A Heavy Burden: The Cardiovascular Health Consequences of Having a Family Member Incarcerated

Objectives. We examined the association of family member incarceration with cardiovascular risk factors and disease by gender.Methods. We used a sample of 5470 adults aged 18 years and older in the National Survey of American Life, a 2001–2003 nationally representative cross-sectional survey of Blacks and Whites living in the United States, to examine 5 self-reported health conditions (diabetes, hypertension, heart attack or stroke, obesity, and fair or poor health).Results. Family member incarceration was associated with increased likelihood of poor health across all 5 conditions for women but not for men. In adjusted models, women with family members who were currently incarcerated had 1.44 (95% confidence interval [CI] = 1.03, 2.00), 2.53 (95% CI = 1.80, 3.55), and 1.93 (95% CI = 1.45, 2.58) times the odds of being obese, having had a heart attack or stroke, and being in fair or poor health, respectively.Conclusions. Family member incarceration has profound implications for women’s cardiovascular health and should be considered a unique risk factor that contributes to racial disparities in health.Over the course of the prison boom, imprisonment has become a common event in the life course for Black men,1 especially those with low levels of education2 who reside in poor neighborhoods,3 and their families.4 Although there is no official figure for women who have a family member imprisoned, it has been estimated that as many as 3 million women annually have an incarcerated partner.5 This is likely a conservative estimate because it includes neither inmates who have multiple concurrent relationships nor other women affected by male incarceration, such as mothers, sisters, and adult children. Because 60% to 70% of Black men who did not complete high school will experience imprisonment by their early 30s,2,4 poor, minority women disproportionately experience family member imprisonment. Yet the only research that has considered the impact of male incarceration on the health of these women has focused on mental rather than physical health.6,7 This is a surprising omission because much research examines the physical and mental health consequences of imprisonment for men8–15 as well as their communities16,17 and children.18,19This oversight is problematic for 2 reasons. First, because the experience of incarceration is concentrated among men, incarceration’s indirect consequences on women’s health—transmitted through the incarceration of a family member—are likely more relevant for health among women than are their own experiences of incarceration at the aggregate level. Because the lifetime risks of imprisonment for Black men2 and paternal imprisonment for Black children20 hover around 20% to 25%, whereas risks of maternal imprisonment for Black children barely exceed 3%, mass incarceration’s indirect effects on health inequalities among women are likely larger than its direct effects. In other words, because women are at least 5 times more likely to have a family member incarcerated than to be incarcerated themselves, the effects of their own incarceration would have to dwarf the effects of having a family member incarcerated to have the same aggregate effect. Likewise, as the cumulative risks of paternal and maternal imprisonment for White children—at 3.3% and 0.6%, respectively—are far lower than are risks for Black children, the consequences are likely much more pronounced for the Black community.20Second, there is a host of reasons to expect the incarceration of a family member to harm women’s physical health beyond increasing their risk of contracting sexually transmitted disease.16,17 Indeed, exposure to family member imprisonment may compromise the physical health, particularly cardiovascular disease–related health outcomes, of women via (1) lowered socioeconomic status and family functioning, (2) reduced social support, and (3) higher levels of chronic stress.21 The incarceration of a family member brings with it not only increases in household expenses22–24 but also substantial decreases in household income25 and increases in material hardship.26 Furthermore, the incarceration of a family member often dramatically increases the stress and social isolation women feel as they struggle to deal with their family member’s absence.22,23,27 The preponderance of research suggests that because of the independent and negative effects of low socioeconomic status, chronic stress, and social isolation on health, the incarceration of a family member may contribute to a novel form of weathering—the early health deterioration of Blacks as a consequence of the accumulation of repeated experience with social and economic adversity28,29—among disadvantaged Black women (Lee and Wildeman21 provide a detailed discussion).We hypothesized that family member incarceration would be positively associated with cardiovascular disease and related risk factors among women but not men. Women shoulder the burden of childcare and household management and maintain connections to their imprisoned male family members or romantic partners.21 In addition, women are more likely to engage in overeating and sedentary behaviors as coping behaviors for stress than are men.30,31 Family member incarceration may lead to racial disparities in physical health among women because of the disproportionate experiences of this stressful life event among Black women.Using data from the National Survey of American Life (NSAL), we tested whether having a family member incarcerated is a distinct stressor that has consequences for cardiovascular risk factors and disease among women and men.     

