A Correctional-Public Health Collaboration for Colorectal Cancer Screening in a State Prison System.

Correctional facilities provide health care to large numbers of medically underserved people. As such, preventive health in correctional settings is an important yet underused investment in public health. Because they often have histories of poor access to health care, the justice-involved population is more likely than the general population to be diagnosed with advanced-stage cancers. We report on the first 2 years of an ongoing collaboration between a state correctional system and state health department to implement annual colorectal cancer screening for sentenced people using fecal immunochemical testing (FIT). Preparation for the annual iterations begins in January, and patient engagement begins in March. In the first year of implementation (2018), 1396 of 1856 (75.2%) sentenced people completed an eligibility screen, and 254 of 321 (79.1%) eligible patients completed a FIT (eligible patients were aged ≥50 [≥45 if Black] in year 1 [lowered to ≥45 in year 2] and reported no previous relevant medical or family history of colorectal cancer); 54 (21.3%) completed FITs were positive. Of the 54 patients with positive FITS, 33 (61.1%) completed follow-up colonoscopies resulting in the identification of polyps in 26 (48.1%) patients with a positive FIT. We found invasive adenocarcinoma for 2 (3.7%) of the positive FITs (6.1% of colonoscopies performed). In the second year (2019), after a conversion from paper to tablet-based eligibility screening, 1707 of 2059 (82.9%) sentenced people completed an eligibility screen, and 200 of 285 (70.2%) eligible patients completed a FIT, 27 (13.5%) of whom had a positive result. We share lessons learned about implementing mass screening to encourage further communication among departments of health and corrections to advance preventive health.

Bringing Personality Into the Public Health Conversation: Evidence From a Correctional Population.

Incarceration provides an opportunity for public health interventions, but communication and the delivery of services are complicated by considerable variability even within this generally high-needs population. Public health practitioners have relied heavily on social determinants of health data in their work, but this does not fully explain key patterns in responses and success. Psychometric work related to the "big five" or "five-factor" personality domains may provide important additional guidance to health communications and interventions. The Contraceptive Awareness and Reproductive Education clinical trial provided health risk factor and personality data on 257 incarcerated women aged 18-35. Of the study population, 85.9% reported at least one of the five forms of childhood trauma. Three of the five personality domains were associated with multiple health risk factors and four of the five were associated with fair or poor general health. Personality data provide important guidance in understanding variability in responses to public health interventions in the correctional setting.

Diabetes Quality of Care and Maintenance in New England: Can Cross-State Collaboration Move Us Forward?

INTRODUCTION: State efforts to identify subpopulations at higher risk for inadequate diabetes maintenance are sometimes hampered by small sample size. We provide a model of a cross-state collaboration that might provide the foundation for identifying political and economic forces underlying inter- and intra-state variability in chronic disease care. METHODS: We collected Behavioral Risk Factor Surveillance System data directly from 5 of 6 New England states and ran multivariate logistic regressions on 5 exposures: race/ethnicity, federal poverty level (FPL) bracket, insurance status (yes or no), insurance type (public or private), and state of residence. Our sample consisted of adults aged 35 or older diagnosed with diabetes. Outcomes included whether respondents with diabetes received complete annual diabetes care (≥2 hemoglobin A1c tests, eye examination, foot examination), had ever taken a diabetes self-management class, or reported diabetes-related retinopathy. RESULTS: Half (50.4%) of our sample had incomplete annual diabetes care. In multivariate logistic regressions, race/ethnicity and FPL bracket were not major drivers of outcomes, although Hispanic/Latino adults had significantly higher risk than non-Hispanic white adults of not knowing how many hemoglobin A1c tests they had had in the past year or what such a test is (adjusted odds ratio = 2.74 [95% confidence interval, 1.15-6.56]) and of diabetes-related retinopathy (adjusted odds ratio = 3.13 [95% confidence interval, 1.61-6.10]). With few exceptions, higher FPL bracket, insurance status, insurance type, and state of residence were not associated with diabetes maintenance. CONCLUSION: Inadequate annual diabetes care among adults with diagnosed diabetes was endemic even in this relatively advantaged US census division, and traditional disparities (eg, race/ethnicity, FPL bracket) only partially explained patterns in diabetes maintenance activities. Interstate analyses can create the foundation for active partnerships to identify and address the causes of lapses in care.

Calculating State-Level Estimates of Upcoming Older Adult Health Needs.

