All-cause and cause-specific mortality among black and white North Carolina state prisoners, 1995-2005

Lung Cancer Screening in the Incarcerated Population Through a Community Imaging Partnership

Limited data exist on cancer screening in carceral facilities. This study evaluates the feasibility and outcomes of a population-based lung cancer screening initiative in a carceral setting. This is a retrospective review of a lung cancer screening event at the Rhode Island Department of Corrections. Sentenced individuals meeting U.S. Preventive Services Task Force age criteria for lung cancer screening were mailed a letter asking about their smoking history. Low-dose computed tomography (LDCT) scans were offered to individuals who responded and met the criteria. Retrospective analyses examined patients' LDCT scoring using the American College of Radiology's Lung CT Screening Reporting and Data System (Lung-RADS v1.1). Among more than 2,000 incarcerated individuals, 282 met the age criteria and 117 (41.5%) replied with interest in screening, of whom 57 (48.7%) verified as eligible. All 57 (100%) received LDCT. Most scans (94.4%) were categorized as Lung-RADS 1 or 2, indicating negative or benign findings. Comparisons with general population estimates showed no significant differences in Lung-RADS scores. The screening identified 21 incidental findings, including aortic aneurysms and severe coronary artery calcification. The implementation of lung cancer screening in a carceral setting was shown to be feasible and accepted by the incarcerated population.

Structural Determinants of Health Literacy Among Formerly Incarcerated Individuals: Insights From the Survey of Racism and Public Health

BACKGROUND

Formerly incarcerated individuals (FIIs) encounter difficulties with covering the cost of dental and medical care, adhering to medication regimens, and receiving fair treatment from health care providers. Yet, no published research has examined modifiable pathways to increase FIIs' health literacy (HL), which is essential for addressing the health needs of this vulnerable population.

OBJECTIVE

The aim of this article is to examine neighborhood characteristics (neighborhood deprivation, racial and economic polarization, and residential segregation) and public assistance program enrollment as structural determinants of limited health literacy (LHL) among FIIs.

METHODS

Using a socioecological framework, we analyzed a subsample of 578 FIIs from the 2023 Survey of Racism and Public Health, an online cross-sectional survey spanning U.S. Department of Health & Human Services Regions 1, 2, and 3. HL was assessed using the Brief Health Literacy Screen. Logistic regression models estimated unadjusted and adjusted associations of LHL with neighborhood characteristics and public assistance program enrollment. Adjusted models controlled for age, race and ethnicity, gender identity, educational attainment, marital and employment status, number of children, chronic health conditions, and incarceration length.

KEY RESULTS

The 578 FIIs had an average age of 46, with 42% having LHL. We observed a statistically significant association between public assistance program enrollment and LHL (unadjusted odds ratio [OR] = 2.72, 95% confidence interval [CI]: 1.87, 4.01; adjusted OR = 2.50, 95% CI: 1.62, 3.88). We found no statistically significant associations of LHL with neighborhood deprivation, racial and economic polarization, and residential segregation.

CONCLUSIONS

Our findings suggest that there may be an opportunity to develop tailored interventions for increasing HL among FIIs through public assistance programs. Dissemination of HL resources among this marginalized group can improve their self-management of chronic diseases. This is of paramount importance because FIIs must simultaneously navigate other challenges after incarceration (e.g., unstable housing). [HLRP: Health Literacy Research and Practice. 2025;9(1):e8-e18.].

The Distribution of Carceral Harm: County-Level Jail Incarceration and Mortality by Race, Sex, and Age

Jail incarceration remains an overlooked yet crucial component of the U.S. carceral system. Although a growing literature has examined the mortality costs associated with residing in areas with high levels of incarceration, far less is known about how local jails shape this burden at the intersection of race, sex, and age. In this study, I examine the relationship between county-level jail incarceration and age-specific mortality for non-Hispanic Black and White men and women, uniquely leveraging race-specific jail rates to account for the unequal racial distribution of jail exposures. This study finds evidence of positive associations between mortality and jail incarceration: this association peaks in late adulthood (ages 50-64), when increases in jail rates are associated with roughly 3% increases in mortality across all race-sex groups. However, patterns vary at the intersection of race, sex, and age. In particular, I find more marked and consistent penalties among women than among men. Additionally, a distinctly divergent age pattern emerges among Black men, who face insignificant but negative associations at younger ages but steep penalties at older ages-significantly larger among those aged 65 or older relative to their White male and Black female counterparts. Evidence further suggests that the use of race-neutral incarceration measures in prior work may mask the degree of harm associated with carceral contexts, because the jail rate for the total population underestimates the association between jail rates and mortality across nearly all race-age-sex combinations. These findings highlight the need for future ecological research to differentiate between jail and prison incarceration, consider the demographic distribution of incarceration's harms, and incorporate racialized measures of exposure so that we may better capture the magnitude of harm associated with America's carceral state.

Mortality, Criminal Sanctions, and Court Diversion in People With Psychosis

Importance

People living with psychosis experience excess premature mortality and are overrepresented in criminal legal systems, but little is known about mortality associated with criminal sanctions or diversion in this population.

Objective

To examine associations of different types of recent (past 2 years) criminal sanction, including court diversion, with mortality among people with psychosis.

Design, Setting, and Participants

This population-based, retrospective, data-linkage cohort study was conducted using 6 routinely collected administrative data collections from New South Wales, Australia, relating to health, court proceedings, imprisonment, and mortality. Participants (adults aged ≥18 years hospitalized for psychotic disorders) entered observation at the time of discharge from their first psychosis-related hospital admission (or their 18th birthday if aged <18 years) between July 2001 and November 2017 and were followed-up until May 2019. Data were analyzed between February 2023 and April 2024.

Exposures

Recent (past 2 years) criminal sanction type, a time-varying variable with 5 categories: no recent criminal sanction, recent mental health court diversion, recent community sanction, current imprisonment, and recent prior imprisonment (ie, recent prison release).

Main Outcomes and Measures

Causes of death were described, and age- and sex-specific mortality rates by recent criminal sanction type were calculated. In those younger than 65 years, Cox regression was used to examine associations of all-cause and external-cause mortality with recent criminal sanction type, adjusting for sociodemographic, health-related, and offense-related confounders.

Results

The cohort included 83 071 persons (35 791 female [43.1%]; 21 208 aged 25-34 years [25.5%]; median [IQR] follow-up, 9.5 [4.8-14.2] years), of whom 25 824 (31.1%) received a criminal sanction. There were 11 355 deaths. In those aged younger than 65 years, recent mental health court diversion, community sanctions, and prior imprisonment were associated with increased hazards of all-cause and external-cause mortality compared with no recent sanction, with the largest adjusted hazard ratios (aHRs) observed for recent prior imprisonment (all-cause mortality: aHR, 1.69; 95% CI, 1.50-1.91; external-cause mortality: aHR, 2.64; 95% CI, 2.27-3.06).

Conclusions and Relevance

In this cohort study of people with psychosis, recent criminal sanctions were associated with increased mortality irrespective of sanction type. These findings suggest that future research should develop strategies to improve health and safety in people with psychosis who have criminal legal system contact.

Increased Mortality of Black Incarcerated and Hospitalized People: a Single State Cohort Analysis

OBJECTIVE

To quantify racial disparities in mortality and post-hospitalization outcomes among incarcerated individuals that were hospitalized during their incarceration period.