A Systematic Review of Randomized Controlled Trials of Interventions to Improve the Health of Persons During Imprisonment and in the Year After Release

We systematically reviewed randomized controlled trials of interventions to improve the health of people during imprisonment or in the year after release. We searched 14 biomedical and social science databases in 2014, and identified 95 studies.Most studies involved only men or a majority of men (70/83 studies in which gender was specified); only 16 studies focused on adolescents. Most studies were conducted in the United States (n = 57). The risk of bias for outcomes in almost all studies was unclear or high (n = 91). In 59 studies, interventions led to improved mental health, substance use, infectious diseases, or health service utilization outcomes; in 42 of these studies, outcomes were measured in the community after release.Improving the health of people who experience imprisonment requires knowledge generation and knowledge translation, including implementation of effective interventions.Worldwide, more than 11 million people are imprisoned at any given time, and the prison population continues to grow at a rate faster than that of the general population.1 Substantial evidence reveals that people who have experienced imprisonment have poor health compared with the general population, as indicated by the prevalence of mental illness, infectious diseases, chronic diseases, and mortality.2There are several reasons to focus on improving the health of people who experience imprisonment.3 The burden of disease in this population affects the general population directly through increased health care costs and through the transmission of communicable diseases (e.g., HIV, HCV, and tuberculosis) after people are released from detention. Imprisonment has also been associated with worse health in family members of those who are detained, compared with the general population, including chronic diseases4 and poor mental health5,6 in adult relatives and mortality in male children.7 At the community level, higher rates of incarceration have been associated with adverse health outcomes, such as sexually transmitted infections and teen pregnancies.8 There is also evidence that poor health in persons who are released from detention, particularly those with inadequately treated mental illness and substance use disorders,3 may affect public safety and reincarceration rates,3 and that better access to health care is associated with less recidivism.9,10 Finally, the right to health and health care is enshrined in international human rights documents,11,12 and is a legislated responsibility of governments in many countries.Intervening during imprisonment and at the time of release could improve the health of people who experience imprisonment and public health overall.13 Knowledge translation efforts, such as syntheses of effective interventions, could lead to the implementation and further evaluation of interventions,14 and identify areas where further research is needed. To date, only syntheses with a limited focus have been conducted in this population, for example, reviews of interventions related to HIV15 or for persons with serious mental illness.16 Decision makers, practitioners, and researchers in this field would benefit from a broader understanding of the state of evidence regarding interventions to improve health in people who experience imprisonment.To address this gap, we systematically reviewed randomized controlled trials of interventions to improve health in persons during imprisonment and in the year after release. We chose this population because we view imprisonment as a unique opportunity to deliver and to link with interventions for this population, and to highlight interventions that could be implemented by those responsible for the administration of correctional facilities. We limited this study to randomized controlled trials, recognizing that randomized controlled trials provide the highest quality of evidence compared with other study designs.17     