OBJECTIVES: Census demographers have provided projections of the increased numbers of older adults in upcoming decades, but it is less clear whether they will also be any more or less healthy than current seniors. This is critical information for state planners, as the majority of older adults will need assistance with activities of daily living to remain in their homes. Previous longitudinal and cohort studies have yielded national estimates, but those more costly sources are generally beyond the resources of state public health agencies. We provide a more practicable model for assessing state-level changes in health-related quality of life (HRQOL) among middle-aged versus older adults as a guide to probable upcoming home- and community-based service needs. METHODS: We used 2 sets of state Behavioral Risk Factor Surveillance System data 15 years apart to calculate and compare adjusted odds ratios of 8 poor HRQOL measures for middle-aged and older adults. RESULTS: Compared with their peers only 15 years earlier, recent middle-aged adults had higher odds of poor outcomes across all HRQOL measures, whereas adults 65-74 years had higher odds of poor outcomes for far fewer of the measures. Among adults 75 years and older, odds were higher compared with 15 years ago for only 1 measure (multiple days of poor mental health). CONCLUSIONS: Compared with older adults, the health profile of middle-aged adults in this state appears to have worsened much more rapidly in the past 15 years, indicating that these adults will have many more health-related needs when they become seniors. While this model is less sophisticated than others using longitudinal data, it provides the state-level data that are often more compelling to state policy makers.

State-Level Surveillance of Underinsurance and Health Care-Related Financial Burden.

BACKGROUND: The Affordable Care Act (ACA) has reduced uninsurance, but underinsurance, health care-related financial burden, and dental uninsurance may not follow suit. Underinsurance is associated with reduced access to care, household debt, and bankruptcy but has been difficult to track without economic data. METHODS: We used readily available state-level survey data to build a model that states can adopt to implement surveillance over underinsurance and health care-related financial burden, as well as assess related disparities and health profiles. RESULTS: The state prevalence of underinsurance and dental uninsurance did not change in the first year of the ACA's individual mandate. Underinsurance was associated with poorer health-related quality-of-life measures: compared with the fully insured, underinsured adults had an adjusted odds ratio of 2.40 (95% CI, 1.71-3.38) of fair or poor general health. CONCLUSION: Tracking underinsurance and medical debt can help public health and health care access stakeholders evaluate which mechanisms (deductibles, co-pays, uncovered services, or is proportionately priced health care services and products) are barriers to care and improved health outcomes.

Diabetes and BMI: Health Equity through Early Intervention on Dysglycemia, and How Providers Can Help.

Like most states in the U.S., Rhode Island's rate of type 2 Diabetes Mellitus (DM) is rising as its population has both aged and become heavier. Risk of both BMI>=30 and DM has risen across almost all demographics, but disparities continue to exist in both conditions. We analyzed state health survey data to assess race/ethnicity-stratified DM and BMI and the age-adjusted rate of DM by weight status relative to the late 1990s. The prevalence of obesity increased across almost all demographic groups relative to 15 years ago, but the rise was greatest among non-Hispanic whites. The age-adjusted rate of DM had a similar increase across racial/ethnic categories where BMI>=30, but black adults were still at higher risk of DM even at a BMI<30. In sum, non-Hispanic whites and Hispanics are "catching up" to blacks' historically higher prevalence of obesity and DM, but disparities remain in both conditions. We describe two ways providers can collaborate with the Department of Health to address these growing health problems. [Full article available at http://rimed.org/rimedicaljournal-2016-11.asp].

A systematic review and meta-analysis of racial and ethnic disparities in hepatitis C antibody prevalence in United States correctional populations.

PURPOSE: Hepatitis C virus (HCV) is highly prevalent among correctional populations. We aimed to explore racial and ethnic disparities in hepatitis C antibody (anti-HCV) prevalence in U.S. correctional populations. METHODS: We systematically searched the literature for reports of anti-HCV prevalence among U.S. jail and prison populations, by race and ethnicity. We calculated summary prevalence estimates for non-Hispanic White, non-Hispanic Black, Hispanic, and "Other" race/ethnicity jail detainees and prisoners and determined the proportion of anti-HCV positive persons from racial/ethnic minority backgrounds. RESULTS: Few studies reported anti-HCV prevalence data by race and ethnicity, and they suffered from methodologic weaknesses. Anti-HCV prevalence was highest among non-Hispanic Whites (35% [95% CI: 28%, 43%; k = 9], compared to 26% [95% CI: 21%, 32%; k = 10] among racial and ethnic minorities). However, the majority (63%) of persons with anti-HCV were from racial and ethnic minority backgrounds. CONCLUSIONS: Racial and ethnic minority persons appear to comprise the majority of HCV burden in U.S. correctional settings. Universal screening and treatment of HCV infection in correctional settings may impact on community-level health disparities.

