presentation at imcc
TRANSCRIPT
1
The Health of Prisoners In Iowa
from a Public Health Perspective
Findings from a cross-sectional data analysis 2015
Tala Al- Rousan, MD MPH candidate Practicum Project
Robert Wallace, MD MScProfessor of Epidemiology and Internal Medicine
The University of IowaCollege of Public Health
Linda Rubenstein, PhD Senior Biostatistician
2
“Health is a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity”
― WHO definition of Health
3
Public Health Approach to Incarceration
• More than 3 million Americans are incarcerated, more than
anywhere else in the world
• The impact of imprisonment is clear on those imprisoned
and their families and communities
• A national trend of increasing mental illnesses is seen in
prisons all over the U.S.
4
Public Health Approach to Incarceration
• Outbreaks of scabies, MRSA, TB and Hepatitis are on
the rise in many prisons.
• Prevalence of chronic conditions, and contrasting
numbers inside prisons with those outside prison, are
not fully understood
5
• As a science of prevention and health
promotion, public health is positioned to
mitigate risks and promote healthy living
within one’s environment
• It is essential to strengthen
multidisciplinary linkages to deal with the
challenges of mass incarceration
6
• ICON- Medical data is an important source of
information that could tell us how prisoners are doing
• We requested a set of variables to look at data at one
point in time
• Data were received on February 7, 2015 and analyzed
by an experienced biostatistician using specialized
software
Data Source for Today’s Talk
7
Research Questions:
1. What are the general characteristics of Iowa’s prisoners?
2. What is the prevalence of chronic conditions among
prisoners? Does it differ between younger and older
prisoners?
3. Can we better understand the burden of mental illnesses in
prisons?
4. Are there areas that need to be improved and policy
recommendations from a public health perspective?
8
99%
91%
Female Male
26.9; 27%
7.1; 7%
62.9; 63%
3; 3%Race
BlackHispanic White Other
Gender
Demographics of Inmates
Blacks and Hispanics are overrepresented and female prisoners are growing in numbers
9
83%
17%
Age Distribution
Younger
OlderN= 7107
N= 1467
Younger inmates
• Total Number of Prisoners = 8574
• Total Number of younger prisoners 49 Years old or
less = 7107
• Total Number of older prisoners 50 Years or older
= 1467
• Mean age for younger prisoners = 32.4 ± 8.4
• Mean age for older prisoners = 57.2 ± 6.8
• Mean age for all prisoners = 36.7 ± 12.4
Data from February 2015
10
0
5
10
15
20
25
30
35
40
Conviction Class
Younger 2015 Older 2015 Younger 2006 Older 2006
Younger
Older
Conviction Class:• A felony = Life in prison• B felony = 25- 50 years• C felony = 10 years• D felony = 5 years• Aggravated misdemeanor = 2
years• Other classes = Irregular
penalties, others
Comparing
11
Younger Older
93.3 96.5
Supervision Status
Prison Work release
Drug Violent Public order
Property Other
23.9
44.4
22
6.82.8
16.2
64
9.9 7.72.2
Crime Type
Younger Older
Demographics
12
Married Single Divorced/widowed
1713.5
69.4
Marital status
Other
Less than high school
High school/ equivalent
Some college
College graduate
0 10 20 30 40 50 60 70 80
2.3
18.8
76
2.1
0.8
Highest Level of Edu-cation
Demographics
13Hx of Tobacco use0
10
20
30
40
50
6054
38.1
51.2
History of Smoking
Younger AllOlder
About half the prisoners have a positive history of smoking with a mean of 16.1 packs/year. The documented data on older prisoners may be under-representative
Younger Older All prisoners0
5
10
15
20
25
30
35
40
13.3
34.9
16.1
Mean pack.year (smokers only)
History of Smoking at Admission
14
Body Mass Index and Diagnosis of Obesity
Underweight Normal Overweight Obese
BMI by Age
Younger OlderUnderweight Normal Overweight Obese
0
10
20
30
40
50
60
BMI by Gender
Females Males
But the rate of ICD-9 diagnosis of obesity was only 4.3%!
Energy intake, programs and atypical antipsychotic medications may explain disparities in BMI and gender?
15
Subst
ance
use (D
SM)
Subst
ance
use (IC
D9)
Corona
ry art
ery di
sease
Hypert
ensio
n
Hyperl
ipidem
ia
Hepati
tis C
Chronic
lung
disea
se
Proble
ms with
vision
Neurol
ogica
l dise
ase
Obesity
Diabete
sPPD
+Can
cer
Sexu
ally tra
nsmitte
d dise
ase
Proble
ms with
heari
ng05
10152025303540
Prevalence of Chronic Conditions in Younger versus Older Prisoners
Younger Older All prisoners
16Infectious and parasitic diseases
Neoplasms
Diseases of the blood and blood-forming organs
Mental diseases
Endocrine, nutritional and metabolic diseases
Diseases of the nervous system
Diseases of the sense organs
Diseases of the circulatory system
Diseases of the respiratory system
Diseases of the digestive system
Diseases of the skin and subcutaneous tissue
Diseases of the musculoskeletal system and connective tissue
Diseases of the genitourinary system
Congenital malformations
Injury, poisoning and other consequences of external causes
8.2
0.6
0.4
45.3
11.3
3.9
31.5
9.8
8.5
5
3
6.3
1.6
0.3
1.4
17.9
3.5
1.7
38.9
8.1
8.2
62
37.9
15.1
16.7
5.5
23.2
13.2
0.9
3.2
Older prisoners Younger prisoners
Prevalence Rates of Diagnostic Categories by Age Groups
Sense organs ICD-9:360-390 (includes vision codes that are not really diseases
17
Comparing Prevalence of Chronic Conditions to the 2006 study studying the prisoners population
Hepatitis Hypertension Hyperlipidemia Diabetes II Coronary artery disease0
10
20
30
40
50
60Comparison Between 2006 and 2015 in Older and Younger prisoners
Younger 2006 Younger 2015 Older 2006 Older 2015
Increase in rates of diagnosis inmates or real increase in prevalence?