Self-Reported Health Among Recently Incarcerated Mothers

Objectives. We examined self-reported health among formerly incarcerated mothers.Methods. We used data from the Fragile Families and Child Wellbeing Study (n = 4096), a longitudinal survey of mostly unmarried parents in urban areas, to estimate the association between recent incarceration (measured as any incarceration in the past 4 years) and 5 self-reported health conditions (depression, illicit drug use, heavy drinking, fair or poor health, and health limitations), net of covariates including health before incarceration.Results. In adjusted logistic regression models, recently incarcerated mothers, compared with their counterparts, have an increased likelihood of depression (odds ratio [OR] = 1.60; 95% confidence interval [CI] = 1.18, 2.17), heavy drinking (OR = 1.79; 95% CI = 1.19, 2.68), fair or poor health (OR = 1.49; 95% CI = 1.08, 2.06), and health limitations (OR = 1.78; 95% CI = 1.27, 2.50). This association is similar across racial/ethnic subgroups and is larger among mothers who share children with fathers who have not been recently incarcerated.Conclusions. Recently incarcerated mothers struggle with even more health conditions than expected given the disadvantages they experience before incarceration. Furthermore, because incarceration is concentrated among those who are most disadvantaged, incarceration may increase inequalities in population health.The US incarceration rate, though recently stabilized, has increased rapidly over the past 4 decades. Accordingly, researchers have become acutely aware of the sheer number of individuals who experience incarceration and the vulnerabilities these individuals face before, during, and after incarceration.1 In particular, a growing literature has documented the consequences of mass incarceration, defined as the historically and comparatively extreme rates of incarceration in the United States, for population health.2–5 Formerly incarcerated individuals, compared with their counterparts, have elevated rates of mortality,6 infectious diseases,7 cardiovascular diseases,8 and disability,9 as well as an array of mental health problems including depression,10 anxiety,9 and life dissatisfaction.11Despite the fact that, since the early 1980s, women’s incarceration rates have increased faster than men’s incarceration rates,12,13 very little research has explicitly considered the health of formerly incarcerated women. Instead, research on incarcerated women often focuses on the consequences of incarceration for their families and children.14–19 The dearth of research on formerly incarcerated women’s health is an important oversight because these women are an extremely vulnerable population and present a pressing public health concern. Formerly incarcerated mothers are an especially important group because poor physical and mental health among mothers may have deleterious consequences for their children.20–23We used data from the Fragile Families and Child Wellbeing Study, a longitudinal study of mostly unmarried parents living in urban areas, to provide the first examination of the relationship between recent incarceration, measured as any incarceration experience in the past 4 years, and 5 self-reported health conditions among mothers: depression, illicit drug use, heavy drinking, fair or poor health, and health limitations. First, we estimated the association between recent incarceration and self-reported health. We then estimated this association by race/ethnicity and by romantic partner’s incarceration history. Our analyses adjusted for a large number of individual characteristics that may render the association between recent incarceration and health conditions spurious (including health before incarceration). Adjusting for these characteristics is especially important because incarcerated mothers are at risk for poor physical and mental health before incarceration.5,24–26     

All-Cause and External Mortality in Released Prisoners: Systematic Review and Meta-Analysis

Objectives. We systematically reviewed studies of mortality following release from prison and examined possible demographic and methodological factors associated with variation in mortality rates.Methods. We searched 5 computer-based literature indexes to conduct a systematic review of studies that reported all-cause, drug-related, suicide, and homicide deaths of released prisoners. We extracted and meta-analyzed crude death rates and standardized mortality ratios by age, gender, and race/ethnicity, where reported.Results. Eighteen cohorts met review criteria reporting 26 163 deaths with substantial heterogeneity in rates. The all-cause crude death rates ranged from 720 to 2054 per 100 000 person-years. Male all-cause standardized mortality ratios ranged from 1.0 to 9.4 and female standardized mortality ratios from 2.6 to 41.3. There were higher standardized mortality ratios in White, female, and younger prisoners.Conclusions. Released prisoners are at increased risk for death following release from prison, particularly in the early period. Aftercare planning for released prisoners could potentially have a large public health impact, and further work is needed to determine whether certain groups should be targeted as part of strategies to reduce mortality.The global prison population in 2008 was estimated at 9.8 million with a median rate of imprisonment of 145 prisoners per 100 000 persons, most of whom are aged between 18 and 44 years.1 More than 2.3 million of these prisoners reside in the United States, which has the highest rate of imprisonment of 756 per 100 000 population. Natural cause mortality inside prison has been reported to be lower than that of the general population in France,2 Russia,3 England and Wales,4 and the United States.5 However, it is well-established that prisoner suicide rates are elevated compared with age-matched general populations.6 For example, the suicide rate of male prisoners in England and Wales between 1973 and 2003 was found to be 5 times higher than that of the general population,7 and in US jails, it has been reported to be 8 times higher.8 The odds of chronic medical conditions are increased by up to 4 times in US prisons.9 As prison populations are drawn from socioeconomically deprived backgrounds with reduced access to health care and health-seeking behavior when living in the community,10 prison provides an opportunity to provide public health interventions including health education and improving engagement with health services following release.11 For example, targeted health interventions such as medication review12 and HIV health education13,14 have been proposed.The health of prisoners following release from prison is less understood. At the end of 2009 in the United States, 819 308 prisoners were on parole or release following a prison term,15 and in England and Wales 20 895 offenders were released from prison in the first quarter of 2011.16 Despite these high absolute numbers, research has demonstrated that most sampled US jails did not plan for release of prisoners with mental illness, cardiovascular disease, or HIV/AIDS even though they considered it important.17 Mortality from suicide and drug-related causes has been reported to be particularly high in the immediate postrelease period,18,19 and, thus, public health interventions to target this period for those with a history of substance misuse have been outlined.20 The current review aims to synthesize evidence on mortality rates following release from prison and examine possible demographic and methodological factors associated with variation in these rates.     