Incarceration and perinatal smoking: a missed public health opportunity.

BACKGROUND: Incarceration is simultaneously a public health opportunity and a public health concern. We examined the association between maternal/partner incarceration in the year prior to birth and perinatal smoking. METHODS: We pooled 2006-2010 data from the Centers for Disease Control and Prevention's Pregnancy Risk Assessment and Monitoring System. Controlling for age, race/ethnicity, education, marital status and other stressors, we assessed prevalence and heaviness of perinatal smoking. FINDINGS: Women who reported incarceration of themselves or their partners in the year prior to delivery were more likely to smoke during the last trimester of pregnancy (adjusted OR (AOR) 1.51 (95% CI 1.36 to 1.67)), and they were more likely to smoke more than 10 cigarettes a day compared to smokers who did not report incarceration (AOR 1.35 (95% CI 1.10 to 1.65)). Patterns were similar for the 3 months prior to pregnancy and postbirth smoking. CONCLUSIONS: Incarceration of a parent in the 12 months before birth is associated with increased risk of fetal and newborn exposure to smoking. The criminal justice system can be utilised by public health practitioners to target perinatal smoking reduction interventions.

A latent class model to identify city/town chronic disease patterns.

OBJECTIVE: Most departments of health grapple with how to most effectively allocate resources to address chronic diseases. We adapted a model created by Massachusetts to create customized city/town profiles in order to identify the patterns of chronic disease among 39 cities/towns in Rhode Island. METHODS: We used four data sources to identify 20 indicators of four domains: demographics and socioeconomic status; health behaviors and chronic diseases prevalence; no regular provider and non-emergent emergency department visits; and chronic disease-related hospitalizations. A latent class model was used to group cities/towns into distinct latent class memberships based on similar patterns of indicators. Data were analyzed in 2014. RESULTS: The latent class model differentiated three distinct classes of city/town, reflecting three levels of economic and health indicators. CONCLUSIONS: Our model was a simplified version of one constructed by Massachusetts that larger states can also use to understand chronic disease patterns among cities/towns. Chronic disease programs and policies can use the findings to direct resources toward targets not always identified by more traditional analyses.

Adverse childhood events: incarceration of household members and health-related quality of life in adulthood.

BACKGROUND: Incarceration of a household member has been associated with adverse outcomes for child well-being. METHODS: We assessed the association between childhood exposure to the incarceration of a household member and adult health-related quality of life (HRQOL) in the 2009/2010 Behavioral Risk Factor Surveillance System controlling for age, race/ethnicity, education, and additional adverse childhood experiences. RESULTS: Adults who lived in childhood with an incarcerated household member had higher risk of poor HRQOL compared with adults who had not (adjusted relative risk [ARR] 1.18; 95% CI 1.07, 1.31). Among Black adults the association was strongest with the physical health component of HRQOL (ARR 1.58 [95% CI 1.18, 2.12]); among White adults, the association was strongest with the mental health component of HRQOL (ARR 1.29, [95% CI 1.07-1.54]). CONCLUSIONS: Living with an incarcerated household member during childhood is associated with higher risk of poor HRQOL during adulthood, suggesting that the collateral damages of incarceration for children are long-term.

Incarceration, maternal hardship, and perinatal health behaviors.

Parental incarceration is associated with mental and physical health problems in children, yet little research directly tests mechanisms through which parental incarceration could imperil child health. We hypothesized that the incarceration of a woman or her romantic partner in the year before birth constituted an additional hardship for already-disadvantaged women, and that these additionally vulnerable women were less likely to engage in positive perinatal health behaviors important to infant and early childhood development. We analyzed 2006-2010 data from the Pregnancy Risk Assessment and Monitoring System to assess the association between incarceration in the year prior to the birth of a child and perinatal maternal hardships and behaviors. Women reporting incarceration of themselves or their partners in the year before birth of a child had .86 the odds (95 % CI .78-.95) of beginning prenatal care in the first trimester compared to women not reporting incarceration. They were nearly twice as likely to report partner abuse and were significantly more likely to rely on WIC and/or Medicaid for assistance during pregnancy. These associations persist after controlling for socioeconomic measures and other stressors, including homelessness and job loss. Incarceration of a woman or her partner in the year before birth is associated with higher odds of maternal hardship and poorer perinatal health behaviors. The unprecedented scale of incarceration in the US simultaneously presents an underutilized public health opportunity and constitutes a social determinant of health that may contribute to disparities in early childhood development.

