’s pad that exit like we have padded their entrance.” 13 KI “[It’s] almost having like a roadmap, not just what do you need but what do you do first, because a lot of times when I think about when I’ve worked with folks affected by homelessness, you’re told to go to Department of Social Services but you’re not told what to bring and how to use it. So, I think the order of things becomes super important … so I think just being able to kind of front-load your roadmap and what are you entitled to as a returning citizen, I think is super important.” 14 KI “I think 1 of the opportunities may be to bring in peers or folks that have been through similar things like, ‘Hey, here’s 5 things I didn’t know were going to be problems for me when I got out,’ and that would be a nice way to kind of summarize and pull together.” Quote # . Typea . Quotation . 1 KI “I would say way at the bottom… If they’re not in total distress, I think they'll put it at the bottom.” 2 KI “Typically, people are stressed by a number of other things, so they’re not sitting around thinking ‘Oh, I hope my health is doing better now.’” Housing and Jobs/Income 3 KI “The most common [needs] is housing, transportation, food, clothing and just the matter of general support.” 4 KI “Well, people don’t ordinarily attack healthcare when they come out of incarceration. That’s not the first priority. And I’ve dealt with so many people. The first priority is usually, ‘Where am I going to stay?’ and ‘I have to get a job because I’ve been in there 15 years. I’m leaving with $72.’” 5 RC “We going on to a year that I’ve been home. I’m sitting here fighting and sleeping from this girlfriend’s house to this mother house to this cousin house to this homeboy house…I’m still trying to do your program, duck the police because I got a hustle on the side a little bit to make some type of income. To still be able to abstain and hold on my end of the bargain that y’all asking me, do you feel that pain? That’s real.” 6 RC “Because when you just coming out of incarceration, a lot of companies, they not trying to hire you, but they got this [idea of] return to society, like you supposed—you just supposed to automatically return to society, like you never left.” 7 KI “So, the most common need we see is unstable housing … They return with a limited number or amount of income, and transitional housing is $20 a week. So, they can usually get by 2 or 3 weeks and after that we’re in alarm mode… The second thing I would say is medication and not being connected to a medical service… So, I get people in crisis who [are saying], ‘I need my medication. I have 2 days left and I don’t know where to go.’ That and, ‘I have nowhere to stay.’ Or ‘I don’t have the money for the transitional housing.’ Sometimes food is an issue, but more so the housing.” Substance Use and Mental Health 8 KI “People aren’t necessarily really healthy, right… I have so many people who are HIV-positive, and they’ll have been on super-hard street drugs. They’ll get somewhat clean or maybe totally clean for a while, and then they go to a doctor and are like ‘Whoa. I was better off using. I don’t want to know this stuff. I don’t want to deal with it.’… A lot of people are kind of fighting for survival…, and then to be like ‘Oh, about that heart and that cholesterol’— I think it’s just difficult for a lot of people just to keep their head above water.” 9 RC “Being educated and being smart enough to see the whole process but knowing that I’m counted among all the transgressors in the world. I've been to jail. I have mental health issues. I’ve had drug problems. I’m homeless.” Support and Guidance Needed to Navigate Reentry 10 KI “I just think about the whole transition process and that really it seems to me there is no process. I’ve heard these stories about this van dropping people off Wilkins Avenue, and I’m like, ‘Well, welcome to freedom.’” 11 KI “They should leave the jail with some type of package that involves your mental, physical, emotional, and financial health. Where to go and how to get there. Each area of life. And then let them go from there. You gotta give them some type of guidelines. ‘Cuz once you step outside of jail, if you don’t have a home to go to…. If you don’t give them some type of information, they end up right back in jail. They give up.” 12 KI “These are situations that have to be tailored. When they come out, they come out to nothing. And so much nothing until where they came from looks better than what they’d been released to. If you really want a solution, let’s pad that exit like we have padded their entrance.” 13 KI “[It’s] almost having like a roadmap, not just what do you need but what do you do first, because a lot of times when I think about when I’ve worked with folks affected by homelessness, you’re told to go to Department of Social Services but you’re not told what to bring and how to use it. So, I think the order of things becomes super important … so I think just being able to kind of front-load your roadmap and what are you entitled to as a returning citizen, I think is super important.” 14 KI “I think 1 of the opportunities may be to bring in peers or folks that have been through similar things like, ‘Hey, here’s 5 things I didn’t know were going to be problems for me when I got out,’ and that would be a nice way to kind of summarize and pull together.” a Participant type. Abbreviations: RC, returning citizen; KI, key informant. Open in new tab Table 4. Multiple concerns take priority over cardiovascular health suggesting the need for general solutions Quote # . Typea . Quotation . 1 KI “I would say way at the bottom… If they’re not in total distress, I think they'll put it at the bottom.” 2 KI “Typically, people are stressed by a number of other things, so they’re not sitting around thinking ‘Oh, I hope my health is doing better now.’” Housing and Jobs/Income 3 KI “The most common [needs] is housing, transportation, food, clothing and just the matter of general support.” 4 KI “Well, people don’t ordinarily attack healthcare when they come out of incarceration. That’s not the first priority. And I’ve dealt with so many people. The first priority is usually, ‘Where am I going to stay?’ and ‘I have to get a job because I’ve been in there 15 years. I’m leaving with $72.’” 5 RC “We going on to a year that I’ve been home. I’m sitting here fighting and sleeping from this girlfriend’s house to this mother house to this cousin house to this homeboy house…I’m still trying to do your program, duck the police because I got a hustle on the side a little bit to make some type of income. To still be able to abstain and hold on my end of the bargain that y’all asking me, do you feel that pain? That’s real.” 6 RC “Because when you just coming out of incarceration, a lot of companies, they not trying to hire you, but they got this [idea of] return to society, like you supposed—you just supposed to automatically return to society, like you never left.” 7 KI “So, the most common need we see is unstable housing … They return with a limited number or amount of income, and transitional housing is $20 a week. So, they can usually get by 2 or 3 weeks and after that we’re in alarm mode… The second thing I would say is medication and not being connected to a medical service… So, I get people in crisis who [are saying], ‘I need my medication. I have 2 days left and I don’t know where to go.’ That and, ‘I have nowhere to stay.’ Or ‘I don’t have the money for the transitional housing.’ Sometimes food is an issue, but more so the housing.” Substance Use and Mental Health 8 KI “People aren’t necessarily really healthy, right… I have so many people who are HIV-positive, and they’ll have been on super-hard street drugs. They’ll get somewhat clean or maybe totally clean for a while, and then they go to a doctor and are like ‘Whoa. I was better off using. I don’t want to know this stuff. I don’t want to deal with it.’… A lot of people are kind of fighting for survival…, and then to be like ‘Oh, about that heart and that cholesterol’— I think it’s just difficult for a lot of people just to keep their head above water.” 9 RC “Being educated and being smart enough to see the whole process but knowing that I’m counted among all the transgressors in the world. I've been to jail. I have mental health issues. I’ve had drug problems. I’m homeless.” Support and Guidance Needed to Navigate Reentry 10 KI “I just think about the whole transition process and that really it seems to me there is no process. I’ve heard these stories about this van dropping people off Wilkins Avenue, and I’m like, ‘Well, welcome to freedom.’” 11 KI “They should leave the jail with some type of package that involves your mental, physical, emotional, and financial health. Where to go and how to get there. Each area of life. And then let them go from there. You gotta give them some type of guidelines. ‘Cuz once you step outside of jail, if you don’t have a home to go to…. If you don’t give them some type of information, they end up right back in jail. They give up.” 12 KI “These are situations that have to be tailored. When they come out, they come out to nothing. And so much nothing until where they came from looks better than what they’d been released to. If you really want a solution, let’s pad that exit like we have padded their entrance.” 13 KI “[It’s] almost having like a roadmap, not just what do you need but what do you do first, because a lot of times when I think about when I’ve worked with folks affected by homelessness, you’re told to go to Department of Social Services but you’re not told what to bring and how to use it. So, I think the order of things becomes super important … so I think just being able to kind of front-load your roadmap and what are you entitled to as a returning citizen, I think is super important.” 14 KI “I think 1 of the opportunities may be to bring in peers or folks that have been through similar things like, ‘Hey, here’s 5 things I didn’t know were going to be problems for me when I got out,’ and that would be a nice way to kind of summarize and pull together.” Quote # . Typea . Quotation . 1 KI “I would say way at the bottom… If they’re not in total distress, I think they'll put it at the bottom.” 2 KI “Typically, people are stressed by a number of other things, so they’re not sitting around thinking ‘Oh, I hope my health is doing better now.’” Housing and Jobs/Income 3 KI “The most common [needs] is housing, transportation, food, clothing and just the matter of general support.” 4 KI “Well, people don’t ordinarily attack healthcare when they come out of incarceration. That’s not the first priority. And I’ve dealt with so many people. The first priority is usually, ‘Where am I going to stay?’ and ‘I have to get a job because I’ve been in there 15 years. I’m leaving with $72.’” 5 RC “We going on to a year that I’ve been home. I’m sitting here fighting and sleeping from this girlfriend’s house to this mother house to this cousin house to this homeboy house…I’m still trying to do your program, duck the police because I got a hustle on the side a little bit to make some type of income. To still be able to abstain and hold on my end of the bargain that y’all asking me, do you feel that pain? That’s real.” 6 RC “Because when you just coming out of incarceration, a lot of companies, they not trying to hire you, but they got this [idea of] return to society, like you supposed—you just supposed to automatically return to society, like you never left.” 7 KI “So, the most common need we see is unstable housing … They return with a limited number or amount of income, and transitional housing is $20 a week. So, they can usually get by 2 or 3 weeks and after that we’re in alarm mode… The second thing I would say is medication and not being connected to a medical service… So, I get people in crisis who [are saying], ‘I need my medication. I have 2 days left and I don’t know where to go.’ That and, ‘I have nowhere to stay.’ Or ‘I don’t have the money for the transitional housing.’ Sometimes food is an issue, but more so the housing.” Substance Use and Mental Health 8 KI “People aren’t necessarily really healthy, right… I have so many people who are HIV-positive, and they’ll have been on super-hard street drugs. They’ll get somewhat clean or maybe totally clean for a while, and then they go to a doctor and are like ‘Whoa. I was better off using. I don’t want to know this stuff. I don’t want to deal with it.’… A lot of people are kind of fighting for survival…, and then to be like ‘Oh, about that heart and that cholesterol’— I think it’s just difficult for a lot of people just to keep their head above water.” 9 RC “Being educated and being smart enough to see the whole process but knowing that I’m counted among all the transgressors in the world. I've been to jail. I have mental health issues. I’ve had drug problems. I’m homeless.” Support and Guidance Needed to Navigate Reentry 10 KI “I just think about the whole transition process and that really it seems to me there is no process. I’ve heard these stories about this van dropping people off Wilkins Avenue, and I’m like, ‘Well, welcome to freedom.’” 11 KI “They should leave the jail with some type of package that involves your mental, physical, emotional, and financial health. Where to go and how to get there. Each area of life. And then let them go from there. You gotta give them some type of guidelines. ‘Cuz once you step outside of jail, if you don’t have a home to go to…. If you don’t give them some type of information, they end up right back in jail. They give up.” 12 KI “These are situations that have to be tailored. When they come out, they come out to nothing. And so much nothing until where they came from looks better than what they’d been released to. If you really want a solution, let’s pad that exit like we have padded their entrance.” 13 KI “[It’s] almost having like a roadmap, not just what do you need but what do you do first, because a lot of times when I think about when I’ve worked with folks affected by homelessness, you’re told to go to Department of Social Services but you’re not told what to bring and how to use it. So, I think the order of things becomes super important … so I think just being able to kind of front-load your roadmap and what are you entitled to as a returning citizen, I think is super important.” 14 KI “I think 1 of the opportunities may be to bring in peers or folks that have been through similar things like, ‘Hey, here’s 5 things I didn’t know were going to be problems for me when I got out,’ and that would be a nice way to kind of summarize and pull together.” a Participant type. Abbreviations: RC, returning citizen; KI, key informant. Open in new tab Returning citizens noted that a smartphone app could be focused on problem-solving to help with societal reintegration in combination with addressing barriers to dealing with CVD and its risk factors. This was informed by general agreement among KIs that, given the multiple problems returning citizens face, health was not a priority. When asked where CVD-related health ranked, service providers suggested that it would be very low in returning citizens’ priorities (Table 4, Quote 1 and Quote 2). Housing and jobs/income Basic needs were seen as pressing (Table 4, Quote 3). Service providers emphasized that issues that urgently need to be addressed were housing and jobs (Table 4, Quote 4). Persons released from incarceration typically do not have employment or an income source and frequently have only temporary housing. Additionally, many are required to obtain both as a condition of parole. Some returning citizens described the stress of this situation (Table 4, Quote 5). Jobs were perceived as hard to obtain, as returning citizens have both a police record and have been out of the workforce (Table 4, Quote 6). Others described access to medications and medical services for CVD-related conditions, as other examples of the multiple competing issues (like income, housing, and food insecurity) that returning citizens deal with (Table 4, Quote, 7). Substance use and mental health Other common issues that were described as distracting from CVD-related problems were substance use and mental health problems. As a service provider explained, many returning citizens have a history of substance use and emotional disorders, both issues that can require more pressing attention than CVD (Table 4, Quotes 8 and 9). Support and guidance needed to navigate reentry When asked about what could make it easier to address CVD and other health problems, participants mentioned that returning citizens often feel a lack of guidance (Table 4, Quote 10). Service providers felt that returning citizens would benefit from more direction regarding how to access services needed to address their reentry challenges (Table 4, Quote 11). A community organizer emphasized that to properly address the multiple complex problems facing