METHODS

We designed a retrospective cohort study using administrative and hospital data collected from a preferred healthcare referral center for all Massachusetts jails and prisons between January 2011 and December 2018 with linkage to Massachusetts Vital Records and Statistics. We identified 4260 incarcerated individuals with complete data on race/ethnicity that were hospitalized during the study period. The primary study indicators were age, race, ethnicity, length of hospital stay, Elixhauser comorbidity score, incarceration facility type, and number of hospital admissions. The primary outcome was time to death.

RESULTS

Of the incarcerated individuals that were hospitalized, 2606 identified as White, 1214 identified as Black, and 411 people who identified as some other race. The hazard of death significantly increased by 3% (OR: 1.03; 95% CI: 1.02-1.03) for each additional yearly increase in age. After adjusting for the interaction between race and age, Black race was significantly associated with 3.01 increased hazard (95% CI: 1.75-5.19) of death for individuals hospitalized while incarcerated compared to White individuals hospitalized while incarcerated. Hispanic ethnicity and being incarcerated in a prison facility was not associated with time to mortality, while increased mean Elixhauser score (HR: 1.07; 95% CI: 1.06-1.08) and ≥ 3 hospital admissions (HR: 2.47; 95% CI: 2.07-2.95) increased the hazard of death.

CONCLUSIONS

Our findings suggest disparities exist in the mortality outcomes among Black and White individuals who are hospitalized during incarceration, with an increased rate of death among Black individuals. Despite hypothesized equal access to healthcare within correctional facilities, our findings suggest that incarcerated and hospitalized Black individuals may experience worse disparities than their White counterparts, which has not been previously explored or reported in the literature. In addition to decarceration, advocacy, and political efforts, increased efforts to support research access to datasets of healthcare outcomes, including hospitalization and death, for incarcerated people should be encouraged. Further research is needed to identify and address the implicit and explicit sources of these racial health disparities across the spectrum of healthcare provision.

Medicaid Expansion and Mortality Among Persons Who Were Formerly Incarcerated

Importance

Since 2014, Medicaid expansion has been implemented in many states across the US, increasing health care access among vulnerable populations, including formerly incarcerated people who experience higher mortality rates than the general population.

Objective

To examine population-level association of Medicaid expansion with postrelease mortality from all causes, unintentional drug overdoses, opioid overdoses, polydrug overdoses, suicides, and homicides among formerly incarcerated people in Rhode Island (RI), which expanded Medicaid, compared with North Carolina (NC), which did not expand Medicaid during the study period.

Design, Setting, and Participants

A cohort study was conducted using incarceration release data from January 1, 2009, to December 31, 2018, linked to death records from January 1, 2009, to December 31, 2019, on individuals released from incarceration in RI and NC. Data analysis was performed from August 20, 2022, to February 15, 2024. Participants included those aged 18 years or older who were released from incarceration. Individuals who were temporarily held during ongoing judicial proceedings, died during incarceration, or not released from incarceration during the study period were excluded.

Exposure

Full Medicaid expansion in RI effective January 1, 2014.

Main Outcomes and Measures

Mortality from all causes, unintentional drug overdoses, unintentional opioid and polydrug overdoses, suicides, and homicides.

Results

Between 2009 and 2018, 17 824 individuals were released from RI prisons (mean [SD] age, 38.39 [10.85] years; 31 512 [89.1%] male) and 160 861 were released from NC prisons (mean [SD] age, 38.28 [10.84] years; 209 021 [87.5%] male). Compared with NC, people who were formerly incarcerated in RI experienced a sustained decrease of 72 per 100 000 person-years (95% CI, -108 to -36 per 100 000 person-years) in all-cause mortality per quarter after Medicaid expansion. Similar decreases were observed in RI in drug overdose deaths (-172 per 100 000 person-years per 6 months; 95% CI, -226 to -117 per 100 000 person-years), including opioid and polydrug overdoses, and homicide deaths (-23 per 100 000 person-years per year; 95% CI, -50 to 4 per 100 000 person-years) after Medicaid expansion. Suicide mortality did not change after Medicaid expansion. After Medicaid expansion in RI, non-Hispanic White individuals experienced 3 times greater sustained decreases in all-cause mortality than all racially minoritized individuals combined, while non-Hispanic Black individuals did not experience any substantial benefits. There was no modification by sex. Individuals aged 30 years or older experienced greater all-cause mortality reduction after Medicaid expansion than those younger than 30 years.

Conclusions and Relevance

Medicaid expansion in RI was associated with a decrease in all-cause, overdose, and homicide mortality among formerly incarcerated people. However, these decreases were most observed among White individuals, while racially minoritized individuals received little to no benefits in the studied outcomes.

History of incarceration and age-related neurodegeneration: Testing models of genetic and environmental risks in a longitudinal panel study of older adults

History of incarceration is associated with an excess of morbidity and mortality. While the incarceration experience itself comes with substantive health risks (e.g., injury, psychological stress, exposure to infectious disease), most individuals eventually return from prison to the general population where they will be diagnosed with the same age-related conditions that drive mortality in the non-incarcerated population but at exaggerated rates. However, the interplay between history of incarceration as a risk factor and more traditional risk factors for age-related diseases (e.g., genetic risk factors) has not been studied. Here, we focus on cognitive impairment, a hallmark of neurodegenerative conditions like Alzheimer's disease, as an age-related state that may be uniquely impacted by the confluence of environmental stressors (e.g., incarceration) and genetic risk factors. Using data from the Health and Retirement Study, we found that incarceration and APOE-ε4 genotype (i.e., the chief genetic risk factor for Alzheimer's disease) both constituted substantive risk factors for cognitive impairment in terms of overall risk and earlier onset. The observed effects were mutually independent, however, suggesting that the risk conveyed by incarceration and APOE-ε4 genotype operate across different risk pathways. Our results have implications for the study of criminal-legal contact as a public health risk factor for age-related, neurodegenerative conditions.

Suicides in state prisons in the United States: Highlighting gaps in data

OBJECTIVES

Our objectives were to document data availability and reporting on suicide mortality in state prison systems. The United States leads the world in mass incarceration, a structural determinant of health, but lacks real-time reporting of prison health statistics. This absence is particularly notable in suicides, a leading cause of death that carceral policies play a key role in mitigating.

METHODS

Suicide data for each state prison system from 2017-2021 were gathered through statistical reports, press releases, and Freedom of Information Act requests. We graded states based on data availability.

RESULTS

Only sixteen states provide updated, frequent, granular, freely provided suicide data. An additional thirteen states provided frequently updated data but that had little granularity, was incomplete, or was not freely provided. Eight states provided sparse, infrequent, or outdated data, and thirteen provided no data at all.

CONCLUSIONS

The 2000 Death in Custody Reporting Act requires that states provide these data freely, yet the majority of states do not. There is a need for reliable, real-time data on suicides, suicide attempts, and conditions of confinement to better understand the harms of the carceral system and to advocate for change.

Race-gender variation in the relationship between arrest history and poor health from adolescence to adulthood

OBJECTIVE

The objective of this study is to examine how criminal justice involvement, specifically arrests, shapes health by race-gender status and age for Black, Latinx, and White men and women from adolescence to adulthood.

METHOD

Data were from sixteen waves (1997-2013) of data of National Longitudinal Survey of Youth 1997 cohort (N = 7,674). Respondents were 12-16 years during the first wave of the survey. Multivariate logistic regression with interactions were used to determine how age and race-gender status shape the association between poor health and arrests over time.