Health status, neighborhood socioeconomic context, and premature mortality in the United States: The National Institutes of Health-AARP Diet and Health Study

Objectives. We examined whether the risk of premature mortality associated with living in socioeconomically deprived neighborhoods varies according to the health status of individuals.Methods. Community-dwelling adults (n = 566 402; age = 50–71 years) in 6 US states and 2 metropolitan areas participated in the ongoing prospective National Institutes of Health–AARP Diet and Health Study, which began in 1995. We used baseline data for 565 679 participants on health behaviors, self-rated health status, and medical history, collected by mailed questionnaires. Participants were linked to 2000 census data for an index of census tract socioeconomic deprivation. The main outcome was all-cause mortality ascertained through 2006.Results. In adjusted survival analyses of persons in good-to-excellent health at baseline, risk of mortality increased with increasing levels of census tract socioeconomic deprivation. Neighborhood socioeconomic mortality disparities among persons in fair-to-poor health were not statistically significant after adjustment for demographic characteristics, educational achievement, lifestyle, and medical conditions.Conclusions. Neighborhood socioeconomic inequalities lead to large disparities in risk of premature mortality among healthy US adults but not among those in poor health.Research dating back to at least the 1920s has shown that the United States has experienced persistent and widening socioeconomic disparities in premature mortality over time.^1–5 However, it has been unclear whether socioeconomic inequalities affect the longevity of persons in good and poor health equally. Socioeconomic status (SES) and health status are interrelated,^6–8 and both are strong independent predictors of mortality.⁹ Low SES is associated with greater risk of ill health and premature death,^{1–5,8,10–13} partly attributable to disproportionately high prevalence of unhealthful lifestyle practices^10,14,15 and physical and mental health conditions.^13,16 Correspondingly, risk of premature mortality is higher in poor than in more affluent areas.^16,17 Although the association between neighborhood poverty and mortality is independent of individual-level SES,^17,18 aggregation of low-SES populations in poor areas may contribute to variations in health outcomes across neighborhoods. Conversely, economic hardships resulting from ill health may lead persons in poor physical or mental health to move to poor neighborhoods.¹⁹ This interrelatedness may create spurious associations between neighborhood poverty and mortality.Although previous studies have found that the risk of premature death associated with poor health status varies according to individuals'' SES,^20,21 no published studies have examined whether the relative risks for premature mortality associated with living in neighborhoods with higher levels of socioeconomic deprivation vary by health status of individuals. Clarifying these relationships will inform social and public health policies and programs that aim to mitigate the health consequences of neighborhood poverty.^22,23We used data from a large prospective study to examine whether the risk of premature mortality associated with neighborhood socioeconomic context differs according to health status at baseline and remains after adjustment for person-level risk factors for mortality, such as SES, lifestyle practices, and chronic medical illnesses.     