returning citizens, the solutions offered have to be tailored to an individual’s needs (Table 4, Quote 12). One service provider summed up the way these multiple needs could be met with the metaphor of a roadmap that helped a returning citizen to determine not just what needed to be done, but also to determine the order those things needed to be done, and how to prioritize competing demands (Table 4, Quote 13). Other service providers noted that such a roadmap could be made more effective by tapping into advice from others who had similar reentry experiences (Table 4, Quote 14). DISCUSSION We found that returning citizens face multiple barriers to improving their cardiovascular health and accessing healthcare services after release. Based on how CVD health concerns are situated within the context of returning citizens’ lives, results suggested that a smartphone app for this population should provide a general roadmap to resources to facilitate jobs and housing, in addition to providing CVD-specific functionality. That is, addressing CVD risk factors might be ineffective if returning citizens are not able to simultaneously deal with issues— related to employment and housing or substance use/mental health problems—that they consider more pressing. This is consistent with prior research on women released from jail that found health was not a priority for most women and was considered less important than employment and childcare concerns.24 Desired app features include guidance to streamline medical and social service care by helping returning citizens find resources that are matched to specific needs, locally available, and affordable. This concept of combining healthcare and social services, particularly from the perspective of an app, is novel. While some research has focused on integrating information on social services into electronic health records so that primary care physicians can use it to counsel patients,25–27 for returning citizens without regular health care providers, such provider-centric solutions are less relevant and were not identified by any of our study participants. Some indexed databases of social service resources are available for browser-based searches, most notably the 211 service, created by United Way, and the private Aunt Bertha service.28,29 However, the geospatial indexing for both is coarse (at the level of ZIP code), and neither is app-based. There was a theme of distrust of the health system for people who have been incarcerated and crowdsourcing may help to address this barrier. This finding aligns with research suggesting the importance of social networks in care-seeking, indicating that returning citizens prefer to seek advice from others rather than through formal informational searches.30 Other studies have similarly noted concerns about stigma and confidentiality as barriers to healthcare engagement and informal support as a preferred type of support.31,32 The use of an app could mitigate such concerns by providing an organized and confidential platform to access resources, while educating app users about CVD symptoms and risk factors. Currently, apps such as Link2Care are being researched for their ability to increase treatment service utilization among incarcerated homeless adults through direct buttons to shelter-based case managers, crisis interventionists, and resource websites.33 Given our results, app features could provide a standardized platform that is adapted to returning citizens’ particular needs, such as improving access to care. A pilot study on Care + Corrections, an mHealth intervention to increase utilization of HIV community-based care among returning citizens, found positive—although not significant—associations between the intervention and viral suppression, with an increase in care engagement in all study groups.34 The Care + Corrections intervention included computerized counseling sessions for people living with HIV released from correctional facilities, with content focused on linkage to HIV care, medication adherence, and risk-reduction behaviors.35 This example suggests that a similar approach could be applied to modification of behaviors that mediate CVD risk, particularly for smoking, which is both widespread among returning citizens and that our participants recognized as unhealthy. Despite these promising studies of apps for care coordination among returning citizens, technology and access may still be an issue. There are lower levels of smartphone use among people who are older, have less education and lower income than the general population,36 and low-income people are less likely to have stable mobile service.37 However this was not a major concern among participants in this study, and many people find ways around these barriers through the availability of free wifi at places like local libraries. Further, incarceration may leave returning citizens disconnected from smartphones and digital technologies for long periods, contributing to a ‘digital divide’ and feeling detached from technology and how to use it.38 Nonetheless, this did not appear to be a significant issue for our participants. Study strengths include the relatively large sample, including male and female participants and a majority African-American sample, who are disproportionately incarcerated.39 The extent of data collection allowed us to reach saturation, though more research is needed on other ethnic/racial groups. Another strength was data from both returning citizens and service providers. The convergence of multiple perspectives on similar themes reinforces the credibility of our data. Limitations include lack of sociodemographic information on age and other characteristics and a focus on an urban population, decreasing the study’s generalizability. Groups were conducted in English only, which limits transferability to non-English speaking individuals. CONCLUSION Smartphone applications are an mHealth technology that may be able to engage returning citizens in addressing cardiovascular health. An app that is useful, useable, and trusted will need to be broadly focused on the social and structural determinants of health and reentry and incorporate social networking among previously incarcerated people. Future research is needed to fully implement and test the use of such an app for returning citizens. FUNDING This research reported in this publication was 100% supported by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health under award number R43HL144412. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. AUTHOR CONTRIBUTIONS PJS contributed to the conceptualization and design of the study, data collection/data analysis, interpretation, and drafted the original manuscript. LBP contributed to the design of the study, interpretation of the results, and critical revision of the manuscript. KB contributed to the design of the study, data collection, and interpretation of the results. NE contributed to the writing of the manuscript and interpretation of the data. WWZ contributed to the conceptualization and design of the study, data collection/data analysis, interpretation, and writing of the manuscript. All authors approved the final version of the manuscript. SUPPLEMENTARY MATERIAL Supplementary material is available at Journal of the American Medical Informatics Association online. DATA AVAILABILITY STATEMENT The data underlying this article will be shared on reasonable request to the corresponding author. ACKNOWLEDGMENTS We would like to thank the participants who took part in this study. We are also grateful for the support of Ms. Emily Heckel and Dr. Craig Tower on this project. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1 Bronson J , Carson EA. Prisoners in 2017. US Department of Justice, Office of Justice Programs. Bureau of Justice Statistics; 2019 . 2 Office of the Assistant Secretary for Planning and Evaluation , US Department of Health & Human Services. Incarceration & Reentry. https://aspe.hhs.gov/incarceration-reentryAccessed March 12, 2020 3 Rabuy B , Kopf D. Prisons of Poverty: Uncovering the pre-incarceration incomes of the imprisoned; July 9, 2015 . https://www.prisonpolicy.org/reports/income.htmlAccessed September 26, 2020 4 Wang EA , Redmond N, Dennison Himmelfarb CR, et al. Cardiovascular disease in incarcerated populations . J Am Coll Cardiol 2017 ; 69 ( 24 ): 2967 – 76 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Kochanek KD , Murphy SL, Xu J, Arias E. Deaths: final data for 2017 . Natl Vital Stat Rep 2019 ; 68 ( 9 ): 1 – 77 . Google Scholar OpenURL Placeholder Text WorldCat 6 Noonan M , Rohloff H, Ginder S. Mortality in Local Jails and State Prisons. Statistical Tables. US Department of Justice 2000–2013; 2015 . https://www.bjs.gov/index.cfm?ty=pbdetail&iid=5341 Accessed June 7, 2020. 7 Binswanger IA , Blatchford PJ, Mueller SR, Stern MF. Mortality after prison release: opioid overdose and other causes of death, risk factors, and time trends from 1999 to 2009 . Ann Intern Med 2013 ; 159 ( 9 ): 592 – 600 . Google Scholar Crossref Search ADS PubMed WorldCat 8 Howell BA , Long JB, Edelman EJ, et al. Incarceration history and uncontrolled blood pressure in a multi-site cohort . J Gen Intern Med 2016 ; 31 ( 12 ): 1496 – 502 . Google Scholar Crossref Search ADS PubMed WorldCat 9 Wang EA , Pletcher M, Lin F, et al. Incarceration, incident hypertension, and access to health care: findings from the coronary artery risk development in young adults (CARDIA) study . Arch Intern Med 2009 ; 169 ( 7 ): 687 – 93 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Wang EA , Wang Y, Krumholz HM. A high risk of hospitalization following release from correctional facilities in Medicare beneficiaries: a retrospective matched cohort study, 2002 to 2010 . JAMA Intern Med 2013 ; 173 ( 17 ): 1621 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 11 Cui M , Wu X, Mao J, Wang X, Nie M. T2DM self-management via smartphone applications: a systematic review and meta-analysis . PLoS One 2016 ; 11 ( 11 ): e0166718 . Google Scholar Crossref Search ADS PubMed WorldCat 12 Neubeck L , Lowres N, Benjamin EJ, Freedman SB, Coorey G, Redfern J. The mobile revolution–using smartphone apps to prevent cardiovascular disease . Nat Rev Cardiol 2015 ; 12 ( 6 ): 350 – 60 . Google Scholar Crossref Search ADS PubMed WorldCat 13 Reynoldson C , Stones C, Allsop M, et al. Assessing the quality and usability of smartphone apps for pain self-management . Pain Med 2014 ; 15 ( 6 ): 898 – 909 . Google Scholar Crossref Search ADS PubMed WorldCat 14 Wang J , Wang Y, Wei C, et al. Smartphone interventions for long-term health management of chronic diseases: an integrative review . Telemed J E Health 2014 ; 20 ( 6 ): 570 – 83 . Google Scholar Crossref Search ADS PubMed WorldCat 15 Delva S , Waligora Mendez KJ, Cajita M, et al. Efficacy of mobile health for self-management of cardiometabolic risk factors: a theory-guided systematic review . J Cardiovasc Nurs 2021 ; 36 ( 1 ): 34 – 55 . Google Scholar Crossref Search ADS PubMed WorldCat 16 Piette JD , List J, Rana GK, Townsend W, Striplin D, Heisler M. Mobile health devices as tools for worldwide cardiovascular risk reduction and disease management . Circulation 2015 ; 132 ( 21 ): 2012 – 27 . Google Scholar Crossref Search ADS PubMed WorldCat 17 Bandura A. Health promotion by social cognitive means . Health Educ Behav 2004 ; 31 ( 2 ): 143 – 64 . Google Scholar Crossref Search ADS PubMed WorldCat 18 Scott CK , Johnson K, Dennis ML. Using mobile phone technology to provide recovery support for women offenders . Telemed J E Health 2013 ; 19 ( 10 ): 767 – 71 . Google Scholar Crossref Search ADS PubMed WorldCat 19 McInnes DK , Li AE, Hogan TP. Opportunities for engaging low-income, vulnerable populations in health care: a systematic review of homeless persons' access to and use of information technologies . Am J Public Health 2013 ; 103 ( S2 ): e11-24 – e24 . Google Scholar Crossref Search ADS PubMed WorldCat 20 Mitchell SJ , Godoy L, Shabazz K, Horn IB. Internet and mobile technology use among urban African American parents: survey study of a clinical population . J Med Internet Res 2014 ; 16 ( 1 ): e9 . Google Scholar Crossref Search ADS PubMed WorldCat 21 Post LA , Vaca FE, Biroscak BJ, et al. The prevalence and characteristics of emergency medicine patient use of new media . JMIR mHealth uHealth 2015 ; 3 ( 3 ): e72 . Google Scholar Crossref Search ADS PubMed WorldCat 22 Braun V , Clarke V. Thematic analysis In: Handbook of Research Methods in Psychology. Vol 2 Research Designs . Washington, DC : American Psychological Association ; 2012 : 57 – 71 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 23 Brabham DC , Ribisl KM, Kirchner TR, Bernhardt JM. Crowdsourcing applications for public health . Am J Prev Med 2014 ; 46 ( 2 ): 179 – 87 . Google Scholar Crossref Search ADS PubMed WorldCat 24 Ramaswamy M , Upadhyayula S, Chan KY, Rhodes K, Leonardo A. Health priorities among women recently released from jail . Am J Health Behav 2015 ; 39 ( 2 ): 222 – 31 . Google Scholar Crossref Search ADS PubMed WorldCat 25 Cohen DJ , Wyte-Lake T, Dorr DA, et al. Unmet information needs of clinical teams delivering care to complex patients and design strategies to address those needs . J Am Med Inform Assoc 2020 ; 27 ( 5 ): 690 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 26 O'Gurek DT , Henke C. A practical approach to screening for social determinants of health . Fam Pract Manag 2018 ; 25 ( 3 ): 7 – 12 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 27 Palakshappa D , Strane D, Griffis H, Fiks AG. Determining food-insecure families’ resource access with health system and public data . J Health Care Poor Underserved 2019 ; 30 ( 1 ): 265 – 79 . Google Scholar Crossref Search ADS PubMed WorldCat 28 Aunt Bertha. Aunt Bertha - The Social Care Network . https://www.auntbertha.com/Accessed September 29, 2020 29 United Way . 211. https://www.211.org/pages/aboutAccessed September 29, 2020 30 Mallik-Kane K , Paddock E, Jannetta J. Health Care after Incarceration: How Do Formerly Incarcerated Men Choose Where and When to Access Physical and Behavioral Health Services ? Washington, DC : Urban Institute ; 2018 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 31 Robards F , Kang M, Usherwood T, Sanci L. How marginalized young people access, engage with, and navigate health-care systems in the digital age: systematic review . J Adolesc Health 2018 ; 62 ( 4 ): 365 – 81 . Google Scholar Crossref Search ADS PubMed WorldCat 32 Walsh J , Scaife V, Notley C, Dodsworth J, Schofield G. Perception of need and barriers to access: the mental health needs of young people attending a Youth Offending Team in the UK . Health Soc Care Commun 2011 ; 19 ( 4 ): 420 – 8 . Google Scholar Crossref Search ADS WorldCat 33 Reingle Gonzalez JM , Businelle MS, Kendzor D, Staton M, North CS, Swartz M. Using mHealth to increase treatment utilization among recently incarcerated homeless adults (Link2Care): protocol for a randomized controlled trial . JMIR Res Protoc 2018 ; 7 ( 6 ): e151 . Google Scholar Crossref Search ADS PubMed WorldCat 34 Kuo I , Liu T, Patrick R, et al. Use of an mHealth intervention to improve engagement in HIV community-based care among persons recently released from a correctional facility in Washington, DC: a pilot study . AIDS Behav 2019 ; 23 ( 4 ): 1016 – 31 . Google Scholar Crossref Search ADS PubMed WorldCat 35 Peterson J , Cota M, Gray H, et al. Technology use in linking criminal justice reentrants to HIV care in the community: a qualitative formative research study . J Health Commun 2015 ; 20 ( 3 ): 245 – 51 . Google Scholar Crossref Search ADS PubMed WorldCat 36 Pew Research Center. Mobile Fact Sheet . https://www.pewresearch.org/internet/fact-sheet/mobile/Accessed January 26, 2021 37 Gonzales AL. Health benefits and barriers to cell phone use in low-income urban US neighborhoods: indications of technology maintenance . Mobile Media Commun 2014 ; 2 ( 3 ): 233 – 48 . Google Scholar Crossref Search ADS WorldCat 38 Reisdorf B , DeCook J, Foster M, Cobbina J, LaCourse A. Digital reentry: uses of and barriers to ICTs in the prisoner reentry process . Available at SSRN 3427342; 2019 . Google Scholar OpenURL Placeholder Text WorldCat 39 Sakala L. Breaking Down Mass Incarceration in the 2010 Census: State-by-State Incarceration Rates by Race/Ethnicity; 2014 . https://www.prisonpolicy.org/reports/rates.html. Accessed March 22, 2020. © The Author(s) 2021. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the American Medical Informatics Association Oxford University Press http://www.deepdyve.com/lp/oxford-university-press/a-roadmap-for-cardiovascular-care-after-release-from-incarceration-87rFS8FuZq

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References (34)

J. Walsh, Victoria Scaife, C. Notley, J. Dodsworth, G. Schofield (2011)
Perception of need and barriers to access: the mental health needs of young people attending a Youth Offending Team in the UK.
