Carceral epidemiology: mass incarceration and structural racism during the COVID-19 pandemic

COVID-19 Related Knowledge, Attitudes, and Behaviors Among Black Men with Chronic Health Conditions: A Latent Profile Analysis

Research indicates that Black communities experienced disproportionately higher numbers of confirmed cases and fatalities throughout the COVID-19 pandemic with Black men experiencing marked reductions in life expectancy. Inequities were further magnified by known COVID-19 such as hypertension, diabetes, obesity, and higher prevalence of cardiovascular disease. The current project aimed to assess the knowledge, attitudes, and behaviors related to COVID-19 among Black men with chronic conditions. Specifically, we sought to determine whether COVID-19-related perspectives and behaviors impacted cross-sectional health outcomes. A national sample of Black men (N = 312) who self-reported at least one chronic disease responded to survey questions about their knowledge, attitude, and preventative behaviors (KAP) related to COVID-19. Analyses suggest that unique latent profiles based on COVID-19-related KAP differentially impacted participants' self-reported health and well-being for those low on KAP items. The discussion includes considerations on viral hygiene interventions, misinformation, stigma, and perceptions of discrimination.

Mass Incarceration, Maternal Vulnerability, and Birth Outcomes Across U.S. Counties

OBJECTIVES

To examine the associations among mass incarceration, maternal vulnerability, and disparities in birth outcomes across U.S. counties, utilizing an ecological model and reproductive justice perspective was used. This study tests whether mass incarceration is associated with infant mortality and low birthweight across U.S. counties, and whether maternal vulnerability explains the relationship between mass incarceration and birth disparities.

METHODS

Data were derived from a variety of public sources and were merged using federal FIPS codes. Outcomes from the CDC Vitality Statistics include percent low birth weight births (births below 2499 g divided by singleton births to women aged 20 to 39) and infant mortality (infant deaths per 1000 live births). Black-White rate ratios were calculated for the birth outcomes to specifically examine the large Black-White disparity in birth outcomes. The analysis controlled for urbanicity, income inequality, median household income, residential segregation, and southern region, as well as a fixed effect for state level differences.

RESULTS

Findings show that counties with higher rates of incarceration have higher prevalence of infant mortality and low birthweight, as well as greater Black-White disparity in infant mortality. Mass incarceration is associated with increases in adverse birth outcomes and maternal vulnerability partially mediates this relationship.

CONCLUSIONS

Findings provide evidence that heightened levels of incarceration affect birth outcomes for all residents at the county-level. It is imperative to address the overuse of mass incarceration in order to support adequate reproductive healthcare of vulnerable populations in the United States.

Implementation of Rapid COVID-19 Testing in Criminal Justice Residential Reentry Sites

The goal was to study the implementation of rapid BINAX COVID-19 testing at criminal justice reentry sites, focusing on framework-guided implementation outcomes. We implemented rapid COVID-19 testing at nine reentry sites in four states (Massachusetts, New Hampshire, Rhode Island, and New York) and collected test results to measure the (1) adoptability and (2) implementability of COVID-19 testing at reentry sites. We collected data on the acceptability, appropriateness, and feasibility of the implementation of COVID-19 testing using an anonymous employee Qualtrics survey. Testing was available to symptomatic and exposed residents and employees. COVID-19 testing results were collected from October 2021 to March 2022. Guided by the Expert Recommendations in Implementing Change (ERIC) framework, we chose nine implementation strategies to address barriers during the implementation process. Acceptability, appropriateness, and feasibility outcomes were captured from employees using validated measures. A total of 302 BINAX COVID-19 tests were used and 26 positive cases were identified. Forty-seven percent of employees participated in the survey. More than half of respondents either agreed or completely agreed with statements about the acceptability, appropriateness, or feasibility of COVID-19 testing. Funding and attention toward COVID-19 testing at reentry sites should be provided to help prevent the spread of COVID-19 in these sites.

Addressing COVID-19 and Health Literacy Disparities Among Correctional Facility Residents Through Dialogue-Based Education

Carceral communities face heightened COVID-19-related risks while simultaneously experiencing medical mistrust and limited access to health information and services. Health education programs that incorporate dialogue-based, participatory learning models have been shown to motivate health behavior and increase health knowledge in carceral settings. To increase health literacy and change COVID-19-related health behavior among jail residents in the United States, a local health department developed a dialogue-based education program centered around COVID-19 prevention, misinformation, and navigating health care systems. Dialogue-based health information sessions took place in person in a county jail. Pre- and postsurveys gauged the sessions' influence on self-reported health literacy and behavior intention. Overall, 595 residents collectively attended 43 facilitated discussions. Key findings indicate that dialogue-based education can temper medical mistrust, influencing COVID-19 preventive behaviors and increasing health literacy in a carceral setting.

