'But who's gonna listen?' A qualitative study of voicing experiences of healthcare in provincial correctional facilities in Ontario, Canada.

Experiences of healthcare services are an important indicator of quality and health system improvement. In correctional facilities, structural and contextual factors affect experiences of healthcare services and processes for voicing these experiences. This study explores barriers and opportunities for people in custody to voice their experiences of healthcare services in custody. We held four focus groups and one interview with people living in the community who had accessed, or tried to access, healthcare services while incarcerated in a provincial correctional facility in Ontario, Canada in the previous five years. Using template analysis, we developed four interacting themes related to expectations and experiences of healthcare, and of submitting complaints or asking for help: i) the system is not designed for healthcare, ii) gatekeeping and perceptions of 'deserving' healthcare, iii) impact of healthcare on other outcomes, and iv) calling the abyss. These factors affected perceptions of the potential efficacy of a patient feedback process, and how people in custody were likely to engage with it. Participants also identified five key features that should be components of any patient feedback processes. This study highlights challenges to patient-reported experiences of care in quality improvement work in restrictive environments and with incarcerated populations.