Health & social care in the community, 19 4
E. Wang, M. Pletcher, F. Lin, E. Vittinghoff, S. Kertesz, C. Kiefe, K. Bibbins-Domingo (2009)
Incarceration, incident hypertension, and access to health care: findings from the coronary artery risk development in young adults (CARDIA) study.
Archives of internal medicine, 169 7
J. Piette, J. List, G. Rana, W. Townsend, D. Striplin, M. Heisler (2015)
Mobile Health Devices as Tools for Worldwide Cardiovascular Risk Reduction and Disease Management
Circulation, 132
S Delva, Mendez KJ Waligora, M Cajita (2021)
Efficacy of mobile health for self-management of cardiometabolic risk factors: a theory-guided systematic review
J Cardiovasc Nurs, 36
K Mallik-Kane, E Paddock, J. Jannetta (2018)
Health Care after Incarceration: How Do Formerly Incarcerated Men Choose Where and When to Access Physical and Behavioral Health Services
Daren Brabham, K. Ribisl, Thomas Kirchner, J. Bernhardt (2014)
Crowdsourcing applications for public health.
American journal of preventive medicine, 46 2
Mingxuan Cui, Xueyan Wu, J. Mao, Xi Wang, M. Nie (2016)
T2DM Self-Management via Smartphone Applications: A Systematic Review and Meta-Analysis
PLoS ONE, 11
Fiona Robards, Melissa Kang, T. Usherwood, L. Sanci (2018)
How Marginalized Young People Access, Engage With, and Navigate Health-Care Systems in the Digital Age: Systematic Review.
The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 62 4
I. Kuo, Tao Liu, R. Patrick, Claudia Trezza, L. Bazerman, Breana Castonguay, J. Peterson, A. Kurth, C. Beckwith (2019)
Use of an mHealth Intervention to Improve Engagement in HIV Community-Based Care Among Persons Recently Released from a Correctional Facility in Washington, DC: A Pilot Study
AIDS and Behavior, 23
Jingting Wang, Yuanyuan Wang, Chunlan Wei, N. Yao, Avery Yuan, Yuying Shan, C. Yuan (2014)
Smartphone interventions for long-term health management of chronic diseases: an integrative review.
Telemedicine journal and e-health : the official journal of the American Telemedicine Association, 20 6
A. Bandura (2004)
Health Promotion by Social Cognitive Means
Health Education & Behavior, 31
B Reisdorf, J DeCook, M Foster, J Cobbina, A. LaCourse (2019)
Digital reentry: uses of and barriers to ICTs in the prisoner reentry process
Available at SSRN, 3427342
J. Peterson, M. Cota, Holly Gray, L. Bazerman, I. Kuo, A. Kurth, C. Beckwith (2015)
Technology Use in Linking Criminal Justice Reentrants to HIV Care in the Community: A Qualitative Formative Research Study
Journal of Health Communication, 20
K. Kochanek, S. Murphy, Jiaquan Xu, E. Arias (2019)
Deaths: Final Data for 2017.
National vital statistics reports : from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, 68 9
L. Post, F. Vaca, B. Biroscak, J. Dziura, C. Brandt, S. Bernstein, R. Taylor, L. Jagminas, G. D'Onofrio (2015)
The Prevalence and Characteristics of Emergency Medicine Patient Use of New Media
JMIR mHealth and uHealth, 3
J. Gonzalez, M. Businelle, Darla Kendzor, Michele Staton, C. North, M. Swartz (2018)
Using mHealth to Increase Treatment Utilization Among Recently Incarcerated Homeless Adults (Link2Care): Protocol for a Randomized Controlled Trial
JMIR Research Protocols, 7
Sabianca Delva, Kyra Mendez, Mia Cajita, Binu Koirala, R. Shan, S. Wongvibulsin, V. Vilarino, Danielle Gilmore, Hae-Ra Han (2020)
Efficacy of Mobile Health for Self-management of Cardiometabolic Risk Factors
The Journal of Cardiovascular Nursing, 36
S. Mitchell, L. Godoy, Kanya Shabazz, I. Horn (2012)
Internet and Mobile Technology Use Among Urban African American Parents: Survey Study of a Clinical Population
Journal of Medical Internet Research, 16
David O’Gurek, C. Henke (2018)
A Practical Approach to Screening for Social Determinants of Health.
Family practice management, 25 3
E. Wang, Yongfei Wang, H. Krumholz (2013)
A high risk of hospitalization following release from correctional facilities in Medicare beneficiaries: a retrospective matched cohort study, 2002 to 2010.
JAMA internal medicine, 173 17
KD Kochanek, SL Murphy, J Xu, E. Arias (2019)
Deaths: final data for 2017
Natl Vital Stat Rep, 68
V Braun, V. Clarke (2012)
Handbook of Research Methods in Psychology. Vol 2 Research Designs
D. Cohen, Tamar Wyte-Lake, D. Dorr, Rachel Gold, R. Holden, R. Koopman, Joshua Colasurdo, Nate Warren (2020)
Unmet information needs of clinical teams delivering care to complex patients and design strategies to address those needs
Journal of the American Medical Informatics Association : JAMIA
Charmian Reynoldson, C. Stones, M. Allsop, P. Gardner, Michael Bennett, S. Closs, Rick Jones, P. Knapp (2014)
Assessing the quality and usability of smartphone apps for pain self-management.
Pain medicine, 15 6
E. Wang, Nicole Redmond, C. Himmelfarb, B. Pettit, M. Stern, Jue Chen, Susan Shero, E. Iturriaga, P. Sorlie, A. Roux (2017)
Cardiovascular Disease in Incarcerated Populations.
Journal of the American College of Cardiology, 69 24
D. McInnes, Alice Li, T. Hogan (2013)
Opportunities for engaging low-income, vulnerable populations in health care: a systematic review of homeless persons' access to and use of information technologies.
American journal of public health, 103 Suppl 2
A. Gonzales (2014)
Health benefits and barriers to cell phone use in low-income urban U.S. neighborhoods: Indications of technology maintenance
Mobile Media & Communication, 2
D. Palakshappa, Douglas Strane, H. Griffis, Alexander Fiks (2019)
Determining Food-Insecure Families' Resource Access with Health System and Public Data
Journal of Health Care for the Poor and Underserved, 30
L. Neubeck, N. Lowres, E. Benjamin, S. Freedman, G. Coorey, J. Redfern (2015)
The mobile revolution—using smartphone apps to prevent cardiovascular disease
Nature Reviews Cardiology, 12
Megha Ramaswamy, Satyasree Upadhyayula, K. Chan, K. Rhodes, A. Leonardo (2015)
Health priorities among women recently released from jail.
American journal of health behavior, 39 2
I. Binswanger, P. Blatchford, Shane Mueller, M. Stern (2013)
Mortality After Prison Release: Opioid Overdose and Other Causes of Death, Risk Factors, and Time Trends From 1999 to 2009
Annals of Internal Medicine, 159
Bianca Reisdorf, J. DeCook, Megan Foster, Jennifer Cobbina, Ashleigh LaCourse (2019)
Digital reentry: uses of and barriers to ICTs in the prisoner reentry process
Information, Communication & Society, 25
Christy Scott, Kimberly Johnson, M. Dennis (2013)
Using mobile phone technology to provide recovery support for women offenders.