Area-Level Social Vulnerability and Severe COVID-19: A Case-Control Study Using Electronic Health Records from Multiple Health Systems in the Southeastern Pennsylvania Region

Knowledge about neighborhood characteristics that predict disease burden can be used to guide equity-based public health interventions or targeted social services. We used a case-control design to examine the association between area-level social vulnerability and severe COVID-19 using electronic health records (EHR) from a regional health information hub in the greater Philadelphia region. Severe COVID-19 cases (n = 15,464 unique patients) were defined as those with an inpatient admission and a diagnosis of COVID-19 in 2020. Controls (n = 78,600; 5:1 control-case ratio) were a random sample of individuals who did not have a COVID-19 diagnosis from the same geographic area. Retrospective data on comorbidities and demographic variables were extracted from EHR and linked to area-level social vulnerability index (SVI) data using ZIP codes. Models adjusted for different sets of covariates showed incidence rate ratios (IRR) ranging from 1.15 (95% CI, 1.13-1.17) in the model adjusted for individual-level age, sex, and marital status to 1.09 (95% CI, 1.08-1.11) in the fully adjusted model, which included individual-level comorbidities and race/ethnicity. The fully adjusted model indicates that a 10% higher area-level SVI was associated with a 9% higher risk of severe COVID-19. Individuals in neighborhoods with high social vulnerability were more likely to have severe COVID-19 after accounting for comorbidities and demographic characteristics. Our findings support initiatives incorporating neighborhood-level social determinants of health when planning interventions and allocating resources to mitigate epidemic respiratory diseases, including other coronavirus or influenza viruses.

Correctional nurses' practices and perceptions of family engagement

BACKGROUND

In healthcare, family engagement has been recognized as critical to improved nursing care and outcomes. However, the practice of family engagement in corrections is unknown, despite the large amount of nursing care delivered there.

PURPOSE

The study's aim was to describe correctional nurses' perceptions of family engagement and the extent to which it is practiced.

METHOD

A qualitative descriptive study design was used, composed of semistructured interviews. Thematic analysis was conducted, including line-by-line coding.

DISCUSSION

The main themes of the study were: (a) Family engagement is rare, and (b) Systems friction which describe the lack of family engagement in correctional nursing practice, and the need to balance advocating for patients while maintaining a collegial relationship with correction staff.

CONCLUSION

Despite the lack of family engagement in correctional nurses' practice, most participants felt that family engagement would be beneficial for incarcerated patients but would require changes to institutional policies.

Rapid jail-based implementation of overdose education and naloxone distribution in response to the COVID-19 pandemic

BACKGROUND

People incarcerated in jails are highly impacted by the opioid epidemic, and overdose education and naloxone distribution (OEND) is an effective strategy to reduce opioid overdose deaths. This study examines barriers and facilitators of fast-track OEND implementation within the jails in the Wave 1 Kentucky counties of the HEALing Communities Study during the COVID-19 pandemic.

METHODS

Meeting minutes with jail stakeholders were qualitatively coded using the Practical, Robust Implementation and Sustainability Model (PRISM) as the coding framework. The analysis highlighted the top barriers and facilitators to fast-track OEND implementation within the PRISM framework.

RESULTS

Space and staffing shortages related to the COVID-19 pandemic, disruptions in interorganizational programming from pandemic-related service suspensions, and a lack of technological solutions (e.g., reliable Internet access) for socially distanced delivery were the top barriers to fast-track OEND implementation. In addition, there were limitations on non-jail staff access to jails during COVID-19. Top facilitators included jail leadership support, the option to prioritize high-risk groups, and the incorporation of OEND processes into existing communications and management software. While the COVID-19 pandemic strained jail infrastructure, jail and partner agency collaboration led to creative implementation strategies for the successful integration of OEND into jail operations. Urban jails were more likely than rural jails to be early adopters of OEND during the public health emergency.

