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

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• 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?

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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

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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

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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?

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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

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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

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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

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0

5

10

15

20

25

30

35

40Mental Illnesses Across Older and Younger Inmates by Gender

Younger Females Younger Males Older Females

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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

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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

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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

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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.