Telemedicine journal and e-health : the official journal of the American Telemedicine Association, 19 10
B. Howell, J. Long, E. Edelman, K. McGinnis, D. Rimland, D. Fiellin, Amy Justice, Amy Justice, Emily Wang (2016)
Incarceration History and Uncontrolled Blood Pressure in a Multi-Site Cohort
Journal of General Internal Medicine, 31

Publisher: Oxford University Press
Copyright: Copyright © 2021 American Medical Informatics Association
ISSN: 1067-5027
eISSN: 1527-974X
DOI: 10.1093/jamia/ocab079
Publisher site: See Article on Publisher Site

Abstract

Abstract Objective Cardiovascular disease (CVD) and its risk factors disproportionately affect people returning from incarceration. These individuals face multiple barriers to obtaining care, which can impact CVD and risk factor management and may be mitigated through use of a smartphone application (app). Therefore, we explored the CVD-related needs of people released from incarceration and which app features would support these needs. Materials and Methods In 2019, we collected qualitative data through 7 focus groups with 76 returning citizens and 19 key informants through interviews and small group discussions in Baltimore, Maryland. Verbal data were audio-recorded, transcribed, and analyzed using inductive thematic coding with N-Vivo qualitative software. Results Returning citizens face multiple barriers when trying to engage in care and services related to cardiovascular health, including around medications and health insurance. Some major challenges were identifying trusted social services and making cardiovascular health a priority. Findings suggested that CVD risk factors could be more effectively addressed in combination with attending to other pressing needs related to employment, housing, behavioral health, and building trust. Participants suggested that a smartphone app would be most useful if it broadly addressed these issues by linking returning citizens to social services, including recommendations from peers, and facilitating access to healthcare. Discussion Returning citizens need broad support for societal reintegration. Addressing social issues would allow them to focus on cardiovascular health. Conclusion Given the challenges experienced after release from incarceration, an app focused on social and health-access issues may help returning citizens meet their CVD needs. mHealth, mobile application, cardiovascular disease, prison, jail, incarceration INTRODUCTION The population of persons returning from incarceration (henceforth termed returning citizens) is large, with over 600 000 returning citizens yearly since the 1990s.1,2 The incarcerated population is more economically disadvantaged than the overall population and in poorer health.3,4 Cardiovascular disease (CVD), the number 1 cause of death in the US,5 is also among the leading causes of mortality for people in jail6 and is a frequent cause of death after release.7 Cardiovascular risk factors, such as hypertension, are also more common among individuals with a history of incarceration.8–10 Acknowledging the critical need for interventions to improve cardiovascular health after release, the US National Heart Lung and Blood Institute held a 2017 workshop leading to recommendations for more research on cardiovascular health of returning citizen populations and new and innovative interventions to address these problems.4 Many smartphone applications (apps) have been created to improve chronic health conditions in the general population,11–14 including some that have shown efficacy for controlling cardiometabolic risk factors.15,16 None of these apps have focused on the needs of people who have been incarcerated. Moreover, there are reasons why these apps designed for a general population may not be accessible and may not align with the chronic health needs of returning citizens, despite their portability and convenience. Social Cognitive Theory asserts that individuals are nested within social environments that provide a context for their decisions and actions including health-related decisions, such as smoking, diet, and physical activity.17 For example, research on female returning citizens with substance use disorders found that mobile phones were a feasible way to deliver recovery support through access to their social networks.18 Such findings along with widespread penetration of smartphones in specific low-income subpopulations (eg, homeless youth),19–21 suggest app approaches may be effective, but also point out that their design and development must be rooted in an understanding of the social context of their users. Practically, the solution to this problem requires empirical data on the needs of returning citizens and constraints in their social environment. Given the complex situation around reentry, the aim of this study was to develop an understanding of the context returning citizens face and use this information to inform the design of a smartphone app to improve care of CVD and cardiovascular risk factors in this population. MATERIALS AND METHODS We used a community-engaged approach to guide the development of an app. In 2019, we collected qualitative data from returning citizens and key informants (KIs). The research team included students with graduate-level training in qualitative methods, 2 public health researchers with at least a decade of qualitative experience, an anthropologist, and 2 community health workers who work with returning citizens and have, themselves, been previously incarcerated. These community health workers were integrally involved in the project, bringing expertise about the experiences of formerly incarcerated individuals to the team, and shared in developing the research question as well as decisions about how to carry out the study. The research team also involved and received advice from 2 grassroots community organizations that support returning citizens in the reentry process. Data from returning citizens were collected through focus groups. Returning citizen inclusion criteria were 1) having returned from 1 year or more of prison, or ≥6 months of jail, within the last 5 years, 2) residing in Baltimore, Maryland on a planned permanent basis, and 3) having cardiovascular disease or at least 1 of the following CVD risk factors: being a smoker, overweight/obese, having type 2 diabetes or metabolic syndrome, or hypertension. For the returning citizen focus groups, we also allowed family or close friends of a returning citizen who had actively supported him/her within the last 2 years. In practice, many participants also met both criteria for inclusion, as a returning citizen and as a family/friend to another returning citizen. Recruitment was led by a field coordinator who was a community health worker with extensive ties to community organizations that serve returning citizens. Recruitment was done via snowball sampling based on his networks and affiliations with organizations working with this population. Upon arriving at the focus group, eligibility criteria were confirmed, as returning citizens filled out a sign-in sheet indicating whether they had a CVD diagnosis and which risk factors for CVD they had. Participants were asked to first list problems that they had related to CVD (or that they discuss to help someone with CVD) as well as barriers experienced in caring for these problems since returning to the community. The items on both lists were written on a poster visible to the group, as a basis for continued discussion. Key informants were people who worked in a professional capacity with returning citizens and met the following criteria: be a worker (paid or unpaid) in a governmental, nongovernmental, faith-based, or medical organization that seeks to support or provide healthcare services to returning citizens in the city of Baltimore, MD, and/or a corrections organization that provides oversight to those returning persons and that also actively works full or part-time with returning citizens. Using snowball sampling, we identified initial seeds who suggested others who would be knowledgeable about working with returning citizens through contacts of our team members and organizations supporting returning citizens. Additional key informants were then recruited from referrals made by key informants in focus groups or interviews. Data from key informants were collected through in-depth interviews or small group discussions until saturation was reached (ie, no new ideas were being obtained with additional data collection). Semi-structured guides were used to capture information on the needs and problems faced by returning citizens that could be addressed by an app as well as what returning citizens or service providers deemed desirable on such an app. Separate guides were used for returning citizens and family members versus for key informants (See Supplementary Material). Verbal data from focus groups and interviews were audio-recorded, transcribed verbatim, anonymized, and analyzed primarily using inductive thematic coding. We followed analytic steps that included: data familiarization, generating initial codes, creating themes, reviewing the themes, defining and naming them, followed by write-up.22 We used N-Vivo qualitative data analysis software (QSR International, Melbourne, Australia) for data management. Data collection was approved by the Western and Johns Hopkins Bloomberg School of Public Health Institutional Review Boards. Participants provided oral informed consent that specified that deidentified data could be shared for research purposes. RESULTS Seven community focus groups included a total of 76 returning citizens. Participants were approximately equal in gender (55% male) and were predominantly African American (82%). Seventy-four percent reported having smartphones, though often older or secondhand devices. Data were collected from 19 key informants through 3 small-group discussions and 7 in-depth interviews (Table 1). Table 1. Demographic makeup of participants and data collection event Data collection type/event . Gender . Race . Ethnicity . Returning Citizen Data . Total N . Male . Female . African American . White . Other/Unknown . Hispanic (1) . Focus group 1 15 15 0 15 0 0 0 Focus group 2 18 0 18 13 4 1 1 Focus group 3 9 9 0 9 0 0 0 Focus group 4 10 0 10 8 1 1 0 Focus group 5 12 12 0 11 1 0 0 Focus group 6 6 0 6 5 1 0 1 Focus group 7 6 6 0 0 5 1 0 Subtotals 76 42 34 61 12 3 2 Key Informant Data Small group 1 5 2 3 3 1 1 0 Small group 2 5 5 0 5 0 0 0 Small group 3 2 1 1 2 0 0 0 In-depth interview (2) 7 5 1 3 3 1 0 Subtotals 19 13 5 13 4 2 0 TOTALS 95 55 39 74 16 5 2 Data collection type/event . Gender . Race . Ethnicity . Returning Citizen Data . Total N . Male . Female . African American . White . Other/Unknown . Hispanic (1) . Focus group 1 15 15 0 15 0 0 0 Focus group 2 18 0 18 13 4 1 1 Focus group 3 9 9 0 9 0 0 0 Focus group 4 10 0 10 8 1 1 0 Focus group 5 12 12 0 11 1 0 0 Focus group 6 6 0 6 5 1 0 1 Focus group 7 6 6 0 0 5 1 0 Subtotals 76 42 34 61 12 3 2 Key Informant Data Small group 1 5 2 3 3 1 1 0 Small group 2 5 5 0 5 0 0 0 Small group 3 2 1 1 2 0 0 0 In-depth interview (2) 7 5 1 3 3 1 0 Subtotals 19 13 5 13 4 2 0 TOTALS 95 55 39 74 16 5 2 Open in new tab Table 1. Demographic makeup of participants and data collection event Data collection type/event . Gender . Race . Ethnicity . Returning Citizen Data . Total N . Male . Female . African American . White . Other/Unknown . Hispanic (1) . Focus group 1 15 15 0 15 0 0 0 Focus group 2 18 0 18 13 4 1 1 Focus group 3 9 9 0 9 0 0 0 Focus group 4 10 0 10 8 1 1 0 Focus group 5 12 12 0 11 1 0 0 Focus group 6 6 0 6 5 1 0 1 Focus group 7 6 6 0 0 5 1 0 Subtotals 76 42 34 61 12 3 2 Key Informant Data Small group 1 5 2 3 3 1 1 0 Small group 2 5 5 0 5 0 0 0 Small group 3 2 1 1 2 0 0 0 In-depth interview (2) 7 5 1 3 3 1 0 Subtotals 19 13 5 13 4 2 0 TOTALS 95 55 39 74 16 5 2 Data collection type/event . Gender . Race . Ethnicity . Returning Citizen Data . Total N . Male . Female . African American . White . Other/Unknown . Hispanic (1) . Focus group 1 15 15 0 15 0 0 0 Focus group 2 18 0 18 13 4 1 1 Focus group 3 9 9 0 9 0 0 0 Focus group 4 10 0 10 8 1 1 0 Focus group 5 12 12 0 11 1 0 0 Focus group 6 6 0 6 5 1 0 1 Focus group 7 6 6 0 0 5 1 0 Subtotals 76 42 34 61 12 3 2 Key Informant Data Small group 1 5 2 3 3 1 1 0 Small group 2 5 5 0 5 0 0 0 Small group 3 2 1 1 2 0 0 0 In-depth interview (2) 7 5 1 3 3 1 0 Subtotals 19 13 5 13 4 2 0 TOTALS 95 55 39 74 16 5 2 Open in new tab All data were collected between March and August 2019. Participants were asked if they identified as Hispanic or not (independently of their racial identification). In 1 in-depth interview conducted by phone, gender and ethnicity were not recorded. Challenges to cardiovascular health and app functions to address them Most returning citizens cited existing CVD diagnoses or a range of risk factors, including prior heart attacks and stroke, high blood pressure, diabetes and diabetes complications (amputations), smoking and obesity, and other possibly CVD-related symptoms (eg, shortness of breath, chest pains). They described awareness of the need to deal with these problems as well as barriers that prevented them from doing so. Barriers reflected 5 themes: problems related to health insurance; problems finding and accessing healthcare resources; the complexity of treatment and self-management plans; knowledge/information gaps; and distrust in healthcare and broader social institutions. Table 2 summarizes the barriers/needs identified in the analysis and potential app functionality derived to meet these needs. Table 2. Specific cardiovascular health support needs and corresponding app functionality from returning citizen participants Problem themes/subthemes from returning citizens . Corresponding app functionality suggested by returning citizens . Health insurance Poor/no insurance Limited understanding of coverage App gives user access to data on that user’s insurance benefits and coverage Finding and accessing healthcare Aids to find or gain access to health resources Can’t find resources for medications, healthcare providers Transportation is difficult and expensive App offers users ability to communicate with returning citizen peers to find health resources chance to use telemedicine, tele-triage, tele-diagnosis consults healthy food and nutritional information walking/public transportation maps of health resources and calculators that give user estimates of time and cost of travel to a health resource Barriers to keeping focus on health during reentry Aids to support health management Difficulty keeping track of healthcare needs and appointments Difficulty keeping track of health history Few opportunities for exercise Involvement in pleasurable activities inaccessible while “inside” App offers users automated checklists of how to complete specific tasks and reminders to follow up on scheduled tasks (eg, appointments) access to personal health record and supports access to providers’ patient portals a way to find others to join with them in exercise/physical activity Overcoming knowledge and information gaps Includes learning and information finding tools Lack of knowledge of medications and their intended effects and side effects CVD, related conditions, and risk factors how healthcare and social safety-net services are organized, and how to find and utilize them App offers users information on medical procedures, medication indications, contra-indications, interactions access and learning tools public-transit maps and help-finding mechanisms Lack of trust in health care, social, or penal system Reviews and comments from other returning citizens Expectations based on negative past experiences as returning citizens Openness to using experiences of other returning citizens to guide what to trust App allows and displays crowd-sourced reviews of healthcare (and other) resources entered by other returning citizen users of the app Problem themes/subthemes from returning citizens . Corresponding app functionality suggested by returning citizens . Health insurance Poor/no insurance Limited understanding of coverage App gives user access to data on that user’s insurance benefits and coverage Finding and accessing healthcare