CONCLUSIONS

Understanding the barriers to and facilitators of OEND within jails will improve implementation efforts seeking to curb opioid overdose deaths. Jail leadership support and interorganizational efforts were key facilitators to implementation; therefore, it is recommended to increase buy-in with multiple agencies to promote success. Challenges brought on by COVID-19 have resulted in a need for innovative solutions for implementation.

CLINICAL TRIAL INFORMATION

ClinicalTrials.gov, NCT04111939, Submitted 30 September 2019, https://clinicaltrials.gov/study/NCT04111939?titles=HEALing%20Communities%20Study&rank=1 .

Medicaid Inmate Exclusion Policy and Infectious Diseases Care for Justice-Involved Populations

The Medicaid Inmate Exclusion Policy (MIEP) prohibits using federal funds for ambulatory care services and medications (including for infectious diseases) for incarcerated persons. More than one quarter of states, including California and Massachusetts, have asked the federal government for authority to waive the MIEP. To improve health outcomes and continuation of care, those states seek to cover transitional care services provided to persons in the period before release from incarceration. The Massachusetts Sheriffs' Association, Massachusetts Department of Correction, Executive Office of Health and Human Services, and University of Massachusetts Chan Medical School have collaborated to improve infectious disease healthcare service provision before and after release from incarceration. They seek to provide stakeholders working at the intersection of criminal justice and healthcare with tools to advance Medicaid policy and improve treatment and prevention of infectious diseases for persons in jails and prisons by removing MIEP barriers through Section 1115 waivers.

Mass Probation: Effects of Sentencing Severity on Mental Health for Black and White Individuals

BACKGROUND

Incarceration is associated with negative impacts on mental health. Probation, a form of community supervision, has been lauded as an alternative. However, the effect of probation versus incarceration on mental health is unclear. Our objective was to estimate the impact on mental health of reducing sentencing severity at individuals' first adult criminal-legal encounter.

METHODS

We used the US National Longitudinal Survey on Youth 1997, a nationally representative dataset of youth followed into their mid-thirties. Restricting to those with an adult encounter (arrest, charge alone or no sentence, probation, incarceration), we used parametric g-computation to estimate the difference in mental health at age 30 (Mental Health Inventory-5) if (1) everyone who received incarceration for their first encounter had received probation and (2) everyone who received probation had received no sentence.

RESULTS

Among 1835 individuals with adult encounters, 19% were non-Hispanic Black and 65% were non-Hispanic White. Median age at first encounter was 20. Under hypothetical interventions to reduce sentencing, we did not see better mental health overall (Intervention 1, incarceration to probation: RD = -0.01; CI = -0.02, 0.01; Intervention 2, probation to no sentence: RD = 0.00; CI = -0.01, 0.01) or when stratified by race.

CONCLUSION

Among those with criminal-legal encounters, hypothetical interventions to reduce sentencing, including incremental sentencing reductions, were not associated with improved mental health. Future work should consider the effects of preventing individuals' first criminal-legal encounter.

The application of implementation science methods in correctional health intervention research: a systematic review

BACKGROUND

Improving access to high-quality healthcare for individuals in correctional settings is critical to advancing health equity in the United States. Compared to the general population, criminal-legal involved individuals experience higher rates of chronic health conditions and poorer health outcomes. Implementation science frameworks and strategies offer useful tools to integrate health interventions into criminal-legal settings and to improve care. A review of implementation science in criminal-legal settings to date is necessary to advance future applications. This systematic review summarizes research that has harnessed implementation science to promote the uptake of effective health interventions in adult criminal-legal settings.

METHODS

A systematic review of seven databases (Academic Search Premier, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Social Work Abstracts, ProQuest Criminal Justice Database, ProQuest Sociological Abstracts, MEDLINE/PubMed) was conducted. Eligible studies used an implementation science framework to assess implementation outcomes, determinants, and/or implementation strategies in adult criminal-legal settings. Qualitative synthesis was used to extract and summarize settings, study designs, sample characteristics, methods, and application of implementation science methods. Implementation strategies were further analyzed using the Pragmatic Implementation Reporting Tool.