RESULTS

With the exception of Black men, arrest history is positively associated with the probability of poor health and this relationship strengthens with age. Arrests have the least detrimental impact on the health of Black men. For those without an arrest history, the probability of poor health also increases with age, but with a less steep incline over time than those who have been arrested. Overall, women who have been arrested, regardless of race, have the worst health prospects.

CONCLUSIONS

A history of arrest is important for health from adolescence to adulthood and varies by race-gender status and age. Those without arrests in their backgrounds enjoy better health at both younger and older ages. For those who experience arrest, they generally report poorer health from adolescence into adulthood. One exception is Black men for whom those with an arrest history report the lowest probability of poor health, compared to Black women, Latinx men, Latinx women, White men, and White women.

[Mortality and causes of deaths in prisons in Rio de Janeiro, Brazil]

Mortality in prisons, a basic indicator of the right to health for incarcerated persons, has never been studied extensively in Brazil. An assessment of all-cause and cause-specific mortality in prison inmates was conducted in 2016-2017 in the state of Rio de Janeiro, based on data from the Mortality Information System and Prison Administration. Mortality rates were compared between prison population and general population after standardization. The leading causes of death in inmates were infectious diseases (30%), cardiovascular diseases (22%), and external causes (12%). Infectious causes featured HIV/AIDS (43%) and TB (52%, considering all deaths with mention of TB). Only 0.7% of inmates who died had access to extramural health services. All-cause mortality rate was higher among prison inmates than in the state's general population. Among inmates, mortality from infectious diseases was 5 times higher, from TB 15 times higher, and from endocrine diseases (especially diabetes) and cardiovascular diseases 1.5 and 1.3 times higher, respectively, while deaths from external causes were less frequent in prison inmates. The study revealed important potentially avoidable excess deaths in prisons, reflecting lack of care and exclusion of this population from the Brazilian Unified National Health System. This further highlights the need for a precise and sustainable real-time monitoring system for deaths, in addition to restructuring of the prison staff through implementation of the Brazilian National Policy for Comprehensive Healthcare for Persons Deprived of Freedom in the Prison System in order for inmates to fully access their constitutional right to health with the same quality and timeliness as the general population.

Disparities in cancer prevalence, incidence, and mortality for incarcerated and formerly incarcerated patients: A scoping review

BACKGROUND

Racial and ethnic minority status, structural racism, low educational attainment, and poverty are consistently associated with cancer disparities and with higher rates of incarceration. The objective of this scoping review is to conduct a qualitative synthesis of the literature on cancer prevalence, incidence, mortality, and disparities in these outcomes for incarcerated and formerly incarcerated patients, as this literature is fragmented and heterogenous.

METHODS

This scoping review included Bureau of Justice Statistics reports and searched PubMed in May 2021 for all English language studies published between 1990 and 30 April 2021, that reported on cancer prevalence, incidence, or mortality for incarcerated or formerly incarcerated individuals in the United States.

RESULTS

Twenty studies were selected. Data on cancer prevalence and incidence were scarce but suggested that incarcerated and formerly incarcerated patients have a similar overall risk of cancer diagnosis as the general population, but elevated risk of certain cancers such as cervical, lung, colorectal, and hepatocellular carcinoma for which effective prevention and screening interventions exist. Cancer mortality data in state and local jails as well as prisons were robust and suggests that both incarcerated and formerly incarcerated patients have higher cancer mortality than the general population.

CONCLUSIONS

Incarcerated and formerly incarcerated patients likely have a higher risk of dying from cancer than the general population, but important gaps in our knowledge about the extent and drivers of disparities for this population remain. Additional research is needed to guide interventions to reduce cancer disparities for patients experiencing incarceration.

All-cause and cause-specific mortality during and following incarceration in Brazil: A retrospective cohort study

BACKGROUND

Mortality during and after incarceration is poorly understood in low- and middle-income countries (LMICs). The need to address this knowledge gap is especially urgent in South America, which has the fastest growing prison population in the world. In Brazil, insufficient data have precluded our understanding of all-cause and cause-specific mortality during and after incarceration.

METHODS AND FINDINGS

We linked incarceration and mortality databases for the Brazilian state of Mato Grosso do Sul to obtain a retrospective cohort of 114,751 individuals with recent incarceration. Between January 1, 2009 and December 31, 2018, we identified 3,127 deaths of individuals with recent incarceration (705 in detention and 2,422 following release). We analyzed age-standardized, all-cause, and cause-specific mortality rates among individuals detained in different facility types and following release, compared to non-incarcerated residents. We additionally modeled mortality rates over time during and after incarceration for all causes of death, violence, or suicide. Deaths in custody were 2.2 times the number reported by the national prison administration (n = 317). Incarcerated men and boys experienced elevated mortality, compared with the non-incarcerated population, due to increased risk of death from violence, suicide, and communicable diseases, with the highest standardized incidence rate ratio (IRR) in semi-open prisons (2.4; 95% confidence interval [CI]: 2.0 to 2.8), police stations (3.1; 95% CI: 2.5 to 3.9), and youth detention (8.1; 95% CI: 5.9 to 10.8). Incarcerated women experienced increased mortality from suicide (IRR = 6.0, 95% CI: 1.2 to 17.7) and communicable diseases (IRR = 2.5, 95% CI: 1.1 to 5.0). Following release from prison, mortality was markedly elevated for men (IRR = 3.0; 95% CI: 2.8 to 3.1) and women (IRR = 2.4; 95% CI: 2.1 to 2.9). The risk of violent death and suicide was highest immediately post-release and declined over time; however, all-cause mortality remained elevated 8 years post-release. The limitations of this study include inability to establish causality, uncertain reliability of data during incarceration, and underestimation of mortality rates due to imperfect database linkage.

CONCLUSIONS

Incarcerated individuals in Brazil experienced increased mortality from violence, suicide, and communicable diseases. Mortality was heightened following release for all leading causes of death, with particularly high risk of early violent death and elevated all-cause mortality up to 8 years post-release. These disparities may have been underrecognized in Brazil due to underreporting and insufficient data.

Is There a Temporal Relationship between COVID-19 Infections among Prison Staff, Incarcerated Persons and the Larger Community in the United States?

Background: Our objective was to examine the temporal relationship between COVID-19 infections among prison staff, incarcerated individuals, and the general population in the county where the prison is located among federal prisons in the United States. Methods: We employed population-standardized regressions with fixed effects for prisons to predict the number of active cases of COVID-19 among incarcerated persons using data from the Federal Bureau of Prisons (BOP) for the months of March to December in 2020 for 63 prisons. Results: There is a significant relationship between the COVID-19 prevalence among staff, and through them, the larger community, and COVID-19 prevalence among incarcerated persons in the US federal prison system. When staff rates are low or at zero, COVID-19 incidence in the larger community continues to have an association with COVID-19 prevalence among incarcerated persons, suggesting possible pre-symptomatic and asymptomatic transmission by staff. Masking policies slightly reduced COVID-19 prevalence among incarcerated persons, though the association between infections among staff, the community, and incarcerated persons remained significant and strong. Conclusion: The relationship between COVID-19 infections among staff and incarcerated persons shows that staff is vital to infection control, and correctional administrators should also focus infection containment efforts on staff, in addition to incarcerated persons.