Aids to find or gain access to health resources Can’t find resources for medications, healthcare providers Transportation is difficult and expensive App offers users ability to communicate with returning citizen peers to find health resources chance to use telemedicine, tele-triage, tele-diagnosis consults healthy food and nutritional information walking/public transportation maps of health resources and calculators that give user estimates of time and cost of travel to a health resource Barriers to keeping focus on health during reentry Aids to support health management Difficulty keeping track of healthcare needs and appointments Difficulty keeping track of health history Few opportunities for exercise Involvement in pleasurable activities inaccessible while “inside” App offers users automated checklists of how to complete specific tasks and reminders to follow up on scheduled tasks (eg, appointments) access to personal health record and supports access to providers’ patient portals a way to find others to join with them in exercise/physical activity Overcoming knowledge and information gaps Includes learning and information finding tools Lack of knowledge of medications and their intended effects and side effects CVD, related conditions, and risk factors how healthcare and social safety-net services are organized, and how to find and utilize them App offers users information on medical procedures, medication indications, contra-indications, interactions access and learning tools public-transit maps and help-finding mechanisms Lack of trust in health care, social, or penal system Reviews and comments from other returning citizens Expectations based on negative past experiences as returning citizens Openness to using experiences of other returning citizens to guide what to trust App allows and displays crowd-sourced reviews of healthcare (and other) resources entered by other returning citizen users of the app Open in new tab Table 2. Specific cardiovascular health support needs and corresponding app functionality from returning citizen participants Problem themes/subthemes from returning citizens . Corresponding app functionality suggested by returning citizens . Health insurance Poor/no insurance Limited understanding of coverage App gives user access to data on that user’s insurance benefits and coverage Finding and accessing healthcare Aids to find or gain access to health resources Can’t find resources for medications, healthcare providers Transportation is difficult and expensive App offers users ability to communicate with returning citizen peers to find health resources chance to use telemedicine, tele-triage, tele-diagnosis consults healthy food and nutritional information walking/public transportation maps of health resources and calculators that give user estimates of time and cost of travel to a health resource Barriers to keeping focus on health during reentry Aids to support health management Difficulty keeping track of healthcare needs and appointments Difficulty keeping track of health history Few opportunities for exercise Involvement in pleasurable activities inaccessible while “inside” App offers users automated checklists of how to complete specific tasks and reminders to follow up on scheduled tasks (eg, appointments) access to personal health record and supports access to providers’ patient portals a way to find others to join with them in exercise/physical activity Overcoming knowledge and information gaps Includes learning and information finding tools Lack of knowledge of medications and their intended effects and side effects CVD, related conditions, and risk factors how healthcare and social safety-net services are organized, and how to find and utilize them App offers users information on medical procedures, medication indications, contra-indications, interactions access and learning tools public-transit maps and help-finding mechanisms Lack of trust in health care, social, or penal system Reviews and comments from other returning citizens Expectations based on negative past experiences as returning citizens Openness to using experiences of other returning citizens to guide what to trust App allows and displays crowd-sourced reviews of healthcare (and other) resources entered by other returning citizen users of the app Problem themes/subthemes from returning citizens . Corresponding app functionality suggested by returning citizens . Health insurance Poor/no insurance Limited understanding of coverage App gives user access to data on that user’s insurance benefits and coverage Finding and accessing healthcare Aids to find or gain access to health resources Can’t find resources for medications, healthcare providers Transportation is difficult and expensive App offers users ability to communicate with returning citizen peers to find health resources chance to use telemedicine, tele-triage, tele-diagnosis consults healthy food and nutritional information walking/public transportation maps of health resources and calculators that give user estimates of time and cost of travel to a health resource Barriers to keeping focus on health during reentry Aids to support health management Difficulty keeping track of healthcare needs and appointments Difficulty keeping track of health history Few opportunities for exercise Involvement in pleasurable activities inaccessible while “inside” App offers users automated checklists of how to complete specific tasks and reminders to follow up on scheduled tasks (eg, appointments) access to personal health record and supports access to providers’ patient portals a way to find others to join with them in exercise/physical activity Overcoming knowledge and information gaps Includes learning and information finding tools Lack of knowledge of medications and their intended effects and side effects CVD, related conditions, and risk factors how healthcare and social safety-net services are organized, and how to find and utilize them App offers users information on medical procedures, medication indications, contra-indications, interactions access and learning tools public-transit maps and help-finding mechanisms Lack of trust in health care, social, or penal system Reviews and comments from other returning citizens Expectations based on negative past experiences as returning citizens Openness to using experiences of other returning citizens to guide what to trust App allows and displays crowd-sourced reviews of healthcare (and other) resources entered by other returning citizen users of the app Open in new tab Table 3 provides direct quotes exemplifying each of these themes referenced below. Table 3. Specific cardiovascular health support needs and corresponding app functionality Quote # . Typea . Quotation . Theme: Health insurance 1 RC “I’ve had problems getting medication that I need, because they assigned me to Lantus. That’s an insulin… And the insurance that I got…they don’t want to pay for it.” 2 RC “Your primary care physician does not carry that insurance no more. Every time you go see your primary care, you still got that insurance, it’s a bill on you.” 3 RC “Because some insurances cover certain things that other insurance don’t cover… So, whatever it is, the insurance got to—when you get signed up with insurance, you got a list of everything it covers.” Theme: Finding and accessing healthcare 4 RC “… a list of who does and who don’t. You know what I’m saying? Because then instead of running to the emergency room I can go there, like a 24-hour hotline… because say I had a problem with my teeth, I can get a direct line to a dentist, you know like a non-profit…” 5 RC “I had to see my parole officer. So, I’m all the way up there at Walbatch, but then I had appointment all the way over there on Fleet Street going towards O’Donnell Heights and I had to travel all the way over there from Walbatch to over there to back over here to be back at group [therapy] at a certain time, and it just can be overwhelming sometimes.” 6 RC “So, if I could go on an app or something and talk with someone and deal with somebody, it’d be a lot better… It’d be like a doctor online.” An RC described an app could help with 7 RC “Resources, like, for transportation—like mobility and stuff like that. Like cabs… [The transit authority] has a lot of services that people don’t know about.” Theme: Complexity of treatment and Self-management Plans 8 RC “You could really keep track of your health on that 1 thing. Am I doing this? Did I do this? Did I do this today? Checklists, a tool. That would be good.” 9 RC “The app almost feels like it could be like a reminder… ‘Did you check this? Did you do that? Take your meds’ or just [provide] the regular contact.” 10 RC “I have all my [medical] information on the phone. So, when I go to my primary care doctor, if she doesn’t have the information, I can pull it up and show her.” Theme: Gaps in Knowledge and Information 11 RC “I had 2 back surgeries… I have to look up everything that I get because if they give me a dirty urine, I could get thrown off the [substance treatment] program.” 12 RC “What I like to do is, whenever I get a medication, I’d like to look it up and see what it’s interactive with.” 13 RC “You go to the section with diabetes and it’ll break it down to you just what diabetes is, what the medicine [is], ‘This is what the side effects is, this is what you should be eating, this is what you shouldn’t be eating.” 14 RC “There are a number of reentry programs here and some people may or may not know about that. But if you had that listed on the app, that might be easier for them to pinpoint…’” Theme: Lack of trust in health care, social, or penal system 15 RC “You get choice in your choice of doctor, but you got to also check the doctors. You got to learn something about the doctors, their history. So, you got to get some history about the doctor, because all doctors are not good doctors.” 16 RC “[We would like] actual statements from the people [that reflect] how we feel about the services.” 17 RC “[When you] come back to the community, they might send you to somewhere that ain’t fitting for you. But you got to deal with it until you find out there’s the resources updated.” Quote # . Typea . Quotation . Theme: Health insurance 1 RC “I’ve had problems getting medication that I need, because they assigned me to Lantus. That’s an insulin… And the insurance that I got…they don’t want to pay for it.” 2 RC “Your primary care physician does not carry that insurance no more. Every time you go see your primary care, you still got that insurance, it’s a bill on you.” 3 RC “Because some insurances cover certain things that other insurance don’t cover… So, whatever it is, the insurance got to—when you get signed up with insurance, you got a list of everything it covers.” Theme: Finding and accessing healthcare 4 RC “… a list of who does and who don’t. You know what I’m saying? Because then instead of running to the emergency room I can go there, like a 24-hour hotline… because say I had a problem with my teeth, I can get a direct line to a dentist, you know like a non-profit…” 5 RC “I had to see my parole officer. So, I’m all the way up there at Walbatch, but then I had appointment all the way over there on Fleet Street going towards O’Donnell Heights and I had to travel all the way over there from Walbatch to over there to back over here to be back at group [therapy] at a certain time, and it just can be overwhelming sometimes.” 6 RC “So, if I could go on an app or something and talk with someone and deal with somebody, it’d be a lot better… It’d be like a doctor online.” An RC described an app could help with 7 RC “Resources, like, for transportation—like mobility and stuff like that. Like cabs… [The transit authority] has a lot of services that people don’t know about.” Theme: Complexity of treatment and Self-management Plans 8 RC “You could really keep track of your health on that 1 thing. Am I doing this? Did I do this? Did I do this today? Checklists, a tool. That would be good.” 9 RC “The app almost feels like it could be like a reminder… ‘Did you check this? Did you do that? Take your meds’ or just [provide] the regular contact.” 10 RC “I have all my [medical] information on the phone. So, when I go to my primary care doctor, if she doesn’t have the information, I can pull it up and show her.” Theme: Gaps in Knowledge and Information 11 RC “I had 2 back surgeries… I have to look up everything that I get because if they give me a dirty urine, I could get thrown off the [substance treatment] program.” 12 RC “What I like to do is, whenever I get a medication, I’d like to look it up and see what it’s interactive with.” 13 RC “You go to the section with diabetes and it’ll break it down to you just what diabetes is, what the medicine [is], ‘This is what the side effects is, this is what you should be eating, this is what you shouldn’t be eating.” 14 RC “There are a number of reentry programs here and some people may or may not know about that. But if you had that listed on the app, that might be easier for them to pinpoint…’” Theme: Lack of trust in health care, social, or penal system 15 RC “You get choice in your choice of doctor, but you got to also check the doctors. You got to learn something about the doctors, their history. So, you got to get some history about the doctor, because all doctors are not good doctors.” 16 RC “[We would like] actual statements from the people [that reflect] how we feel about the services.” 17 RC “[When you] come back to the community, they might send you to somewhere that ain’t fitting for you. But you got to deal with it until you find out there’s the resources updated.” a Participant type. Abbreviations: RC, returning citizen; KI, key informant. Open in new tab Table 3. Specific cardiovascular health support needs and corresponding app functionality Quote # . Typea . Quotation . Theme: Health insurance 1 RC “I’ve had problems getting medication that I need, because they assigned me to Lantus. That’s an insulin… And the insurance that I got…they don’t want to pay for it.” 2 RC “Your primary care physician does not carry that insurance no more. Every time you go see your primary care, you still got that insurance, it’s a bill on you.” 3 RC “Because some insurances cover certain things that other insurance don’t cover… So, whatever it is, the insurance got to—when you get signed up with insurance, you got a list of everything it covers.” Theme: Finding and accessing healthcare 4 RC “… a list of who does and who don’t. You know what I’m saying? Because then instead of running to the emergency room I can go there, like a 24-hour hotline… because say I had a problem with my teeth, I can get a direct line to a dentist, you know like a non-profit…” 5 RC “I had to see my parole officer. So, I’m all the way up there at Walbatch, but then I had appointment all the way over there on Fleet Street going towards O’Donnell Heights and I had to travel all the way over there from Walbatch to over there to back over here to be back at group [therapy] at a certain time, and it just can be overwhelming sometimes.” 6 RC “So, if I could go on an app or something and talk with someone and deal with somebody, it’d be a lot better… It’d be like a doctor online.” An RC described an app could help with 7 RC “Resources, like, for transportation—like mobility and stuff like that. Like cabs… [The transit authority] has a lot of services that people don’t know about.” Theme: Complexity of treatment and Self-management Plans 8 RC “You could really keep track of your health on that 1 thing. Am I doing this? Did I do this? Did I do this today? Checklists, a tool. That would be good.” 9 RC “The app almost feels like it could be like a reminder… ‘Did you check this? Did you do that? Take your meds’ or just [provide] the regular contact.” 10 RC “I have all my [medical] information on the phone. So, when I go to my primary care doctor, if she doesn’t have the information, I can pull it up and show her.” Theme: Gaps in Knowledge and Information 11 RC “I had 2 back surgeries… I have to look up everything that I get because if they give me a dirty urine, I could get thrown off the [substance treatment] program.” 