"They are not taking cigarettes from me . . . I'm going to smoke my cigarettes until the day I die. I don't care if I get cancer": smoking behaviors of men under community supervision in New York City.

INTRODUCTION: Cigarette smoking declined from 42.4% in 1965 to 19.3% in 2010 among the general population, but it remains the leading cause of preventable death and illness in the United States, especially among high-risk populations, including those with criminal justice involvement. METHODS: A mixed-methods approach was used to investigate the smoking behaviors of men under parole or probation. Phase I focused on qualitative data of 30 semi-structured interviews of men who were recently released from a state prison and/or jail. Phase II analyzed quantitative data resulting from a study that examined smoking characteristics and treatment approaches of 259 participants, 197 of whom were cigarette smokers. RESULTS: The survey participants' age of tobacco initiation ranged from 7 to 45 years of age. Participants smoked between 1 and 40 cigarettes per day; the mean number of cigarettes smoked per day was 10.37. Men released from prison used cigarettes for more years on average than men released from jail (t[194] = -2.22, p < .05). A linear regression procedure revealed that the influence of friends and family significantly predicted smoking behavior (ß = .25, p < .0001). The qualitative data revealed the following themes: unintended consequences of the prison smoking ban, smoking as anxiety management, smoking cigarettes as part of a daily routine, and barriers to quitting. CONCLUSIONS: Given the rapid growth of individuals under community supervision, public health and policy makers are missing an opportunity to develop strategies that promote smoking cessation treatments, especially among men who are serving parole or probation and during the incarceration period itself.

Medicaid policies and practices in US state prison systems.

Medicaid is an important source of health care coverage for prison-involved populations. From 2011 to 2012, we surveyed state prison system (SPS) policies affecting Medicaid enrollment during incarceration and upon release; 42 of 50 SPSs participated. Upon incarceration, Medicaid benefits were suspended in 9 (21.4%) SPSs and terminated in 28 (66.7%); 27 (64.3%) SPSs screened prisoners for potential Medicaid eligibility. Although many states supported Medicaid enrollment upon release, several did not. We have considered implications for Medicaid expansion.

Incarceration of a household member and Hispanic health disparities: childhood exposure and adult chronic disease risk behaviors.

INTRODUCTION: Incarceration of a household member has been linked to poor mental and behavioral health outcomes in children, but less is known about the health behaviors of these children once they reach adulthood. METHODS: We analyzed data from 81,910 respondents to the 2009-2010 Behavioral Risk Factor Surveillance System to identify associations between the childhood experience of having a household member incarcerated and adult smoking status, weight status, physical activity, and drinking patterns. We used multivariable logistic regression to control for sex, age, education, and additional adverse childhood events in the whole population and in separate models for Hispanic, non-Hispanic white, and non-Hispanic black adults. We also assessed for having multiple risk behaviors. RESULTS: People who lived with an incarcerated household member during childhood were more likely as adults than those who did not to engage in smoking (adjusted odds ratio [AOR] 1.50; 95% confidence interval [CI], 1.27-1.77) and heavy drinking (AOR 1.39; 95% CI, 1.03-1.87), after controlling for demographics and additional adverse childhood events. Exposure to incarceration in the household as a child among Hispanic adults was associated with being a smoker, being a heavy drinker, and having multiple risk behaviors and among white adults was associated with being a smoker and having multiple risk behaviors; among black adults there were no significant associations. CONCLUSION: Incarceration of a household member during childhood is associated with adult risk behaviors, and race/ethnicity may be a factor in this association.

Incarceration, community health, and racial disparities.

Several recent studies have shown that the racial disparities in U.S. mortality nearly disappear in prisons. We review the social determinants of the recent epidemic of incarceration, especially the war on drugs, and describe inmate morbidity and mortality within the context of U.S. health disparities. Incarceration provides an important public health opportunity to address health disparities by accessing a high-need, medically-underserved, largely non-White population, but it has also been associated with poor long-term health outcomes. Viewing incarceration within the context of community health and community life shows that the more equitable mortality rates among inmates are not evidence of the beneficial effects of incarceration so much as an indictment of disparities in the community at large. Because people of color are incarcerated far more frequently than Whites, the experience may ultimately exacerbate rather than mitigate health disparities.