Risk factors for suicide in prisons: a systematic review and meta-analysis

BACKGROUND

Rates of suicide among people in prison are elevated compared with people of similar age and sex who are living in the community. Improving assessments and interventions to reduce suicide risk requires updated evidence on risk factors. We aimed to examine risk factors associated with suicide in prisoners.

METHODS

We did an updated systematic review and meta-analysis of risk factors for suicide among people in prison. We searched five biblographic databases for articles published between Jan 1, 2006, and Aug 13, 2020, and one database for articles published between Jan 1, 1973, and Aug 13, 2020. Eligible studies reported risk factors in individuals who died by suicide while in prison and in controls from the general prison population. Two reviewers independently extracted data for each study using a standardised form. We calculated random-effects pooled odds ratios (ORs) for the association of suicide with demographical, clinical, criminological, and institutional risk factors, and investigated heterogeneity using subgroup and meta-regression analyses. This systematic review is registered with PROSPERO, CRD42020137979.

FINDINGS

We identified 8041 records through our searches, and used 77 eligible studies from 27 countries, including 35 351 suicides, in the main analysis. The strongest clinical factors associated with suicide were suicidal ideation during the current period in prison (OR 15·2, 95% CI 8·5-27·0), a history of attempted suicide (OR 8·2, 4·4-15·3), and current psychiatric diagnosis (OR 6·4, 3·6-11·1). Institutional factors associated with suicide included occupation of a single cell (OR 6·8, 2·3-19·8) and having no social visits (OR 1·9, 1·5-2·4). Criminological factors included remand status (OR 3·6, 3·1-4·1), serving a life sentence (OR 2·4, 1·3-4·6), and being convicted of a violent offence, in particular homicide (OR 3·1, 2·2-4·2).

INTERPRETATION

Several modifiable risk factors, such as psychiatric diagnosis, suicidal ideation during the current period in prison, and single-cell occupancy, are associated with suicide among people in prison. Preventive interventions should target these risk factors and include improved access to evidence-based mental health care. Understanding other factors associated with suicide might improve risk stratification and resource allocation in prison services.

FUNDING

Wellcome Trust, National Institute for Health Research Applied Research Collaboration Oxford and Thames Valley.

Cancer stage at presentation for incarcerated patients at a single urban tertiary care center

Patients who are incarcerated are a vulnerable patient population and may suffer from less access to routine cancer screenings compared to their non-incarcerated counterparts. Therefore, a thorough evaluation of potential differences in cancer diagnosis staging is needed. We sought to examine whether there are differences in cancer stage at initial diagnosis between non-incarcerated and incarcerated patients by pursuing a retrospective chart review from 2010-2017 for all patients who were newly diagnosed with cancer at an urban safety net hospital. Incarceration status was determined by insurance status. Our primary outcome was incarceration status at time of initial cancer diagnosis. Overall, patients who were incarcerated presented at a later cancer stage for all cancer types compared to the non-incarcerated (+.14 T stage, p = .033; +.23 N stage, p < .001). Incarcerated patients were diagnosed at later stages for colorectal (+0.93 T stage, p < .001; +.48 N stage, p < .001), oropharyngeal (+0.37 N stage, p = .003), lung (+0.60 N stage, p = .018), skin (+0.59 N stage, p = 0.014), and screenable cancers (colorectal, prostate, lung) as a whole (+0.23 T stage, p = 0.002; +0.17 N stage, p = 0.008). Incarcerated patients may benefit from more structured screening protocols in order to improve the stage at presentation for certain malignancies.

Solitary confinement placement and post-release mortality risk among formerly incarcerated individuals: a population-based study

BACKGROUND

With more than 10 million people incarcerated worldwide, some of whom will have experienced solitary confinement, a better understanding of health and mortality after release is needed. The aim of this study was to assess the relationship between placement in solitary confinement and mortality in the 5 years following release among formerly incarcerated individuals.

METHODS

In this population-based study we used data from Danish administrative registers and administrative dataset from the Danish Prison and Probation Service. We linked information on all Danish individuals who had been incarcerated for more than 7 days during 2006-11, with information on mortality for the 60 months following release. We used Cox proportional hazards models to estimate the association between being placed in solitary confinement and mortality (death and cause of death) among formerly incarcerated Danish individuals, controlling for several possible confounders (prison security level, release year, sentence length, reason for conviction, age at admission, sex, ethnic minority background, and education level) and using a reference group of incarcerated Danish individuals who had been sanctioned for in-prison infractions but not placed in solitary confinement in some models.

FINDINGS

Our study included 13 776 individuals, which translated to 812 374 person-months of exposure to the risk of mortality up to Dec 31, 2016. Formerly incarcerated Danish individuals who spent time in solitary confinement had higher overall mortality 5 years after release (4·5%) than did those who had not spent time in solitary confinement (2·8%; p<0·0001). After adjusting for possible confounders, our results suggested an association between solitary confinement and elevated mortality due to non-natural causes (hazard ratio 2·342, 95% CI 1·527-3·592). We did not identify a significant association with natural causes.

INTERPRETATION

The results from these analyses indicate that solitary confinement placement might be a key moderator of the association between a history of incarceration and post-release outcomes. Our findings suggest that incarcerated individuals ever placed in solitary confinement are a vulnerable population in need of interventions.

FUNDING

ROCKWOOL Foundation.

Does in-prison physical and mental health impact recidivism?

Incarceration is definitively linked to poor health, and upon release from prison, many individuals experience difficulty in maintaining good health. Given the complexity of the reentry process, one's health status, both in and out of prison, likely influences additional aspects of reentry, such as abstaining from crime or adhering to parole terms. The purpose of this study is to determine whether in-prison physical and mental health, as well as changes to an individual's health upon release from prison, are related to the likelihood of recidivating. We employ the Serious and Violent Reentry Initiative (SVORI) data, a multi-state sample of formerly incarcerated males who are followed from prison to release into the community and interviewed about a number of post-prison release issues, including health. We use hierarchical logistic and multinomial regressions, where survey waves are nested within people, to assess if in-prison physical and mental health and post-release changes to health are associated with recidivism in two ways: general re-incarceration and re-incarceration due to either a technical violation of parole or a new conviction. With right-censoring due to recidivism or “failure,” our final sample size is 2180 person-periods (i.e., waves) nested within 871 respondents. We find that better physical health, both in-prison and changes in health post-release, is related to a higher likelihood of recidivating. Better mental health, both in-prison and changes to mental health post-release, is related to a decrease in the likelihood of recidivating. Individuals with poor mental health in-prison who make significant improvements after release see the largest reduction in their odds of recidivating. Finally, the combination of better mental health in-prison and increases in mental health post-release is associated with reductions in the likelihood of re-offending for both technical violations and new convictions. In sum, in-prison health continues to influence individuals after prison and is associated with their odds of recidivating, thus contributing to the churning of individuals through the prison system.

•

We examine the relationship between in-prison and change in post-release health and recidivism.

•

Better physical health in-prison and post-release is related to higher recidivism likelihood.

•

Better mental health in-prison and post-release is related to lower recidivism likelihood.

•

This mental health benefit applies to both technical violations and new convictions.

•

A person's health in prison may be related to prison system churning.