12 RC “What I like to do is, whenever I get a medication, I’d like to look it up and see what it’s interactive with.” 13 RC “You go to the section with diabetes and it’ll break it down to you just what diabetes is, what the medicine [is], ‘This is what the side effects is, this is what you should be eating, this is what you shouldn’t be eating.” 14 RC “There are a number of reentry programs here and some people may or may not know about that. But if you had that listed on the app, that might be easier for them to pinpoint…’” Theme: Lack of trust in health care, social, or penal system 15 RC “You get choice in your choice of doctor, but you got to also check the doctors. You got to learn something about the doctors, their history. So, you got to get some history about the doctor, because all doctors are not good doctors.” 16 RC “[We would like] actual statements from the people [that reflect] how we feel about the services.” 17 RC “[When you] come back to the community, they might send you to somewhere that ain’t fitting for you. But you got to deal with it until you find out there’s the resources updated.” Quote # . Typea . Quotation . Theme: Health insurance 1 RC “I’ve had problems getting medication that I need, because they assigned me to Lantus. That’s an insulin… And the insurance that I got…they don’t want to pay for it.” 2 RC “Your primary care physician does not carry that insurance no more. Every time you go see your primary care, you still got that insurance, it’s a bill on you.” 3 RC “Because some insurances cover certain things that other insurance don’t cover… So, whatever it is, the insurance got to—when you get signed up with insurance, you got a list of everything it covers.” Theme: Finding and accessing healthcare 4 RC “… a list of who does and who don’t. You know what I’m saying? Because then instead of running to the emergency room I can go there, like a 24-hour hotline… because say I had a problem with my teeth, I can get a direct line to a dentist, you know like a non-profit…” 5 RC “I had to see my parole officer. So, I’m all the way up there at Walbatch, but then I had appointment all the way over there on Fleet Street going towards O’Donnell Heights and I had to travel all the way over there from Walbatch to over there to back over here to be back at group [therapy] at a certain time, and it just can be overwhelming sometimes.” 6 RC “So, if I could go on an app or something and talk with someone and deal with somebody, it’d be a lot better… It’d be like a doctor online.” An RC described an app could help with 7 RC “Resources, like, for transportation—like mobility and stuff like that. Like cabs… [The transit authority] has a lot of services that people don’t know about.” Theme: Complexity of treatment and Self-management Plans 8 RC “You could really keep track of your health on that 1 thing. Am I doing this? Did I do this? Did I do this today? Checklists, a tool. That would be good.” 9 RC “The app almost feels like it could be like a reminder… ‘Did you check this? Did you do that? Take your meds’ or just [provide] the regular contact.” 10 RC “I have all my [medical] information on the phone. So, when I go to my primary care doctor, if she doesn’t have the information, I can pull it up and show her.” Theme: Gaps in Knowledge and Information 11 RC “I had 2 back surgeries… I have to look up everything that I get because if they give me a dirty urine, I could get thrown off the [substance treatment] program.” 12 RC “What I like to do is, whenever I get a medication, I’d like to look it up and see what it’s interactive with.” 13 RC “You go to the section with diabetes and it’ll break it down to you just what diabetes is, what the medicine [is], ‘This is what the side effects is, this is what you should be eating, this is what you shouldn’t be eating.” 14 RC “There are a number of reentry programs here and some people may or may not know about that. But if you had that listed on the app, that might be easier for them to pinpoint…’” Theme: Lack of trust in health care, social, or penal system 15 RC “You get choice in your choice of doctor, but you got to also check the doctors. You got to learn something about the doctors, their history. So, you got to get some history about the doctor, because all doctors are not good doctors.” 16 RC “[We would like] actual statements from the people [that reflect] how we feel about the services.” 17 RC “[When you] come back to the community, they might send you to somewhere that ain’t fitting for you. But you got to deal with it until you find out there’s the resources updated.” a Participant type. Abbreviations: RC, returning citizen; KI, key informant. Open in new tab Health insurance Returning citizens described having reduced access to health insurance if unemployed and many discussed being insured by subsidized low-income public insurance which provided limited coverage and required out-of-pocket expenses (Table 3, Quote 1). They also noted that providers often change which insurance they accept, leaving the patient with unaffordable fees. One participant described finding a primary care provider only to realize soon afterward that the provider no longer accepted their insurance (Table 3, Quote 2). Returning citizens also described problems understanding what coverage their insurance provided, leading to situations where they could not find a provider who would accept them. Participants offered few specific ways in which an app could help, though 1 suggested the app could serve as a resource for insurance information, to make clear what their insurance would and wouldn’t cover (Table 3, Quote 3). Finding and accessing healthcare Separate from insurance, returning citizens noted difficulties finding healthcare resources to deal with acute problems, both as a challenge on its own and in conjunction with finding a way of paying for these resources (See Table 3, Quote 4 for an example regarding care for a toothache). Returning citizens frequently reported that logistics, particularly transportation, were practical barriers to successfully seeking and receiving healthcare. Since most lacked cars, transportation to healthcare services had to be accessed through public transit. But for anything other than simple primary care, they reported that dealing with a problem often required multiple trips to various locations. This required knowledge of the public transit options and time and energy to reach these locations (Table 3, quote 5), a problem that could further be complicated by limited locations being served by public transit. The expense and physical grind of traveling everywhere on foot or by public transit was exacerbated by a poor knowledge of geography, transit, and support options after time spent incarcerated and away from the community. Returning citizens suggested app functions that related to finding healthcare resources. Several returning citizens envisioned uses of telemedicine (including tele-triage and tele-diagnosis) in an app (Table 3, Quote 6). A returning citizen envisioned an app that could help in finding healthcare resources and educate users about what transportation services are available (Table 3, Quote 7). Complexity of treatment and self-management plans Returning citizens reported having simultaneous issues around multiple medications, disease self-monitoring (eg, glucose testing for diabetes), multiple healthcare appointments, and remembering to engage in exercise. These combined needs resulted in many things to keep track of and complex schedules, which were difficult to manage. Many participants perceived that reminders, calendars, and checklists would be helpful app functions (Table 3, Quotes 8 and 9). Separately, the disjointed nature of access to the health system that many returning citizens described was seen as a source of challenges with maintaining a consistent medical history. Several returning citizens thought some form of access to their records via the app was important, and 1 talked about already trying to do that by saving information to share with the doctor on the smartphone (Table 3, Quote 10). Gaps in knowledge and information Numerous returning citizens expressed concern over the number of prescribed medications, lacking understanding of what each was for and of possible side-effects and medication interactions. This appeared to lead them to distrust and potentially discontinue/not start some medications. An example of this lack of information was reported as not knowing which medications could impact urine tests for substance-abuse programs and, therefore, lead to the person being denied treatment (Table 3, Quote 11). A common suggestion was that the app should provide some functionality to identify effects, interactions, and contraindications of medications and analogous information for procedures (Table 3, Quote 12). Other returning citizens expressed similar desires to understand CVD in relation to comorbidities (Table 3, Quote 13). Finally, multiple participants, particularly those who had returned to the community longer ago, had become aware that there were multiple community-level resources and programs intended to support returning citizens and their reentry. They felt that most returning citizens had little knowledge of them, especially of those most geographically accessible to them, and needed more information to support these resources. Lack of trust in healthcare institutions Participants often voiced uncertainty about the quality of healthcare resources. Such comments suggested widespread distrust of healthcare and social services (Table 3, Quote 15). Several returning citizens expressed a desire to have access to other returning citizens’ opinions when dealing with unfamiliar healthcare or social services (Table 3, Quote 16) and indicated that they would read reviews and be willing to register their opinions to help future returning citizens avoid inappropriate resources (Table 3, Quote 17). Thus, they felt distrust in unknown resources could be allayed by positive reviews from other returning citizens. This suggested a specific app functionality based on the concept of crowd-sourcing.23 Specifically, returning citizens wanted crowd-sourced reviews from other returning citizens in similar situations. Multiple concerns take priority over cardiovascular health Returning citizens faced a multiplicity of concerns, especially regarding reliable housing and employment, which they perceived as priorities compared to their health. Mental health and substance use disorders also distracted returning citizens from attending to CVD-related problems. Other distractions may have resulted from discrimination due to belonging to a stigmatized group or to multiple stigmatized groups (eg, being a person with mental illness or with a drug or alcohol use disorder, a racial/ethnic minority, low-income). Table 4 provides direct quotations from the data exemplifying how some of the broader issues discussed below related to multiple stigmas and challenges and how an app might address them. Table 4. Multiple concerns take priority over cardiovascular health suggesting the need for general solutions Quote # . Typea . Quotation . 1 KI “I would say way at the bottom… If they’re not in total distress, I think they'll put it at the bottom.” 2 KI “Typically, people are stressed by a number of other things, so they’re not sitting around thinking ‘Oh, I hope my health is doing better now.’” Housing and Jobs/Income 3 KI “The most common [needs] is housing, transportation, food, clothing and just the matter of general support.” 4 KI “Well, people don’t ordinarily attack healthcare when they come out of incarceration. That’s not the first priority. And I’ve dealt with so many people. The first priority is usually, ‘Where am I going to stay?’ and ‘I have to get a job because I’ve been in there 15 years. I’m leaving with $72.’” 5 RC “We going on to a year that I’ve been home. I’m sitting here fighting and sleeping from this girlfriend’s house to this mother house to this cousin house to this homeboy house…I’m still trying to do your program, duck the police because I got a hustle on the side a little bit to make some type of income. To still be able to abstain and hold on my end of the bargain that y’all asking me, do you feel that pain? That’s real.” 6 RC “Because when you just coming out of incarceration, a lot of companies, they not trying to hire you, but they got this [idea of] return to society, like you supposed—you just supposed to automatically return to society, like you never left.” 7 KI “So, the most common need we see is unstable housing … They return with a limited number or amount of income, and transitional housing is $20 a week. So, they can usually get by 2 or 3 weeks and after that we’re in alarm mode… The second thing I would say is medication and not being connected to a medical service… So, I get people in crisis who [are saying], ‘I need my medication. I have 2 days left and I don’t know where to go.’ That and, ‘I have nowhere to stay.’ Or ‘I don’t have the money for the transitional housing.’ Sometimes food is an issue, but more so the housing.” Substance Use and Mental Health 8 KI “People aren’t necessarily really healthy, right… I have so many people who are HIV-positive, and they’ll have been on super-hard street drugs. They’ll get somewhat clean or maybe totally clean for a while, and then they go to a doctor and are like ‘Whoa. I was better off using. I don’t want to know this stuff. I don’t want to deal with it.’… A lot of people are kind of fighting for survival…, and then to be like ‘Oh, about that heart and that cholesterol’— I think it’s just difficult for a lot of people just to keep their head above water.” 9 RC “Being educated and being smart enough to see the whole process but knowing that I’m counted among all the transgressors in the world. I've been to jail. I have mental health issues. I’ve had drug problems. I’m homeless.” Support and Guidance Needed to Navigate Reentry 10 KI “I just think about the whole transition process and that really it seems to me there is no process. I’ve heard these stories about this van dropping people off Wilkins Avenue, and I’m like, ‘Well, welcome to freedom.’” 11 KI “They should leave the jail with some type of package that involves your mental, physical, emotional, and financial health. Where to go and how to get there. Each area of life. And then let them go from there. You gotta give them some type of guidelines. ‘Cuz once you step outside of jail, if you don’t have a home to go to…. If you don’t give them some type of information, they end up right back in jail. They give up.” 12 KI “These are situations that have to be tailored. When they come out, they come out to nothing. And so much nothing until where they came from looks better than what they’d been released to. If you really want a solution, let’s pad that exit like we have padded their entrance.” 13 KI “[It’s] almost having like a roadmap, not just what do you need but what do you do first, because a lot of times when I think about when I’ve worked with folks affected by homelessness, you’re told to go to Department of Social Services but you’re not told what to bring and how to use it. So, I think the order of things becomes super important … so I think just being able to kind of front-load your roadmap and what are you entitled to as a returning citizen, I think is super important.” 14 KI “I think 1 of the opportunities may be to bring in peers or folks that have been through similar things like, ‘Hey, here’s 5 things I didn’t know were going to be problems for me when I got out,’ and that would be a nice way to kind of summarize and pull together.” Quote # . Typea . Quotation . 1 KI “I would say way at the bottom… If they’re not in total distress, I think they'll put it at the bottom.” 2 KI “Typically, people are stressed by a number of other things, so they’re not sitting around thinking ‘Oh, I hope my health is doing better now.’” Housing and Jobs/Income 3 KI “The most common [needs] is housing, transportation, food, clothing and just the matter of general support.” 4 KI “Well, people don’t ordinarily attack healthcare when they come out of incarceration. That’s not the first priority. And I’ve dealt with so many people. The first priority is usually, ‘Where am I going to stay?’ and ‘I have to get a job because I’ve been in there 15 years. I’m leaving with $72.’” 