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Older offenders have more modifiable risk factors for
developing chronic conditions than younger
offenders like smoking and obesity
Older offenders are more likely to have: CAD,
Hypertension, Hyperlipidemia, vision problems, Hep.
C and cancer than younger offenders
Summary of Chronic Conditions
19
Summary of Chronic Conditions
There is an increase in the prevalence of all chronic
conditions since 2006 for all offenders
Obesity is a big problem and females have higher
rates of obesity
Younger offenders have more substance abuse than
older offenders
20Substance abuseDepression and major depressive disorders
Anxiety, general anxiety and panic disordersPersonality disorders
Psychosis and psychotic disordersDevelopmental disabilities
BipolarPost-Traumatic Stress Disorder (PTSD)
SchizophreniaImpulse control disorders
Dysthymia/ neurotic depressionDementia
Sleep, movement and eating disordersPervasive developmental disorders
Sexual disorders/ ParapheliasSomatization disorders
0 5 10 15 20 25 3026.1
14.814.2
10.18.1
7.86.8
4.82.9
1.40.9
0.60.30.10.10
All prisoners
Prevalence of Mental Illnesses in All Inmates using DSM- 5 and ICD-9 codes
21
0
5
10
15
20
25
30
35
40Mental Illnesses Across Older and Younger Inmates by Gender
Younger Females Younger Males Older Females
22
Diagnosis of Mental Disorders During Incarceration by Gender
01020304050607080
Diagnosed Documented During Incarceration
Females Males
23
Diagnosis of Mental Disorders During Incarceration by Gender
0
10
20
30
40
50
60
70
80Diagnosis Documented During Incarceration
Females Males
24
Almost half of the mental illness diagnoses are not noted during initial screening? This is slightly more common in younger inmates
020406080
100Diagnosed During Incarceration
Younger Older All
Diagnosis During Incarceration by Age
25
Diagnosis During Incarceration by Age
0
20
40
60
80
100
120 Younger OlderAll
26
05
1015202530 26.1
14.8 14.2
6.8 4.80.9
18 17
6.7
1.1
8.6
2.8
Comparison to National Numbers
Prisoners Community
These are crude rates and we may need to adjust for age, gender and other vari-ables
Comparing Mental Health Prevalence Rates to National Data Using The National Comorbidity Study*
Reference: The National Institute for Mental Health (NIMH) Collaborative Psychiatric Epidemiology Surveys (CPES): http://www.hcp.med.harvard.edu/ncs/
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Summary of Mental Illnesses
• About half the offenders have a mental illness diagnosis
• Substance abuse is the most common disorder and rates are higher
than community rates
• Depression, anxiety, psychosis and personality disorders come next
• Mental illnesses are a problem in both younger and older offenders
• Generally, most of the mental illnesses are diagnosed during
incarceration and may be not noted at initial screening
28
Suggested Interventions
Evidence-base interventions to prevent relapse to smoking (Rhode Island DOC example: counseling and CBT while in prison six weeks prior to release)
Health education and health promotion for chronic diseases in all prisons
Dietary modification (energy intake, percentage energy intake as fat, sodium intake monitoring)
Promote physical activity and evidence-base wellness programs
Substance abuse: A recent meta-analysis showed that motivational interviewing, psychotherapy
and pharmacological interventions during imprisonment have a positive result
Mental illness: Psychotherapy, skills training during imprisonment, music and yoga therapy, showed positive effects.
Infectious diseases: Hep B vaccination, HCV dried blood spot testing during incarceration
29
References1. Kouyoumdjian, F. G., McIsaac, K. E., Liauw, J., Green, S., Karachiwalla, F., Siu, W., ... &
Hwang, S. W. (2015). A Systematic Review of Randomized Controlled Trials of Interventions to Improve the Health of Persons During Imprisonment and in the Year After Release. Journal Information, 105(4).
2. Gates, M. L., & Bradford, R. K. (2015). The Impact of Incarceration on Obesity: Are Prisoners with Chronic Diseases Becoming Overweight and Obese during Their Confinement?. Journal of Obesity, 2015.
3. van den Berg, J. J., Bock, B., Roberts, M. B., Stein, L. A., Friedmann, P. D., Martin, S. A., & Clarke, J. G. (2014). Cigarette smoking as an expression of independence and freedom among inmates in a tobacco-free prison in the United States. nicotine & tobacco research, 16(2), 238-242.