Employment and Health Among Recently Incarcerated Men Before and After the Affordable Care Act (2009-2017)

Objectives. To explore whether and how the Affordable Care Act (ACA) affects the relationship between employment and health insurance coverage, health care utilization, and health outcomes among recently incarcerated men aged 18 to 64 years in the United States.Methods. With data from the National Survey on Drug Use and Health (NSDUH), we used a difference-in-differences approach to compare changes in outcomes by employment status among recently incarcerated men.Results. Uninsurance declined significantly among recently incarcerated men after ACA implementation. As the uninsured rate of unemployed men fell below that of their employed counterparts, the ACA helped to fully eliminate the effect of employment on insurance coverage among recently incarcerated men. The employment gap in diabetes widened after ACA implementation as unemployed men saw significant increases in diagnosed diabetes. Employment disparities in hospital visits, diagnosed hypertension, and reported mental illness also declined in the period following ACA implementation, but these changes were not statistically significant.Conclusions. These findings highlight how the ACA, by providing a new route to health care, reduces the confounding forces associated with employment that are linked to both incarceration and health.

Linkages Between Incarceration and Health

The dramatic expansion of the US penal system during the past 4 decades has led to an increase in adverse health conditions that affect an unprecedented number of individuals. This article first provides an overview of the literature on the immediate and lasting associations between incarceration and physical health, highlighting the diverse health conditions linked with incarceration, including health functioning, infectious disease, chronic conditions, and mortality. Next, we discuss potential explanations for the associations between incarceration and these health conditions, focusing on stress, contagion, social integration, and reintegration challenges. We then consider how medical and social science research can be combined to advance our understanding of these health conditions and suggest ways to reduce the negative association between incarceration and health, such as by improving prison conditions and medical care both inside prisons and after release.

Family member death among formerly incarcerated persons

Bereavement carries consequences for the health and socioeconomic well-being of surviving family members. Using data from the National Longitudinal Study of Adolescent to Adult Health, the current study investigates whether formerly incarcerated individuals experience the death of a family member at higher rates than the general population. We find that relative to those without a history of incarceration, formerly incarcerated individuals are more likely to experience the death of an immediate family member by young adulthood. Subsequent analyses demonstrate that deaths occurring during or after a respondent was incarcerated were relevant for health and well-being.

Opioid Overdose Mortality Among Former North Carolina Inmates: 2000-2015

OBJECTIVES

To examine differences in rates of opioid overdose death (OOD) between former North Carolina (NC) inmates and NC residents and evaluate factors associated with postrelease OOD.

METHODS

We linked NC inmate release data to NC death records, calculated OOD standardized mortality ratios to compare former inmates with NC residents, and calculated hazard ratios to identify predictors of time to OOD.

RESULTS

Of the 229 274 former inmates released during 2000 to 2015, 1329 died from OOD after release. At 2-weeks, 1-year, and complete follow-up after release, the respective OOD risk among former inmates was 40 (95% confidence interval [CI] = 30, 51), 11 (95% CI = 9.5, 12), and 8.3 (95% CI = 7.8, 8.7) times as high as general NC residents; the corresponding heroin overdose death risk among former inmates was 74 (95% CI = 43, 106), 18 (95% CI = 15, 21), and 14 (95% CI = 13, 16) times as high as general NC residents, respectively. Former inmates at greatest OOD risk were those within the first 2 weeks after release, aged 26 to 50 years, male, White, with more than 2 previous prison terms, and who received in-prison mental health and substance abuse treatment.

CONCLUSIONS

Former inmates are highly vulnerable to opioids and need urgent prevention measures.

Mass Incarceration and Racial Inequality

Despite two decades of declining crime rates, the United States continues to incarcerate a historically and comparatively large segment of the population. Moreover, incarceration and other forms of criminal justice contact ranging from police stops to community supervision are disproportionately concentrated among African American and Latino men. Mass incarceration, and other ways in which the criminal justice system infiltrates the lives of families, has critical implications for inequality. Differential rates of incarceration damage the social and emotional development of children whose parents are in custody or under community supervision. The removal through incarceration of a large segment of earners reinforces existing income and wealth disparities. Patterns of incarceration and felony convictions have devastating effects on the level of voting, political engagement, and overall trust in the legal system within communities. Incarceration also has damaging effects on the health of families and communities. In short, the costs of mass incarceration are not simply collateral consequences for individuals but are borne collectively, most notably by African Americans living in acutely disadvantaged communities that experience high levels of policing and surveillance. In this article, we review racial and ethnic differences in exposure to the criminal justice system and its collective consequences.

Concerns About Lung Cancer Among Prisoners

BACKGROUND

Few studies have looked at lung cancer in prisoners, despite this population is possibly at increased risk of malignancy. In a previous study, we found an early onset of lung cancer in prisoners. Thus, the present CARCAN study was aimed at assessing the epidemiological characteristics, management, prognosis, and incidence of lung cancer in prisoners compared to a sample of non-prisoner patients.

METHOD

We performed a multi-center observational case-control study. Cases were prisoners diagnosed with lung cancer from 2005 to 2013. Controls were non-prisoner lung cancer patients selected from hospital databases and randomly matched to cases (targeted case-control ratio: 1:3). Incidence rates in both groups were calculated using national statistics.

RESULTS

Seventy-two cases and 170 controls met inclusion criteria. Cases were mainly men (99%). Mean age at diagnosis was 52.9 (± 11.0) in cases and 64.3 (± 10.1) in controls (p < 0.0001). More case patients were current smokers compared to control patients (83% vs 53%; p < 0.0001). We found no significant differences between the two groups as concerns histologic types, TNM stages at diagnosis, initially-employed treatments, times to management or survival. Incidence rates (2008-2012) in male prisoners were higher than those in the general population in all concerned age groups.

CONCLUSION

There is a shift of lung cancer toward young people in prisons. However, the presentation, management, and prognosis of lung cancer are similar between prisoners and non-prisoners. These finding could justify a specific screening policy for the incarcerated populations.

Racial disparities in health conditions among prisoners compared with the general population

This paper compares black-white health disparities among prisoners to disparities in the noninstitutionalized community to provide a more complete portrait of the nation’s heath. We use data from the 2004 Survey of Inmates in State and Federal Correctional Facilities and the 2002 and 2004 National Health and Nutrition Examination Survey for incarcerated and noninstitutionalized adult (aged 18–65) men and women, respectively. Health disparities between black and white male prisoners based on self-reported prevalence are similar to disparities in the general population for hypertension and diabetes but significantly reduced for kidney problems and stroke. Health disparities between black and white female prisoners are similar to disparities in the general population for obesity but significantly reduced for hypertension, diabetes, heart problems, kidney problems, and stroke. Our study reveals that prisoners report far worse health profiles than non-prisoners but there is differential health selection into prison for whites and blacks, and population health estimates for adult black men in particular underreport the true health burden for U.S. adults. Our findings highlight the importance of incorporating prison populations in demographic and public health analyses.

•

Inmates have poorer health overall than the noninstitutionalized population, but more so for white women demonstrating a differential health selection into prison.

•

Health problems increase when inmates are included in national health statistics, especially for black men.

•

U.S. health statistics may underestimate the health of the nation with potential consequences for understanding racial health disparities.

•

Properly characterizing population health and health disparities requires the inclusion of incarcerated adults in mainstream epidemiologic studies.