5 RC “We going on to a year that I’ve been home. I’m sitting here fighting and sleeping from this girlfriend’s house to this mother house to this cousin house to this homeboy house…I’m still trying to do your program, duck the police because I got a hustle on the side a little bit to make some type of income. To still be able to abstain and hold on my end of the bargain that y’all asking me, do you feel that pain? That’s real.” 6 RC “Because when you just coming out of incarceration, a lot of companies, they not trying to hire you, but they got this [idea of] return to society, like you supposed—you just supposed to automatically return to society, like you never left.” 7 KI “So, the most common need we see is unstable housing … They return with a limited number or amount of income, and transitional housing is $20 a week. So, they can usually get by 2 or 3 weeks and after that we’re in alarm mode… The second thing I would say is medication and not being connected to a medical service… So, I get people in crisis who [are saying], ‘I need my medication. I have 2 days left and I don’t know where to go.’ That and, ‘I have nowhere to stay.’ Or ‘I don’t have the money for the transitional housing.’ Sometimes food is an issue, but more so the housing.” Substance Use and Mental Health 8 KI “People aren’t necessarily really healthy, right… I have so many people who are HIV-positive, and they’ll have been on super-hard street drugs. They’ll get somewhat clean or maybe totally clean for a while, and then they go to a doctor and are like ‘Whoa. I was better off using. I don’t want to know this stuff. I don’t want to deal with it.’… A lot of people are kind of fighting for survival…, and then to be like ‘Oh, about that heart and that cholesterol’— I think it’s just difficult for a lot of people just to keep their head above water.” 9 RC “Being educated and being smart enough to see the whole process but knowing that I’m counted among all the transgressors in the world. I've been to jail. I have mental health issues. I’ve had drug problems. I’m homeless.” Support and Guidance Needed to Navigate Reentry 10 KI “I just think about the whole transition process and that really it seems to me there is no process. I’ve heard these stories about this van dropping people off Wilkins Avenue, and I’m like, ‘Well, welcome to freedom.’” 11 KI “They should leave the jail with some type of package that involves your mental, physical, emotional, and financial health. Where to go and how to get there. Each area of life. And then let them go from there. You gotta give them some type of guidelines. ‘Cuz once you step outside of jail, if you don’t have a home to go to…. If you don’t give them some type of information, they end up right back in jail. They give up.” 12 KI “These are situations that have to be tailored. When they come out, they come out to nothing. And so much nothing until where they came from looks better than what they’d been released to. If you really want a solution, let’s pad that exit like we have padded their entrance.” 13 KI “[It’s] almost having like a roadmap, not just what do you need but what do you do first, because a lot of times when I think about when I’ve worked with folks affected by homelessness, you’re told to go to Department of Social Services but you’re not told what to bring and how to use it. So, I think the order of things becomes super important … so I think just being able to kind of front-load your roadmap and what are you entitled to as a returning citizen, I think is super important.” 14 KI “I think 1 of the opportunities may be to bring in peers or folks that have been through similar things like, ‘Hey, here’s 5 things I didn’t know were going to be problems for me when I got out,’ and that would be a nice way to kind of summarize and pull together.” a Participant type. Abbreviations: RC, returning citizen; KI, key informant. Open in new tab Table 4. Multiple concerns take priority over cardiovascular health suggesting the need for general solutions Quote # . Typea . Quotation . 1 KI “I would say way at the bottom… If they’re not in total distress, I think they'll put it at the bottom.” 2 KI “Typically, people are stressed by a number of other things, so they’re not sitting around thinking ‘Oh, I hope my health is doing better now.’” Housing and Jobs/Income 3 KI “The most common [needs] is housing, transportation, food, clothing and just the matter of general support.” 4 KI “Well, people don’t ordinarily attack healthcare when they come out of incarceration. That’s not the first priority. And I’ve dealt with so many people. The first priority is usually, ‘Where am I going to stay?’ and ‘I have to get a job because I’ve been in there 15 years. I’m leaving with $72.’” 5 RC “We going on to a year that I’ve been home. I’m sitting here fighting and sleeping from this girlfriend’s house to this mother house to this cousin house to this homeboy house…I’m still trying to do your program, duck the police because I got a hustle on the side a little bit to make some type of income. To still be able to abstain and hold on my end of the bargain that y’all asking me, do you feel that pain? That’s real.” 6 RC “Because when you just coming out of incarceration, a lot of companies, they not trying to hire you, but they got this [idea of] return to society, like you supposed—you just supposed to automatically return to society, like you never left.” 7 KI “So, the most common need we see is unstable housing … They return with a limited number or amount of income, and transitional housing is $20 a week. So, they can usually get by 2 or 3 weeks and after that we’re in alarm mode… The second thing I would say is medication and not being connected to a medical service… So, I get people in crisis who [are saying], ‘I need my medication. I have 2 days left and I don’t know where to go.’ That and, ‘I have nowhere to stay.’ Or ‘I don’t have the money for the transitional housing.’ Sometimes food is an issue, but more so the housing.” Substance Use and Mental Health 8 KI “People aren’t necessarily really healthy, right… I have so many people who are HIV-positive, and they’ll have been on super-hard street drugs. They’ll get somewhat clean or maybe totally clean for a while, and then they go to a doctor and are like ‘Whoa. I was better off using. I don’t want to know this stuff. I don’t want to deal with it.’… A lot of people are kind of fighting for survival…, and then to be like ‘Oh, about that heart and that cholesterol’— I think it’s just difficult for a lot of people just to keep their head above water.” 9 RC “Being educated and being smart enough to see the whole process but knowing that I’m counted among all the transgressors in the world. I've been to jail. I have mental health issues. I’ve had drug problems. I’m homeless.” Support and Guidance Needed to Navigate Reentry 10 KI “I just think about the whole transition process and that really it seems to me there is no process. I’ve heard these stories about this van dropping people off Wilkins Avenue, and I’m like, ‘Well, welcome to freedom.’” 11 KI “They should leave the jail with some type of package that involves your mental, physical, emotional, and financial health. Where to go and how to get there. Each area of life. And then let them go from there. You gotta give them some type of guidelines. ‘Cuz once you step outside of jail, if you don’t have a home to go to…. If you don’t give them some type of information, they end up right back in jail. They give up.” 12 KI “These are situations that have to be tailored. When they come out, they come out to nothing. And so much nothing until where they came from looks better than what they’d been released to. If you really want a solution, let’s pad that exit like we have padded their entrance.” 13 KI “[It’s] almost having like a roadmap, not just what do you need but what do you do first, because a lot of times when I think about when I’ve worked with folks affected by homelessness, you’re told to go to Department of Social Services but you’re not told what to bring and how to use it. So, I think the order of things becomes super important … so I think just being able to kind of front-load your roadmap and what are you entitled to as a returning citizen, I think is super important.” 14 KI “I think 1 of the opportunities may be to bring in peers or folks that have been through similar things like, ‘Hey, here’s 5 things I didn’t know were going to be problems for me when I got out,’ and that would be a nice way to kind of summarize and pull together.” Quote # . Typea . Quotation . 1 KI “I would say way at the bottom… If they’re not in total distress, I think they'll put it at the bottom.” 2 KI “Typically, people are stressed by a number of other things, so they’re not sitting around thinking ‘Oh, I hope my health is doing better now.’” Housing and Jobs/Income 3 KI “The most common [needs] is housing, transportation, food, clothing and just the matter of general support.” 4 KI “Well, people don’t ordinarily attack healthcare when they come out of incarceration. That’s not the first priority. And I’ve dealt with so many people. The first priority is usually, ‘Where am I going to stay?’ and ‘I have to get a job because I’ve been in there 15 years. I’m leaving with $72.’” 5 RC “We going on to a year that I’ve been home. I’m sitting here fighting and sleeping from this girlfriend’s house to this mother house to this cousin house to this homeboy house…I’m still trying to do your program, duck the police because I got a hustle on the side a little bit to make some type of income. To still be able to abstain and hold on my end of the bargain that y’all asking me, do you feel that pain? That’s real.” 6 RC “Because when you just coming out of incarceration, a lot of companies, they not trying to hire you, but they got this [idea of] return to society, like you supposed—you just supposed to automatically return to society, like you never left.” 7 KI “So, the most common need we see is unstable housing … They return with a limited number or amount of income, and transitional housing is $20 a week. So, they can usually get by 2 or 3 weeks and after that we’re in alarm mode… The second thing I would say is medication and not being connected to a medical service… So, I get people in crisis who [are saying], ‘I need my medication. I have 2 days left and I don’t know where to go.’ That and, ‘I have nowhere to stay.’ Or ‘I don’t have the money for the transitional housing.’ Sometimes food is an issue, but more so the housing.” Substance Use and Mental Health 8 KI “People aren’t necessarily really healthy, right… I have so many people who are HIV-positive, and they’ll have been on super-hard street drugs. They’ll get somewhat clean or maybe totally clean for a while, and then they go to a doctor and are like ‘Whoa. I was better off using. I don’t want to know this stuff. I don’t want to deal with it.’… A lot of people are kind of fighting for survival…, and then to be like ‘Oh, about that heart and that cholesterol’— I think it’s just difficult for a lot of people just to keep their head above water.” 9 RC “Being educated and being smart enough to see the whole process but knowing that I’m counted among all the transgressors in the world. I've been to jail. I have mental health issues. I’ve had drug problems. I’m homeless.” Support and Guidance Needed to Navigate Reentry 10 KI “I just think about the whole transition process and that really it seems to me there is no process. I’ve heard these stories about this van dropping people off Wilkins Avenue, and I’m like, ‘Well, welcome to freedom.’” 11 KI “They should leave the jail with some type of package that involves your mental, physical, emotional, and financial health. Where to go and how to get there. Each area of life. And then let them go from there. You gotta give them some type of guidelines. ‘Cuz once you step outside of jail, if you don’t have a home to go to…. If you don’t give them some type of information, they end up right back in jail. They give up.” 12 KI “These are situations that have to be tailored. When they come out, they come out to nothing. And so much nothing until where they came from looks better than what they’d been released to. If you really want a solution, let’s pad that exit like we have padded their entrance.” 13 KI “[It’s] almost having like a roadmap, not just what do you need but what do you do first, because a lot of times when I think about when I’ve worked with folks affected by homelessness, you’re told to go to Department of Social Services but you’re not told what to bring and how to use it. So, I think the order of things becomes super important … so I think just being able to kind of front-load your roadmap and what are you entitled to as a returning citizen, I think is super important.” 14 KI “I think 1 of the opportunities may be to bring in peers or folks that have been through similar things like, ‘Hey, here’s 5 things I didn’t know were going to be problems for me when I got out,’ and that would be a nice way to kind of summarize and pull together.” a Participant type. Abbreviations: RC, returning citizen; KI, key informant. Open in new tab Returning citizens noted that a smartphone app could be focused on problem-solving to help with societal reintegration in combination with addressing barriers to dealing with CVD and its risk factors. This was informed by general agreement among KIs that, given the multiple problems returning citizens face, health was not a priority. When asked where CVD-related health ranked, service providers suggested that it would be very low in returning citizens’ priorities (Table 4, Quote 1 and Quote 2). Housing and jobs/income Basic needs were seen as pressing (Table 4, Quote 3). Service providers emphasized that issues that urgently need to be addressed were housing and jobs (Table 4, Quote 4). Persons released from incarceration typically do not have employment or an income source and frequently have only temporary housing. Additionally, many are required to obtain both as a condition of parole. Some returning citizens described the stress of this situation (Table 4, Quote 5). Jobs were perceived as hard to obtain, as returning citizens have both a police record and have been out of the workforce (Table 4, Quote 6). Others described access to medications and medical services for CVD-related conditions, as other examples of the multiple competing issues (like income, housing, and food insecurity) that returning citizens deal with (Table 4, Quote, 7). Substance use and mental health Other common issues that were described as distracting from CVD-related problems were substance use and mental health problems. As a service provider explained, many returning citizens have a history of substance use and emotional disorders, both issues that can require more pressing attention than CVD (Table 4, Quotes 8 and 9). Support and guidance needed to navigate reentry When asked about what could make it easier to address CVD and other health problems, participants mentioned that returning citizens often feel a lack of guidance (Table 4, Quote 10). Service providers felt that returning citizens would benefit from more direction regarding how to access services needed to address their reentry challenges (Table 4, Quote 11). A community organizer emphasized that to properly address the multiple complex problems facing returning citizens, the solutions offered have to be tailored to an individual’s needs (Table 4, Quote 12). One service provider summed up the way these multiple needs could be met with the metaphor of a roadmap that helped a returning citizen to determine not just what needed to be done, but also to determine the order those things needed to be done, and how to prioritize competing demands (Table 4, Quote 13). Other service providers noted that such a roadmap could be made more effective by tapping into advice from others who had similar reentry experiences (Table 4, Quote 14). DISCUSSION We found that returning citizens face multiple barriers to improving their cardiovascular health and accessing healthcare