Neighborhood Incarceration Rate and Asthma Prevalence in New York City: A Multilevel Approach

Objectives. We examined the association between neighborhood incarceration rate and asthma prevalence and morbidity among New York City adults.Methods. We used multilevel modeling techniques and data from the New York City Community Health Survey (2004) to analyze the association between neighborhood incarceration rate and asthma prevalence, adjusting for individual-level sociodemographic, behavioral, and environmental characteristics. We examined interactions between neighborhood incarceration rate, respondent incarceration history, and race/ethnicity.Results. The mean neighborhood rate of incarceration was 5.4% (range = 2.1%–12.8%). Neighborhood incarceration rate was associated with individual-level asthma prevalence (odds ratio [OR] = 1.06; 95% confidence interval [CI] = 1.03, 1.10) in unadjusted models but not after adjustment for sociodemographic characteristics (OR = 1.01; 95% CI = 0.98, 1.04). This association did not differ according to respondent race/ethnicity.Conclusions. Among New York City adults, the association between neighborhood incarceration rate and asthma prevalence is explained by the sociodemographic composition of neighborhoods and disparities in asthma prevalence at the individual level. Public health practitioners should further engage with criminal justice professionals and correctional health care providers to target asthma outreach efforts toward both correctional facilities and neighborhoods with high rates of incarceration.In the United States, asthma disproportionately affects non-White individuals living in urban areas and living in poverty.1 Because low socioeconomic status (SES) and racial/ethnic minority group status are closely intertwined with residence in an inner-city environment, characteristics of these inner-city neighborhoods have received much attention in the effort to explain patterns of asthma prevalence and morbidity.2,3 Epidemiological studies have highlighted the influence of poor housing, which may increase exposure to indoor allergens such as rat droppings4; greater likelihood of tobacco smoke exposure5; and overcrowding, which may predispose people to viral respiratory illness.2Because features of the physical environment do not completely explain observed patterns in asthma prevalence, features of the social environment have emerged as important asthma risk factors.6 Observational studies have demonstrated the association between asthma, psychological stress, and exposure to violent neighborhoods.7–9 For example, exposure to violence may influence an individual’s impulse control and risk-taking behavior, resulting in the adoption of coping behaviors, such as smoking, a known trigger for asthma.8–10 Psychological stress may be further compounded by the presence of overburdened or absent social supports and a perceived lack of control over one’s self or environment.6,11 Neighborhood-level constructs such as social capital and social cohesion have been linked to important health outcomes and may have an impact on asthma prevalence.12A natural but overlooked extension of this work is the potential impact of the criminal justice system on communities. Incarceration has a disproportionate impact on poor communities of color and has been linked to increased rates of asthma at the level of the individual.13–15 In addition to the effects on the individuals directly involved with the criminal justice system, neighborhood incarceration rates may play a role in shaping the social environment and thereby affect asthma prevalence. Exposure to high rates of neighborhood violence and crime often accompany exposure to incarceration. Recidivism and the risks of community reentry may further exacerbate this exposure.16 Incarceration has been shown to lead to long-term psychological stress for those affected17,18 and holds significant consequences for their families, creating further stress by removing social supports and weakening families.19 Individuals released from prison face legal barriers to employment, housing, public entitlements, and educational opportunities and various restrictions on political and social rights,20,21 further diminishing the social capital of their communities.Therefore, we sought to examine the association between neighborhood-level incarceration rates and several individual-level asthma outcomes. We hypothesized that increased neighborhood incarceration rates would be associated with increased asthma prevalence. Additionally, we proposed that increased neighborhood incarceration rates would be associated with increased asthma morbidity. We specifically examined factors potentially correlated with both neighborhood incarceration rate and asthma prevalence, such as SES, smoking, and poor housing conditions.     