Health care needs and service use among male prison inmates in the United States: A multi-level behavioral model of prison health service utilization

BACKGROUND

The purpose of this study is to apply Andersen's Behavioral Model of Health Service Use to men's prisons to assess the direct and indirect effects of inmate predisposing characteristics through multiple types of need. Also examined are the effects of prison-specific enabling factors and the variation in use of health services across prisons. This study uses a nationally representative U.S. sample of men incarcerated in state prisons (n = 8816) and generalized structural equation and multilevel modeling. Five types of need-medical condition, illness, dental problem, unintentional injury, and intentional injury-are assessed for their association with use of health services.

RESULTS

Findings indicate that a number of inmate predisposing (age, race, education) and vulnerability (mood/anxiety disorder,) characteristics are associated with use of health services but are partially mediated by enabling and need factors. Each type of medical need has strong direct effects with mood/anxiety disorder emerging as the strongest total effect (including both direct effects and indirect effects through need). There is significant variation in rates of health service utilization across prisons that is not accounted for by the prison-level factors included in the multilevel model.

CONCLUSIONS

The varying patterns of health service use across prisons suggest that incarceration may be an important circumstance that shapes health. In other words, where someone is incarcerated may influence their ability to access and use services in response to medical need. It is important that prisons provide integrated services for inmates with mood/anxiety disorder given high comorbidity with other health conditions.

Cost of an Integrated Care Program to Reduce ED Visits During Diabetic Prisoner Court Hearings

Diabetic events occurring during court hearings previously required emergency medical services (EMS) transport to the emergency department (ED). A new process was implemented whereby the provincial court (PC) was notified by the detention center of diabetes status of prisoners scheduled for court later that day, enabling a community nursing services provider to provide on-site diabetes assessment and treatment at the PC. During the 13-month pre-implementation phase, there were 10 incidents of diabetic distress resulting in an ED visit at a total cost of $797.58/prisoner, including police service personnel, EMS, and ED staff/physician. During the 12.5-month postimplementation phase, insulin was administered on-site during 72 court dates at a cost of $161.93/prisoner. The new process for managing diabetic needs of prisoners during court dates resulted in a substantial cost savings in terms of police services and health care personnel and improved the immediacy and quality of care for prisoners.

Connecting Mentally Ill Detainees in Large Urban Jails with Community Care

Large urban jails have become a collection point for many persons with severe mental illness. Connections between jail and community mental health services are needed to assure in-jail care and to promote successful community living following release. This paper addresses this issue for 2855 individuals with severe mental illness who received community mental health services prior to jail detention in King County (Seattle), Washington over a 5-year time period using a unique linked administrative data source. Logistic regression was used to determine the probability that a detainee with severe mental illness received mental health services while in jail as a function of demographic and clinical characteristics. Overall, 70 % of persons with severe mental illness did receive in-jail mental health treatment. Small, but statistically significant sex and race differences were observed in who received treatment in the jail psychiatric unit or from the jail infirmary. Findings confirm the jail's central role in mental health treatment and emphasize the need for greater information sharing and collaboration with community mental health agencies to minimize jail use and to facilitate successful community reentry for detainees with severe mental illness.

High mortality among male HIV-infected patients after prison release: ART is not enough after incarceration with HIV

Context

French Guiana is a South American French territory, where HIV prevalence consistently exceeds 1% in the adult population. In the only correctional facility, HIV prevalence fluctuates at around 4%.

Aims

After describing the population of HIV-positive inmates, we aimed to evaluate mortality after release from the correctional facility, and to identify its predictive factors.

Rationale

Outside North American settings, data on treatment outcome and vital status of HIV-positive former inmates are scarce. There were no data in French Guiana. Filling this gap represents a basis for potential improvements.

Methods

All HIV-infected adults released from an incarceration of 30 days or more, between 2007 and 2013, were enrolled in a retrospective cohort study. Mortality was described over time, one to seven years following release, using Kaplan-Meier estimates. Factors associated with mortality were identified through a non-parametric survival regression model.

Results

147 former inmates were included. The male to female ratio was 4.4. The median age was 37.3 years. The majority were migrants, 25.8% were homeless, 70.1% suffered from substance abuse, with 34.0% of crack-cocaine users. On admission, 78.1% had an early HIV-stage infection (CDC-stage A), with a median CD4 count of 397.5/mm3, 34.0% had one comorbidity, mainly hypertension. Upon release, 50.3% were on ART. Reasons for not being treated were not fulfilling the criteria for 74.6%, and refusing for 15.1%. Before release, 84.5% of the patients on ART had a viral load≤200cp/ml. After release, 8.2% of the cohort had died, with a crude incidence of 33.8/1000 person-years. All recorded deaths were males, with an incidence of 42.2/1000 person-years. Comparing with the age-specific mortality rates for males in French Guiana, the standardized mortality ratio was 14.8. In multivariate analysis, factors associated with death were age and CD4 count before release.

Conclusion

Despite access to ART while incarcerated, with good virological outcome, the post-release mortality was very high for males, almost 15 times what is observed in the general male population living in French Guiana, after age standardization. Access to ART in correctional facilities may be a necessary, but not sufficient condition to protect male inmates from death after release.

Mass incarceration, public health, and widening inequality in the USA

In this Series paper, we examine how mass incarceration shapes inequality in health. The USA is the world leader in incarceration, which disproportionately affects black populations. Nearly one in three black men will ever be imprisoned, and nearly half of black women currently have a family member or extended family member who is in prison. However, until recently the public health implications of mass incarceration were unclear. Most research in this area has focused on the health of current and former inmates, with findings suggesting that incarceration could produce some short-term improvements in physical health during imprisonment but has profoundly harmful effects on physical and mental health after release. The emerging literature on the family and community effects of mass incarceration points to negative health impacts on the female partners and children of incarcerated men, and raises concerns that excessive incarceration could harm entire communities and thus might partly underlie health disparities both in the USA and between the USA and other developed countries. Research into interventions, policies, and practices that could mitigate the harms of incarceration and the post-incarceration period is urgently needed, particularly studies using rigorous experimental or quasi-experimental designs.

Exploring the Association between Race and Health among Older Adults Who Are Incarcerated

One of the little known ironies in the field of prison health is the notion that prison may actually have health-stabilizing effects for some groups. This study contributes to this line of inquiry by examining a variety of physical and mental health indicators among an older cohort of prisoners. Furthermore, this study's focus on race addresses a notable gap in the growing literature on older prisoner health. A cross-section of 625 males who were incarcerated residing in a northeastern state prison system was surveyed and data on self-reported health status and stress and individual demographics characteristics were collected. Univariate and multivariate logistic regressions were used to quantify racial differences with respect to self-reported stress after adjusting for potential confounders. Results suggest that Black men who are older and incarcerated appear to be more resilient than White men who are older. An association was found between race and self-reported stress though not statistically significant. Health status is a significant predictor of self-reported stress in univariate and multivariate analyses. Having ever committed a violent offense and having received mental health services (in and out patient) are statistically associated with self-reported stress. Black men who were older in this study appear to cope better with stress related to incarceration than White men who were older, which may in turn affect other physical and mental health outcomes. Future research is needed to address factors that stabilize health and reduce stress among a racially diverse, aging prison population.

Predictors of Mortality within Prison and after Release among Persons Living with HIV in Indonesia

Objectives

HIV-related mortality is increasing in Indonesia, where prisons house many people living with HIV and addiction. We examined all-cause mortality in HIV-infected Indonesian prisoners within prison and up to 24 months postrelease.