RESULTS

Twenty-four studies met inclusion criteria. Studies implemented interventions to address infectious diseases (n=9), substance use (n=6), mental health (n=5), co-occurring substance use and mental health (n=2), or other health conditions (n=2). Studies varied in their operationalization and description of guiding implementation frameworks/taxonomies. Sixteen studies reported implementation determinants and 12 studies measured implementation outcomes, with acceptability (n=5), feasibility (n=3), and reach (n=2) commonly assessed. Six studies tested implementation strategies. Systematic review results were used to generate recommendations for improving implementation success in criminal-legal contexts.

CONCLUSIONS

The focus on implementation determinants in correctional health studies reflects the need to tailor implementation efforts to complex organizational and inter-agency contexts. Future studies should investigate policy factors that influence implementation success, design, and test implementation strategies tailored to determinants, and investigate a wider array of implementation outcomes relevant to criminal-legal settings, health interventions relevant to adult and juvenile populations, and health equity outcomes.

TRIAL REGISTRATION

A study protocol (CRD42020114111) was registered with Prospero.

Facilitators and barriers to COVID-19 vaccination among incarcerated people and staff in three large, state prisons: a cross-sectional study

BACKGROUND

The COVID-19 pandemic has disproportionately impacted individuals in carceral facilities - both incarcerated people and staff. Vaccination is an important tool in reducing the risk of COVID-19 infection, hospitalization, and death. While the importance of promoting vaccination is clear, there are considerable barriers to doing so. This study aims to better understand: (1) why individuals chose to receive the COVID-19 vaccine; (2) why individuals were hesitant to vaccinate; (3) what motivators might influence a person's decision to get vaccinated; and (4) what sources of information about COVID-19 vaccination people trust.

METHODS

We conducted a survey of incarcerated people and facility staff in three, large state prisons in Minnesota to identify barriers and facilitators to COVID-19 vaccination. Facilities were recruited to participate through purposive sampling, and surveys were administered between November and December 2021. Descriptive statistics were calculated using Stata.

RESULTS

Findings demonstrate that, for incarcerated individuals (N = 1,392), the most common reason for getting vaccinated was to return to normal activities in prison (61%, n = 801); the most common reason for being hesitant to get vaccinated was "other" (41%, n = 342), with individuals citing a variety of concerns. For staff (N = 190), the most common reason for getting vaccinated was to protect the health of family and friends (79%, n = 114); the most common reasons for being hesitant were disbelief that vaccination is necessary (55%, n = 23) and distrust of healthcare and public health systems (55%, n = 23). Incarcerated individuals reported that monetary and programmatic incentives would help motivate them to get vaccinated, while staff members said speaking with healthcare professionals and monetary incentives would help motivate them. Lastly, trusted sources of information for incarcerated individuals were healthcare professionals outside of prisons and jails, along with friends and family members. Staff members reported that they trusted healthcare professionals and national health organizations for information about COVID-19 vaccination.

CONCLUSIONS

While considerable barriers to COVID-19 vaccination persist among both incarcerated individuals and staff members, these findings also highlight areas of intervention to increase COVID-19 vaccine confidence and promote health equity among those disproportionately impacted by the COVID-19 pandemic.

COVID-19 Vaccination Status as Well as Factors Associated with COVID-19 Vaccine Acceptance and Hesitancy among Prisoners and the Implications

Prisoners form a population who are highly vulnerable to COVID-19 due to overcrowding, limited movement, and a poor living environment. Consequently, there is a need to ascertain the status of COVID-19 vaccination and factors associated with hesitancy among prisoners. A cross-sectional questionnaire-based study was undertaken among prisoners at three district jails in Punjab Province, Pakistan. A total of 381 prisoners participated and none of the study participants had received an influenza vaccine this year. In total, 53% received at least one dose of a COVID-19 vaccine, with the majority having two doses. The top three reasons of vaccine acceptance were "fear of contracting SARS-CoV-2 infection" (56.9%), "desire to return to a pre-pandemic routine as soon as possible" (56.4%), and "having no doubts on the safety of COVID-19 vaccines" (39.6%). There was no statistically significant difference (p > 0.05) in any demographic variables between vaccinated and unvaccinated prisoners except for age, which was strongly association with COVID-19 vaccine uptake (χ²(3) = 76.645, p < 0.001, Cramer's V = 0.457). Among the unvaccinated prisoners (N = 179), only 16 subsequently showed willingness to receive a COVID-19 vaccine. The top three reasons for hesitancy were: COVID-19 is not a real problem/disease (60.1%), safety concerns (51.1%), and COVID-19 vaccine is a conspiracy (50.3%). Efforts are needed to address their concerns given this population's risks and high hesitancy rates, especially among younger prisoners.