Posttraumatic Stress Disorder and Incident Heart Failure Among a Community-Based Sample of US Veterans

Objectives. We investigated the association between posttraumatic stress disorder (PTSD) and incident heart failure in a community-based sample of veterans.Methods. We examined Veterans Affairs Pacific Islands Health Care System outpatient medical records for 8248 veterans between 2005 and 2012. We used multivariable Cox regression to estimate hazard ratios and 95% confidence intervals for the development of heart failure by PTSD status.Results. Over a mean follow-up of 7.2 years, veterans with PTSD were at increased risk for developing heart failure (hazard ratio [HR] = 1.47; 95% confidence interval [CI] = 1.13, 1.92) compared with veterans without PTSD after adjustment for age, gender, diabetes, hyperlipidemia, hypertension, body mass index, combat service, and military service period. Additional predictors for heart failure included age (HR = 1.05; 95% CI = 1.03, 1.07), diabetes (HR = 2.54; 95% CI = 2.02, 3.20), hypertension (HR = 1.87; 95% CI = 1.42, 2.46), overweight (HR = 1.72; 95% CI = 1.25, 2.36), obesity (HR = 3.43; 95% CI = 2.50, 4.70), and combat service (HR = 4.99; 95% CI = 1.29, 19.38).Conclusions. Ours is the first large-scale longitudinal study to report an association between PTSD and incident heart failure in an outpatient sample of US veterans. Prevention and treatment efforts for heart failure and its associated risk factors should be expanded among US veterans with PTSD.Posttraumatic stress disorder (PTSD) is a psychiatric illness that affects approximately 7.7 million Americans aged older than 18 years.1 PTSD typically results after the experience of severe trauma, and veterans are at elevated risk for the disorder. The National Vietnam Veterans Readjustment Study reported the prevalence of PTSD among veterans who served in Vietnam as 15.2% among men and 8.1% among women.2 In fiscal year 2009, nearly 446 045 Veterans Administration (VA) patients had a primary diagnosis of PTSD, a threefold increase since 1999.3 PTSD is of growing clinical concern as evidence continues to link psychiatric illnesses to conditions such as arthritis,4 liver disease,5 digestive disease,6 and cancer.6 When the postwar health status of Vietnam veterans was examined, those with PTSD had higher rates of diseases of the circulatory, nervous, digestive, musculoskeletal, and respiratory systems.7The evidence linking PTSD to coronary heart disease (CHD) is substantial.8–10 Veterans with PTSD are significantly more likely to have abnormal electrocardiograph results, myocardial infarctions, and atrioventricular conduction deficits than are veterans without PTSD.11 In a study of 605 male veterans of World War II and the Korean War, CHD was more common among veterans with PTSD than among those without PTSD.12 Worldwide, adults exposed to the disaster at Chernobyl experienced increased rates of CHD up to 10 years after the event,13 and studies of stressors resulting from the civil war in Lebanon found elevated CHD mortality.14,15Although the exact biological mechanism by which PTSD contributes to CHD remains unclear, several hypotheses have been suggested, including autonomic nervous system dysfunction,16 inflammation,17 hypercoagulability,18 cardiac hyperreactivity,19 altered neurochemistry,20 and co-occurring metabolic syndrome.16 One of the hallmark symptoms of PTSD is hyperarousal,21 and the neurobiological changes brought on from sustained sympathetic nervous system activation affect the release of neurotransmitters and endocrine function.22 These changes have negative effects on the cardiovascular system, including increased blood pressure, heart rate, and cardiac output.22,23Most extant literature to date examining cardiovascular sequelae has shown a positive association between PTSD and coronary artery disease.8–10 Coronary artery disease is well documented as one of the most significant risk factors for future development of heart failure.24 Despite burgeoning evidence for the role of PTSD in the development of coronary artery disease, there are few studies specifically exploring the relationship between PTSD and heart failure. Limited data suggest that PTSD imparts roughly a threefold increase in the odds of developing heart failure in both the general population5 and in a sample of the elderly.25 These investigations, however, have been limited by cross-sectional study design, a small proportion of participants with PTSD, and reliance on self-reported measures for both PTSD and heart failure.5,25 Heart failure is a uniquely large public health issue, as nearly 5 million patients in the United States are affected and there are approximately 500 000 new cases each year.26 Identifying predictors of heart failure can aid in early detection efforts while simultaneously increasing understanding of the mechanism behind development of heart failure.To mitigate the limitations of previous investigations, we undertook a large-scale prospective study to further elucidate the role of prevalent PTSD and development of incident heart failure among veterans, while controlling for service-related and clinical covariates. Many studies investigating heart failure have relied on inpatient records; we leveraged outpatient records to more accurately reflect the community burden of disease.     