Materials and methods

Randomly selected HIV-infected male prisoners (n=102) from two prisons in Jakarta, Indonesia, completed surveys in prison and were followed up for 2 years (until study completion) or until they died or were lost to follow-up. Death dates were determined from medical records and interviews with immediate family members. Kaplan–Meier and Cox proportional hazards regression models were analyzed to identify mortality predictors.

Results

During 103 person-years (PYs) of follow-up, 15 deaths occurred, including ten in prison. The crude mortality rate within prison (125.2 deaths per 1,000 PYs) was surpassed by the crude mortality rate (215.7 deaths per 1,000 PYs) in released prisoners. HIV-associated opportunistic infections were the most common probable cause of death. Predictors of within-prison and overall mortality were similar. Shorter survival overall was associated with being incarcerated within a specialized “narcotic” prison for drug offenders (hazard ratio [HR] 9.2, 95% confidence interval [CI] 1.1–76.5; P=0.03), longer incarceration (HR 1.06, 95% CI 1.01–1.1; P=0.01), and advanced HIV infection (CD4⁺ T-cell count <200/µL, HR 4.8, 95% CI 1.2–18.2; P=0.02). Addiction treatment was associated with longer survival (HR 0.1, 95% CI 0.01–0.9; P=0.03), although treatment with antiretroviral therapy (ART) or methadone was not.

Conclusion

Mortality in HIV-infected prisoners is extremely high in Indonesia, despite limited provision of ART in prisons. Interventions to restore immune function with ART and provide prophylaxis for opportunistic infections during incarceration and after release would likely reduce mortality. Narcotic prisons may be especially high-risk environments for mortality, emphasizing the need for universal access to evidence-based HIV treatments.

Cancer prevalence, incidence and mortality in people who experience incarceration in Ontario, Canada: A population-based retrospective cohort study

Introduction

Evidence suggests that many risk factors for cancer are overrepresented in people who experience incarceration, and data on cancer epidemiology are limited for this population. We aimed to describe cancer prevalence, incidence and mortality in adults admitted to provincial custody in Ontario, Canada in 2000.

Methods

We linked data on 48,166 adults admitted to provincial custody in Ontario in 2000 with Ontario Cancer Registry data to 2012. We calculated cancer prevalence in the 10 years prior to admission to custody in 2000, incidence between 2000 and 2012 and mortality between 2000 and 2011. Standardized for age, we calculated incidence and mortality ratios by sex compared to the general population of Ontario.

Results

The 10-year cancer prevalence was 0.4% in men and 0.6% in women at admission to provincial custody in 2000. Between 2000 and 2012, 2.6% of men and 2.8% of women were diagnosed with new cancer. The standardized incidence ratio for cancer was 1.0 (95% CI 0.9–1.0) for men and 0.9 (95% CI 0.7–1.0) for women compared to the general population, and was significantly increased for cervical, head and neck, liver and lung cancers. The standardized mortality ratio was 1.6 (95% CI 1.4–1.7) in men and 1.4 (95% CI 1.0–1.9) in women, and was significantly increased for head and neck, liver, and lung cancers.

Conclusions

There is an excess burden of cancer in people who experience incarceration. Cancer prevention should include people who experience incarceration, and the period of incarceration may offer an opportunity for intervention.

Mortality among white, black, and Hispanic male and female state prisoners, 2001-2009

Although much research considers the relationship between imprisonment and mortality, little existing research has tested whether the short-term mortality advantage enjoyed by prisoners extends to Hispanics. We compared the mortality rates of non-Hispanic white, non-Hispanic black, and Hispanic male and female state prisoners to mortality rates in the general population using data from the Deaths in Custody Reporting Program, the National Prisoner Statistics, the National Corrections Reporting Program, and the Centers for Disease Control and Prevention. The results indicate that the mortality advantage for prisoners was greatest for black males, followed by black females, Hispanic males, white females, and white males. Hispanic female prisoners were the only group not at a mortality advantage relative to the general population, with an SMR of 1.18 [95% CI: 0.93-1.43]. Taken together, the results suggest that future research should seek to better understand the curious imprisonment-mortality relationship among Hispanic females, although given the small number of inmate deaths that happen to this group (~0.6%), this research should not detract from broader research on imprisonment and mortality.

Hospitalization Among HIV-Infected U.S. Marshals Service Prisoners

The U.S. Marshals Service (USMS) prisoner population is diverse and includes immigration violators, fugitives that have evaded apprehension, perpetrators of Medicaid fraud, and parole and probation violators. Unlike state and local jails, the USMS has numerous housing options for its prisoners. Given the unique characteristics, federal prisoners' quality of care, and subsequent clinical outcomes, may differ from those of state and local inmates. However, little is known about hospitalization rates and length of stay for HIV-positive USMS prisoners. The purpose of this study is to examine hospitalizations among HIV-infected prisoners in the custody of the USMS.

Clinical care of incarcerated people with HIV, viral hepatitis, or tuberculosis

The burden of HIV/AIDS and other transmissible diseases is higher in prison and jail settings than in the non-incarcerated communities that surround them. In this comprehensive review, we discuss available literature on the topic of clinical management of people infected with HIV, hepatitis B and C viruses, and tuberculosis in incarcerated settings in addition to co-occurrence of one or more of these infections. Methods such as screening practices and provision of treatment during detainment periods are reviewed to identify the effect of community-based treatment when returning inmates into the general population. Where data are available, we describe differences in the provision of medical care in the prison and jail settings of low-income and middle-income countries compared with high-income countries. Structural barriers impede the optimal delivery of clinical care for prisoners, and substance use, mental illness, and infectious disease further complicate the delivery of care. For prison health care to reach the standards of community-based health care, political will and financial investment are required from governmental, medical, and humanitarian organisations worldwide. In this review, we highlight challenges, gaps in knowledge, and priorities for future research to improve health-care in institutions for prisoners.

Changes in Depression and Stress after Release from a Tobacco-Free Prison in the United States

Prior research has found high levels of depression and stress among persons who are incarcerated in the United States (U.S.). However, little is known about changes in depression and stress levels among inmates post-incarceration. The aim of this study was to examine changes in levels of depression and stress during and after incarceration in a tobacco-free facility. Questionnaires that included valid and reliable measures of depression and stress were completed by 208 male and female inmates approximately eight weeks before and three weeks after release from a northeastern U.S. prison. Although most inmates improved after prison, 30.8% had a worsening in levels of depression between baseline and the three-week follow-up. In addition, 29.8% had a worsening in levels of stress after release than during incarceration. While it is not surprising that the majority of inmates reported lower levels of depression and stress post-incarceration, a sizable minority had an increase in symptoms, suggesting that environmental stressors may be worse in the community than in prison for some inmates. Further research is needed to address depression and stress levels during and after incarceration in order for inmates to have a healthier transition back into the community and to prevent repeat incarcerations.

Incarceration and adult weight gain in the National Survey of American Life (NSAL)

BACKGROUND

The United States has the unenviable distinction of having both the highest obesity rate among Organisation for Economic Co-operation and Development (OECD) member countries and the highest incarceration rate in the world. Further, both are socially patterned by race/ethnicity and socioeconomic position. Incarceration involves various health behaviors that could influence adult weight trajectory.

METHODS

We evaluated the associations between history and duration of adult incarceration and weight gain using the National Survey of American Life (N=6082 adults residing in the 48 contiguous states between February 2001 and March 2003). We propensity score-matched individuals to control for the probability of having a history of incarceration. To examine the relation between prior incarceration and adult weight gain, we fit gender-stratified generalized estimating equations controlling for propensity of incarceration history, age, education, income, race/ethnicity, and marital status.