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.

COVID-19 amplified racial disparities in the US criminal legal system

The criminal legal system in the USA drives an incarceration rate that is the highest on the planet, with disparities by class and race among its signature features1-3. During the first year of the coronavirus disease 2019 (COVID-19) pandemic, the number of incarcerated people in the USA decreased by at least 17%-the largest, fastest reduction in prison population in American history4. Here we ask how this reduction influenced the racial composition of US prisons and consider possible mechanisms for these dynamics. Using an original dataset curated from public sources on prison demographics across all 50 states and the District of Columbia, we show that incarcerated white people benefited disproportionately from the decrease in the US prison population and that the fraction of incarcerated Black and Latino people sharply increased. This pattern of increased racial disparity exists across prison systems in nearly every state and reverses a decade-long trend before 2020 and the onset of COVID-19, when the proportion of incarcerated white people was increasing amid declining numbers of incarcerated Black people5. Although a variety of factors underlie these trends, we find that racial inequities in average sentence length are a major contributor. Ultimately, this study reveals how disruptions caused by COVID-19 exacerbated racial inequalities in the criminal legal system, and highlights key forces that sustain mass incarceration. To advance opportunities for data-driven social science, we publicly released the data associated with this study at Zenodo6.

Social and structural determinants of COVID-19 vaccine uptake among racial and ethnic groups

Latino, Black, American Indian/Alaska Native (AI/AN), and Native Hawaiian or Other Pacific Islander people have the highest hospitalizations and death rates from COVID-19. Social inequalities have exacerbated COVID-19 related health disparities. This study examines social and structural determinants of COVID-19 vaccine uptake. Results from logistic regressions suggest Latino and Black people were less likely to be vaccinated. People that did not have health insurance, a primary care doctor and were unemployed were more than 30% less likely to be vaccinated for COVID-19. Greater perceived health inequalities in one's neighborhood and perceived racial/ethnic discrimination were associated with a decreased odds in being vaccinated. People that suffered the loss of a household member from COVID-19 were three times more likely to have been vaccinated. Establishing policies that will increase access to health insurance and create jobs with living wages may have lasting impacts. Furthermore, collaboration with local and national community organizations can enhance the development of sustainable solutions.

Inequities in life course criminal legal system sanctions: measuring cumulative involvement

PURPOSE

The impact of incarceration on health is well known. Yet, most studies measure incarceration alone and miss additional exposure to the criminal legal system over time. We evaluated adult criminal legal sanctions - inclusive of arrests, charges, probation, incarceration - from ages 18-35 and inequities by juvenile sanctions and race.

METHODS

Using the National Longitudinal Survey on Youth 1997, a nationally representative data set of adolescents followed into their mid-thirties (1997-2017), we calculated the mean cumulative count, or the average number of criminal legal events per person per study visit, stratified by juvenile sanctions and race.

RESULTS

Of 7024 participants, 1679 experienced 3,075 encounters. There were seven arrests, 30 charges, nine probation encounters, and 13 incarceration events /100 participants by age 35. Juvenile sanctions were most common for Black individuals. Among those experiencing juvenile sanctions, Black and White individuals had similar numbers of encounters, but Black individuals had more arrests and incarceration stays. For those without juvenile encounters, Black individuals had more encounters than White individuals.

CONCLUSIONS

Research on health effects of criminal legal sanctions must consider encounters beyond incarceration and focus on life course trajectories and racial inequities.

Stakeholder-engaged research is necessary across the criminal-legal spectrum

People with lived experience of incarceration have higher rates of morbidity and mortality compared to people without history of incarceration. Research conducted unethically in prisons and jails led to increased scrutiny of research to ensure the needs of those studied are protected. One consequence of increased restrictions on research with criminal-legal involved populations is reluctance to engage in research evaluations of healthcare for people who are incarcerated and people who have lived experience of incarceration. Ethical research can be done in partnership with people with lived experience of incarceration and other key stakeholders and should be encouraged. In this article, we describe how stakeholder engagement can be accomplished in this setting, and further, how such engagement leads to impactful research that can be disseminated and implemented across disciplines and communities. The goal is to build trust across the spectrum of people who work, live in, or are impacted by the criminal-legal system, with the purpose of moving toward health equity.