DOI
https://doi.org/10.25772/ywv5-k829
Author ORCID Identifier
https://orcid.org/0009-0002-1303-5854
Defense Date
2026
Document Type
Dissertation
Degree Name
Doctor of Philosophy
Department
Social and Behavioral Health
First Advisor
Jessica Gokee LaRose, PhD
Second Advisor
Shawn Jones, PhD
Third Advisor
Larkin Francis, PhD, MSW
Fourth Advisor
Richard Brown, PhD
Abstract
Background
Women are the fastest-growing population in the United States criminal legal system, and they enter correctional settings carrying disproportionate burdens of trauma, substance use, and unmet sexual and reproductive health (SRH) needs. Justice-involved women experience elevated rates of cervical cancer, sexually transmitted infections, unintended pregnancy, and barriers to contraceptive access, alongside well-documented histories of reproductive coercion, medical mistrust, and discrimination in clinical settings. Correctional healthcare systems are variable, frequently under-resourced, and rarely designed around women’s distinct SRH needs, leaving incarceration to function as both a point of contact with health services and a driver of long-term disengagement from preventive care. Despite this complex landscape, SRH programming for incarcerated women has remained narrow in scope and is most often evaluated through knowledge change alone, leaving little evidence on whether such programs reshape the trust, beliefs, and self-efficacy that determine whether preventive care is sought after release. Provider preparation has received even less attention: medical trainees enter practice with limited exposure to justice-involved patients, and how they reason about SRH care for this population is largely unexamined. To date, patient-side readiness and provider-side reasoning have not been studied together in this context. This dissertation addresses that gap by evaluating the Women Leading Healthy Change (WLHC) program, a medical-student-facilitated curriculum delivered in a county jail addiction recovery unit, alongside an exploratory study of how fourth-year medical students reason about SRH care for justice-involved women.
Objective
Broadly, the objective of this study was to (a) Evaluate the effectiveness of the WLHC program on justice-involved women’s sexual health knowledge, beliefs about cervical cancer, and self-efficacy for screening; (b) Through an exploratory descriptive study, assess medical students’ knowledge, beliefs, and clinical decision making surrounding SRH care for justice-involved women. A two-phase sequential mixed-methods design was used, with quantitative and qualitative data collected concurrently within each phase (Aim 1, patient-side; Aim 2, provider-side). Aim 1 enrolled 12 justice-involved women who participated in the WLHC program (pretest/post-test, evaluation survey, and interview), and 12 comparison participants from the same housing unit who did not enroll (baseline survey and interview). Aim 2 utilized a sample of 24 fourth-year medical students who completed a survey; 12 also completed a think-aloud interview using a standardized clinical vignette in which incarceration was disclosed (case) or omitted (control). Quantitative analyses included nonparametric tests, descriptive statistics, and bivariate associations; qualitative analysis used thematic, process, and cross-case methods. Within-aim integration used joint displays; cross-aim integration occurred at the study-level interpretation stage.
Results
Among WLHC participants, all 12 reported the program as helpful, relevant, and respectful, and described emotionally safe, peer-connected, humanizing sessions. The clearest measurable change was a significant reduction in perceived Pap smear barriers (median 14.0 to 10.0; p = .011) and increased willingness to disclose incarceration history to providers (p = .020). Comfort with student facilitators and self-rated SRH knowledge increased while perceived benefits, severity, and susceptibility remained stable, suggesting that WLHC altered participants’ expectations of the clinical encounter more than abstract risk appraisal. Self-efficacy gains were modest and not statistically significant, with readiness frequently described as conditional on insurance, transportation, trusted providers, and recovery stability post-release. Interviews indicated that prior contact with SRH services often occurred through pregnancy, symptoms, or fear rather than prevention, and that motherhood, trauma history, and institutional mistrust shaped how participants reasoned about risk.
Among medical students, scale-level survey scores were broadly favorable, with high empathy, low stigma, and moderate trauma-informed care competency. Trust in Patients provided the clearest differentiation: WLHC facilitators scored 9-11 points higher than non-facilitator peers. Exploratory think-aloud analysis suggested three qualitatively distinct reasoning trajectories: protocol-anchored reasoning (eight of 12 participants), in which biomedical tasks organized the encounter and contextual factors were peripheral; relational stabilization (two of 12, both facilitators), in which trust-building preceded biomedical decisions; and context-integrated reasoning (two of 12), in which structural context reorganized the clinical problem. Favorable survey-level attitudes did not consistently translate into context-responsive reasoning. Given Aim 2’s small sample and exploratory, descriptive framing, these patterns are reported as hypothesis-generating rather than as estimates of population-level effects.
Conclusions
WLHC indicated pathway-level change, shifting the cognitive and relational conditions under which SRH care becomes thinkable for women who have learned to expect dismissal from institutional medicine, while leaving downstream behaviors contingent on post-release access and provider trustworthiness. On the provider side, broadly favorable attitudes coexisted with reasoning patterns that rarely organized care around structural-related context, including that survey-level orientation is a starting point rather than a guarantee of context responsive care. Together, these two aims map a bidirectional gap: WLHC may strengthen what justice-involved women could bring into the clinical encounter, yet data suggested that medical training had not yet built the reasoning capacity to reliably receive, protect, and act on that information. These findings support a Bidirectional Gap Model, a Reasoning Trajectories Framework, and a pathway-level conception of proximal outcomes appropriate to community-engaged SRH programming. Implications include trauma-informed and procedurally explicit SRH programs in carceral settings, medical education that develops context-integrated reasoning about justice-involved patients, and policies that support continuity of SRH care across reentry.
Rights
© The Author
Is Part Of
VCU University Archives
Is Part Of
VCU Theses and Dissertations
Date of Submission
7-16-2026
Included in
Community Health and Preventive Medicine Commons, Criminology Commons, Medical Education Commons, Medicine and Health Commons, Obstetrics and Gynecology Commons, Public Health Education and Promotion Commons, Women's Health Commons