The Collateral Damage of Mass Incarceration: Risk of Psychiatric Morbidity Among Nonincarcerated Residents of High-Incarceration Neighborhoods

Objectives. We examined whether residence in neighborhoods with high levels of incarceration is associated with psychiatric morbidity among nonincarcerated community members.Methods. We linked zip code–linked information on neighborhood prison admissions rates to individual-level data on mental health from the Detroit Neighborhood Health Study (2008–2012), a prospective probability sample of predominantly Black individuals.Results. Controlling for individual- and neighborhood-level risk factors, individuals living in neighborhoods with high prison admission rates were more likely to meet criteria for a current (odds ratio [OR] = 2.9; 95% confidence interval [CI] = 1.7, 5.5) and lifetime (OR = 2.5; 95% CI = 1.4, 4.6) major depressive disorder across the 3 waves of follow-up as well as current (OR = 2.1; 95% CI = 1.0, 4.2) and lifetime (OR = 2.3; 95% CI = 1.2, 4.5) generalized anxiety disorder than were individuals living in neighborhoods with low prison admission rates. These relationships between neighborhood-level incarceration and mental health were comparable for individuals with and without a personal history of incarceration.Conclusions. Incarceration may exert collateral damage on the mental health of individuals living in high-incarceration neighborhoods, suggesting that the public mental health impact of mass incarceration extends beyond those who are incarcerated.The United States leads the world in the percentage of its population that serves time in prison or jail.1,2 As of 2012, nearly 7 million men and women are on probation, parole, or under some other form of community supervision, which means that nearly 3% of the American adult population is currently involved in correctional supervision.3 The burden of incarceration in the United States is not equally distributed in the population. Current estimates from the Bureau of Justice Statistics indicate that 1 of every 3 Black men will serve time in prison in their lifetimes.4 In some communities, these figures are even starker. In Washington, DC, for example, more than 95% of Black men have been in prison in their lifetimes.1 Because of the scope of incarceration within particular subgroups, the current state of the US criminal justice system has been described in such terms as mass imprisonment5 and hyperincarceration.6Research on the health consequences of incarceration falls largely into 2 broad categories. The first, which has received the most empirical attention, has focused on individuals directly involved in the criminal justice system. Individual incarceration exposure is associated with adverse mental7–9 and physical10 health outcomes. A second line of inquiry has evaluated the broader health consequences of incarceration—what has been variously called the “long arm” of corrections,11 the collateral consequences of mass incarceration,5 and “spillover” effects related to incarceration.12 For example, female partners of recently released male prisoners experience depression and anxiety symptoms,13,14 and the children of incarcerated parents are at increased risk for behavioral and mental health problems.15,16 The deleterious health effects of incarceration are not merely confined to the family members of incarcerated individuals, however. Nonincarcerated individuals living in the communities from which inmates are drawn also appear to be at heightened risk for a variety of adverse outcomes, including increased crime rates17 and infectious diseases.18Although this research provides important initial insights into some of the negative consequences of incarceration at the community level, it remains largely unknown whether incarceration influences the mental health of community members who reside in neighborhoods with high-incarceration rates. How might incarceration affect community mental health? High levels of incarceration in neighborhoods can alter the social ecology of communities by eroding social capital and disrupting the kinds of social and family networks and relationships that are necessary for sustaining individuals’ mental health as well as the well-being of communities.1,19–22We examined whether high levels of incarceration in neighborhoods affect the mental health of individuals living in these neighborhoods. We treated incarceration as an ecological or contextual effect, rather than as an individual-level risk factor, which has characterized the majority of research on incarceration and mental health.7,23 That is, rather than examining the mental health consequences of incarceration among those who have themselves been incarcerated or among their family members, we examined the mental health of individuals living in communities that have been exposed to elevated levels of incarceration.     