services after release. Based on how CVD health concerns are situated within the context of returning citizens’ lives, results suggested that a smartphone app for this population should provide a general roadmap to resources to facilitate jobs and housing, in addition to providing CVD-specific functionality. That is, addressing CVD risk factors might be ineffective if returning citizens are not able to simultaneously deal with issues— related to employment and housing or substance use/mental health problems—that they consider more pressing. This is consistent with prior research on women released from jail that found health was not a priority for most women and was considered less important than employment and childcare concerns.24 Desired app features include guidance to streamline medical and social service care by helping returning citizens find resources that are matched to specific needs, locally available, and affordable. This concept of combining healthcare and social services, particularly from the perspective of an app, is novel. While some research has focused on integrating information on social services into electronic health records so that primary care physicians can use it to counsel patients,25–27 for returning citizens without regular health care providers, such provider-centric solutions are less relevant and were not identified by any of our study participants. Some indexed databases of social service resources are available for browser-based searches, most notably the 211 service, created by United Way, and the private Aunt Bertha service.28,29 However, the geospatial indexing for both is coarse (at the level of ZIP code), and neither is app-based. There was a theme of distrust of the health system for people who have been incarcerated and crowdsourcing may help to address this barrier. This finding aligns with research suggesting the importance of social networks in care-seeking, indicating that returning citizens prefer to seek advice from others rather than through formal informational searches.30 Other studies have similarly noted concerns about stigma and confidentiality as barriers to healthcare engagement and informal support as a preferred type of support.31,32 The use of an app could mitigate such concerns by providing an organized and confidential platform to access resources, while educating app users about CVD symptoms and risk factors. Currently, apps such as Link2Care are being researched for their ability to increase treatment service utilization among incarcerated homeless adults through direct buttons to shelter-based case managers, crisis interventionists, and resource websites.33 Given our results, app features could provide a standardized platform that is adapted to returning citizens’ particular needs, such as improving access to care. A pilot study on Care + Corrections, an mHealth intervention to increase utilization of HIV community-based care among returning citizens, found positive—although not significant—associations between the intervention and viral suppression, with an increase in care engagement in all study groups.34 The Care + Corrections intervention included computerized counseling sessions for people living with HIV released from correctional facilities, with content focused on linkage to HIV care, medication adherence, and risk-reduction behaviors.35 This example suggests that a similar approach could be applied to modification of behaviors that mediate CVD risk, particularly for smoking, which is both widespread among returning citizens and that our participants recognized as unhealthy. Despite these promising studies of apps for care coordination among returning citizens, technology and access may still be an issue. There are lower levels of smartphone use among people who are older, have less education and lower income than the general population,36 and low-income people are less likely to have stable mobile service.37 However this was not a major concern among participants in this study, and many people find ways around these barriers through the availability of free wifi at places like local libraries. Further, incarceration may leave returning citizens disconnected from smartphones and digital technologies for long periods, contributing to a ‘digital divide’ and feeling detached from technology and how to use it.38 Nonetheless, this did not appear to be a significant issue for our participants. Study strengths include the relatively large sample, including male and female participants and a majority African-American sample, who are disproportionately incarcerated.39 The extent of data collection allowed us to reach saturation, though more research is needed on other ethnic/racial groups. Another strength was data from both returning citizens and service providers. The convergence of multiple perspectives on similar themes reinforces the credibility of our data. Limitations include lack of sociodemographic information on age and other characteristics and a focus on an urban population, decreasing the study’s generalizability. Groups were conducted in English only, which limits transferability to non-English speaking individuals. CONCLUSION Smartphone applications are an mHealth technology that may be able to engage returning citizens in addressing cardiovascular health. An app that is useful, useable, and trusted will need to be broadly focused on the social and structural determinants of health and reentry and incorporate social networking among previously incarcerated people. Future research is needed to fully implement and test the use of such an app for returning citizens. FUNDING This research reported in this publication was 100% supported by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health under award number R43HL144412. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. AUTHOR CONTRIBUTIONS PJS contributed to the conceptualization and design of the study, data collection/data analysis, interpretation, and drafted the original manuscript. LBP contributed to the design of the study, interpretation of the results, and critical revision of the manuscript. KB contributed to the design of the study, data collection, and interpretation of the results. NE contributed to the writing of the manuscript and interpretation of the data. WWZ contributed to the conceptualization and design of the study, data collection/data analysis, interpretation, and writing of the manuscript. All authors approved the final version of the manuscript. SUPPLEMENTARY MATERIAL Supplementary material is available at Journal of the American Medical Informatics Association online. DATA AVAILABILITY STATEMENT The data underlying this article will be shared on reasonable request to the corresponding author. ACKNOWLEDGMENTS We would like to thank the participants who took part in this study. We are also grateful for the support of Ms. Emily Heckel and Dr. Craig Tower on this project. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1 Bronson J , Carson EA. Prisoners in 2017. US Department of Justice, Office of Justice Programs. Bureau of Justice Statistics; 2019 . 2 Office of the Assistant Secretary for Planning and Evaluation , US Department of Health & Human Services. Incarceration & Reentry. https://aspe.hhs.gov/incarceration-reentryAccessed March 12, 2020 3 Rabuy B , Kopf D. Prisons of Poverty: Uncovering the pre-incarceration incomes of the imprisoned; July 9, 2015 . https://www.prisonpolicy.org/reports/income.htmlAccessed September 26, 2020 4 Wang EA , Redmond N, Dennison Himmelfarb CR, et al. Cardiovascular disease in incarcerated populations . J Am Coll Cardiol 2017 ; 69 ( 24 ): 2967 – 76 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Kochanek KD , Murphy SL, Xu J, Arias E. Deaths: final data for 2017 . Natl Vital Stat Rep 2019 ; 68 ( 9 ): 1 – 77 . Google Scholar OpenURL Placeholder Text WorldCat 6 Noonan M , Rohloff H, Ginder S. Mortality in Local Jails and State Prisons. Statistical Tables. US Department of Justice 2000–2013; 2015 . https://www.bjs.gov/index.cfm?ty=pbdetail&iid=5341 Accessed June 7, 2020. 7 Binswanger IA , Blatchford PJ, Mueller SR, Stern MF. Mortality after prison release: opioid overdose and other causes of death, risk factors, and time trends from 1999 to 2009 . Ann Intern Med 2013 ; 159 ( 9 ): 592 – 600 . Google Scholar Crossref Search ADS PubMed WorldCat 8 Howell BA , Long JB, Edelman EJ, et al. Incarceration history and uncontrolled blood pressure in a multi-site cohort . J Gen Intern Med 2016 ; 31 ( 12 ): 1496 – 502 . Google Scholar Crossref Search ADS PubMed WorldCat 9 Wang EA , Pletcher M, Lin F, et al. Incarceration, incident hypertension, and access to health care: findings from the coronary artery risk development in young adults (CARDIA) study . Arch Intern Med 2009 ; 169 ( 7 ): 687 – 93 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Wang EA , Wang Y, Krumholz HM. A high risk of hospitalization following release from correctional facilities in Medicare beneficiaries: a retrospective matched cohort study, 2002 to 2010 . JAMA Intern Med 2013 ; 173 ( 17 ): 1621 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 11 Cui M , Wu X, Mao J, Wang X, Nie M. T2DM self-management via smartphone applications: a systematic review and meta-analysis . PLoS One 2016 ; 11 ( 11 ): e0166718 . Google Scholar Crossref Search ADS PubMed WorldCat 12 Neubeck L , Lowres N, Benjamin EJ, Freedman SB, Coorey G, Redfern J. The mobile revolution–using smartphone apps to prevent cardiovascular disease . Nat Rev Cardiol 2015 ; 12 ( 6 ): 350 – 60 . Google Scholar Crossref Search ADS PubMed WorldCat 13 Reynoldson C , Stones C, Allsop M, et al. Assessing the quality and usability of smartphone apps for pain self-management . Pain Med 2014 ; 15 ( 6 ): 898 – 909 . Google Scholar Crossref Search ADS PubMed WorldCat 14 Wang J , Wang Y, Wei C, et al. Smartphone interventions for long-term health management of chronic diseases: an integrative review . Telemed J E Health 2014 ; 20 ( 6 ): 570 – 83 . Google Scholar Crossref Search ADS PubMed WorldCat 15 Delva S , Waligora Mendez KJ, Cajita M, et al. Efficacy of mobile health for self-management of cardiometabolic risk factors: a theory-guided systematic review . J Cardiovasc Nurs 2021 ; 36 ( 1 ): 34 – 55 . Google Scholar Crossref Search ADS PubMed WorldCat 16 Piette JD , List J, Rana GK, Townsend W, Striplin D, Heisler M. Mobile health devices as tools for worldwide cardiovascular risk reduction and disease management . Circulation 2015 ; 132 ( 21 ): 2012 – 27 . Google Scholar Crossref Search ADS PubMed WorldCat 17 Bandura A. Health promotion by social cognitive means . Health Educ Behav 2004 ; 31 ( 2 ): 143 – 64 . Google Scholar Crossref Search ADS PubMed WorldCat 18 Scott CK , Johnson K, Dennis ML. Using mobile phone technology to provide recovery support for women offenders . Telemed J E Health 2013 ; 19 ( 10 ): 767 – 71 . Google Scholar Crossref Search ADS PubMed WorldCat 19 McInnes DK , Li AE, Hogan TP. Opportunities for engaging low-income, vulnerable populations in health care: a systematic review of homeless persons' access to and use of information technologies . Am J Public Health 2013 ; 103 ( S2 ): e11-24 – e24 . Google Scholar Crossref Search ADS PubMed WorldCat 20 Mitchell SJ , Godoy L, Shabazz K, Horn IB. Internet and mobile technology use among urban African American parents: survey study of a clinical population . J Med Internet Res 2014 ; 16 ( 1 ): e9 . Google Scholar Crossref Search ADS PubMed WorldCat 21 Post LA , Vaca FE, Biroscak BJ, et al. The prevalence and characteristics of emergency medicine patient use of new media . JMIR mHealth uHealth 2015 ; 3 ( 3 ): e72 . Google Scholar Crossref Search ADS PubMed WorldCat 22 Braun V , Clarke V. Thematic analysis In: Handbook of Research Methods in Psychology. Vol 2 Research Designs . Washington, DC : American Psychological Association ; 2012 : 57 – 71 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 23 Brabham DC , Ribisl KM, Kirchner TR, Bernhardt JM. Crowdsourcing applications for public health . Am J Prev Med 2014 ; 46 ( 2 ): 179 – 87 . Google Scholar Crossref Search ADS PubMed WorldCat 24 Ramaswamy M , Upadhyayula S, Chan KY, Rhodes K, Leonardo A. Health priorities among women recently released from jail . Am J Health Behav 2015 ; 39 ( 2 ): 222 – 31 . Google Scholar Crossref Search ADS PubMed WorldCat 25 Cohen DJ , Wyte-Lake T, Dorr DA, et al. Unmet information needs of clinical teams delivering care to complex patients and design strategies to address those needs . J Am Med Inform Assoc 2020 ; 27 ( 5 ): 690 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 26 O'Gurek DT , Henke C. A practical approach to screening for social determinants of health . Fam Pract Manag 2018 ; 25 ( 3 ): 7 – 12 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 27 Palakshappa D , Strane D, Griffis H, Fiks AG. Determining food-insecure families’ resource access with health system and public data . J Health Care Poor Underserved 2019 ; 30 ( 1 ): 265 – 79 . Google Scholar Crossref Search ADS PubMed WorldCat 28 Aunt Bertha. Aunt Bertha - The Social Care Network . https://www.auntbertha.com/Accessed September 29, 2020 29 United Way . 211. https://www.211.org/pages/aboutAccessed September 29, 2020 30 Mallik-Kane K , Paddock E, Jannetta J. Health Care after Incarceration: How Do Formerly Incarcerated Men Choose Where and When to Access Physical and Behavioral Health Services ? Washington, DC : Urban Institute ; 2018 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 31 Robards F , Kang M, Usherwood T, Sanci L. How marginalized young people access, engage with, and navigate health-care systems in the digital age: systematic review . J Adolesc Health 2018 ; 62 ( 4 ): 365 – 81 . Google Scholar Crossref Search ADS PubMed WorldCat 32 Walsh J , Scaife V, Notley C, Dodsworth J, Schofield G. Perception of need and barriers to access: the mental health needs of young people attending a Youth Offending Team in the UK . Health Soc Care Commun 2011 ; 19 ( 4 ): 420 – 8 . Google Scholar Crossref Search ADS WorldCat 33 Reingle Gonzalez JM , Businelle MS, Kendzor D, Staton M, North CS, Swartz M. Using mHealth to increase treatment utilization among recently incarcerated homeless adults (Link2Care): protocol for a randomized controlled trial . JMIR Res Protoc 2018 ; 7 ( 6 ): e151 . Google Scholar Crossref Search ADS PubMed WorldCat 34 Kuo I , Liu T, Patrick R, et al. Use of an mHealth intervention to improve engagement in HIV community-based care among persons recently released from a correctional facility in Washington, DC: a pilot study . AIDS Behav 2019 ; 23 ( 4 ): 1016 – 31 . Google Scholar Crossref Search ADS PubMed WorldCat 35 Peterson J , Cota M, Gray H, et al. Technology use in linking criminal justice reentrants to HIV care in the community: a qualitative formative research study . J Health Commun 2015 ; 20 ( 3 ): 245 – 51 . Google Scholar Crossref Search ADS PubMed WorldCat 36 Pew Research Center. Mobile Fact Sheet . https://www.pewresearch.org/internet/fact-sheet/mobile/Accessed January 26, 2021 37 Gonzales AL. Health benefits and barriers to cell phone use in low-income urban US neighborhoods: indications of technology maintenance . Mobile Media Commun 2014 ; 2 ( 3 ): 233 – 48 . Google Scholar Crossref Search ADS WorldCat 38 Reisdorf B , DeCook J, Foster M, Cobbina J, LaCourse A. Digital reentry: uses of and barriers to ICTs in the prisoner reentry process . Available at SSRN 3427342; 2019 . Google Scholar OpenURL Placeholder Text WorldCat 39 Sakala L. Breaking Down Mass Incarceration in the 2010 Census: State-by-State Incarceration Rates by Race/Ethnicity; 2014 . https://www.prisonpolicy.org/reports/rates.html. Accessed March 22, 2020. © The Author(s) 2021. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. 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A roadmap for cardiovascular care after release from incarceration: uses of a smartphone application

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A roadmap for cardiovascular care after release from incarceration: uses of a smartphone application

A roadmap for cardiovascular care after release from incarceration: uses of a smartphone application

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