RESULTS

For males (N=563), incarceration was associated with about a 1.77 kg/m(2) lower gain in body mass index (BMI) during adulthood, after adjusting for age, education, income, race/ethnicity, and marital status in addition to the propensity of having a history of incarceration (95% CI: -2.63, -0.92). For females (N=286), no significant overall relationship was found between a history of incarceration and adult weight gain. In subgroup analyses among those with an incarceration history, we found no overall association between duration of incarceration and adult weight gain in men or women. In sensitivity analyses, neither tobacco smoking nor parity changed the results.

CONCLUSIONS

The results of this study indicate that incarceration is associated with a lower transition of weight gain in males, but not in females..

The Institutional Effects of Incarceration: Spillovers From Criminal Justice to Health Care

POLICY POINTS

The steady increase in incarceration is related to the quality and functioning of the health care system. US states that incarcerate a larger number of people show declines in overall access to and quality of care, rooted in high levels of uninsurance and relatively poor health of former inmates. Providing health care to former inmates would ease the difficulties of inmates and their families. It might also prevent broader adverse spillovers to the health care system. The health care system and the criminal justice system are related in real but underappreciated ways.

CONTEXT

This study examines the spillover effects of growth in state-level incarceration rates on the functioning and quality of the US health care system.

METHODS

Our multilevel approach first explored cross-sectional individual-level data on health care behavior merged to aggregate state-level data regarding incarceration. We then conducted an entirely aggregate-level analysis to address between-state heterogeneity and trends over time in health care access and utilization.

FINDINGS

We found that individuals residing in states with a larger number of former prison inmates have diminished access to care, less access to specialists, less trust in physicians, and less satisfaction with the care they receive. These spillover effects are deep in that they affect even those least likely to be personally affected by incarceration, including the insured, those over 50, women, non-Hispanic whites, and those with incomes far exceeding the federal poverty threshold. These patterns likely reflect the burden of uncompensated care among former inmates, who have both a greater than average need for care and higher than average levels of uninsurance. State-level analyses solidify these claims. Increases in the number of former inmates are associated simultaneously with increases in the percentage of uninsured within a state and increases in emergency room use per capita, both net of controls for between-state heterogeneity.

CONCLUSIONS

Our analyses establish an intersection between systems of care and corrections, linked by inadequate financial and administrative mechanisms for delivering services to former inmates.

Incarceration and Health

The expansion of the penal system has been one of the most dramatic trends in contemporary American society. A wealth of research has examined the impact of incarceration on a range of later life outcomes and has considered how the penal system has emerged as a mechanism of stratification and inequality in the United States. In this article, we review the literature from a comparatively new vein of this research: the impact of incarceration on health outcomes. We first consider the impact of incarceration on a range of individual outcomes, from chronic health conditions to mortality. We then consider outcomes beyond the individual, including the health of family members and community health outcomes. Next, we discuss mechanisms linking incarceration and health outcomes before closing with a consideration of limitations in the field and directions for future research.

Nearly invisible: the psychosocial and health needs of women with male partners in prison

Very little research has been conducted investigating the health status and social needs of women with incarcerated male partners, despite the large number of men from underserved communities who are currently incarcerated. Research with women who have incarcerated male partners has primarily focused on communicable disease risk and family interactions. Women with incarcerated partners are often mothering children who are at risk for early and repeated incarceration, behavioral problems, and poverty. Gaining a better understanding of the health and social needs, and the resources use of these women and their children may lead to developing policies and programs that help them better manage their health, as well as aid in strengthening their family relationships.

Understanding death in custody: a case for a comprehensive definition

Prisoners sometimes die in prison, either due to natural illness, violence, suicide, or a result of imprisonment. The purpose of this study is to understand deaths in custody using qualitative methodology and to argue for a comprehensive definition of death in custody that acknowledges deaths related to the prison environment. Interviews were conducted with 33 experts, who primarily work as lawyers or forensic doctors with national and/or international organisations. Responses were coded and analysed qualitatively. Defining deaths in custody according to the place of death was deemed problematic. Experts favoured a dynamic approach emphasising the link between the detention environment and occurrence of death rather than the actual place of death. Causes of deaths and different patterns of deaths were discussed, indicating that many of these deaths are preventable. Lack of an internationally recognised standard definition of death in custody is a major concern. Key aspects such as place, time, and causes of death as well as relation to the prison environment should be debated and incorporated into the definition. Systematic identification of violence within prison institutions is critical and efforts are needed to prevent unnecessary deaths in prison and to protect vulnerable prisoners.

Opioid substitution therapy as a strategy to reduce deaths in prison: retrospective cohort study

OBJECTIVES

To describe deaths in prison among opioid-dependent people, and examine associations between receipt of opioid substitution therapy (OST) and risk of death in prison.

DESIGN

Retrospective cohort study.

SETTING

Adult prisons in New South Wales (NSW), Australia.

PARTICIPANTS

16 715 opioid-dependent people who were received to prison between 2000 and 2012.

INTERVENTIONS

Opioid substitution therapy.

PRIMARY OUTCOME MEASURES

Natural and unnatural (suicide, drug-induced, violent and other injury) deaths in prison.

RESULTS

Cohort members were in prison for 30 998 person-years (PY), during which time there were 51 deaths. The all-cause crude mortality rate (CMR) in prison was 1.6/1000 PY (95% CI 1.2 to 2.2/1000 PY), and the unnatural death CMR was 1.1/1000 PY (95% CI 0.8 to 1.6/1000 PY). Compared to time out of OST, the hazard of all-cause death was 74% lower while in OST (adjusted HR (AHR): 0.26; 95% CI 0.13 to 0.50), and the hazard of unnatural death was 87% lower while in OST (AHR: 0.13; 95% CI 0.05 to 0.35). The all-cause and unnatural death CMRs during the first 4 weeks of incarceration were 6.6/1000 PY (95% CI 3.8 to 10.6/1000 PY) and 5.5/1000 PY (95% CI 2.9 to 9.4/1000 PY), respectively. Compared to periods not in OST, the hazard of all-cause death during the first 4 weeks of incarceration was 94% lower while in OST (AHR: 0.06; 95% CI 0.01 to 0.48), and the hazard of unnatural death was 93% lower while in OST (AHR: 0.07; 95% CI 0.01 to 0.53).

CONCLUSIONS

Mortality of opioid-dependent prisoners was significantly lower while in receipt of OST.

Parental incarceration and child mortality in Denmark

OBJECTIVES

We used Danish registry data to examine the association between parental incarceration and child mortality risk.

METHODS

We used a sample of all Danish children born in 1991 linked with parental information. We conducted discrete-time survival analysis separately for boys (n = 30 146) and girls (n = 28 702) to estimate the association of paternal and maternal incarceration with child mortality, controlling for parental sociodemographic characteristics. We followed the children until age 20 years or death, whichever came first.

RESULTS

Results indicated a positive association between paternal and maternal imprisonment and male child mortality. Paternal imprisonment was associated with lower child mortality risks for girls. The relationship between maternal imprisonment and female child mortality changed directions depending on the model, suggesting no clear association.

CONCLUSIONS

These results indicate that the incarceration of a parent may influence child mortality but that it is important to consider the gender of both the child and the incarcerated parent.