Meta-analysis of All-Cause Mortality According to Serum 25-Hydroxyvitamin D

We examined the relationship between serum 25-hydroxyvitamin D (25[OH]D) and all-cause mortality. We searched biomedical databases for articles that assessed 2 or more categories of 25(OH)D from January 1, 1966, to January 15, 2013. We identified 32 studies and pooled the data.The hazard ratio for all-cause mortality comparing the lowest (0–9 nanograms per milliliter [ng/mL]) to the highest (> 30 ng/mL) category of 25(OH)D was 1.9 (95% confidence interval = 1.6, 2.2; P < .001). Serum 25(OH)D concentrations less than or equal to 30 ng/mL were associated with higher all-cause mortality than concentrations greater than 30 ng/mL (P < .01).Our findings agree with a National Academy of Sciences report, except the cutoff point for all-cause mortality reduction in this analysis was greater than 30 ng/mL rather than greater than 20 ng/mL.An inverse association was proposed between solar irradiance and incidence of colon and breast cancer, based on a mechanism involving insufficient vitamin D. Individuals with lower serum 25-hydroxyvitamin D (25[OH]D) have higher risk of breast1–3 and colon cancer,4–6 other specific cancers,7 all invasive cancers combined,8 and coronary heart disease.9,10 Physiological mechanisms for the inverse association of 25(OH)D with cancer have been reported.11Despite research on the association between low vitamin D status and many diseases,12 no consensus has emerged on the optimal serum 25(OH)D concentration. The concern is whether it is safe to maintain serum 25(OH)D concentrations in the range high enough to prevent some types of cancers13–15 and coronary heart disease.9,10We decided to analyze the strength and consistency of the inverse association between levels of serum 25(OH)D and age-adjusted mortality hazard ratios in a rapidly expanding field of public health. A previous meta-analysis summarized 12 studies,16 another summarized 14,17 and another summarized a broader range.18We hypothesized that lower serum 25(OH)D was associated with higher all-cause mortality hazard ratios, and defined the age-adjusted hazard ratio for death from any cause as the outcome addressed by the meta-analysis. This analysis includes all studies of all-cause mortality hazard ratios by categories of serum 25(OH)D in healthy or general medical clinic cohorts that met the eligibility criteria. Twenty new studies of serum 25(OH)D and all-cause mortality entered the literature since the Zittermann et al. review,17 for a total of 32 in this review.19–50 Two studies in the review by Zittermann et al. did not meet the stringent inclusion criterion of the present study, and were not included.     

The High Prevalence of Incarceration History Among Black Men Who Have Sex With Men in the United States: Associations and Implications

Objectives. We examined lifetime incarceration history and its association with key characteristics among 1553 Black men who have sex with men (BMSM) recruited in 6 US cities.Methods. We conducted bivariate analyses of data collected from the HIV Prevention Trials Network 061 study from July 2009 through December 2011 to examine the relationship between incarceration history and demographic and psychosocial variables predating incarceration and multivariate logistic regression analyses to explore the associations between incarceration history and demographic and psychosocial variables found to be significant. We then used multivariate logistic regression models to explore the independent association between incarceration history and 6 outcome variables.Results. After adjusting for confounders, we found that increasing age, transgender identity, heterosexual or straight identity, history of childhood violence, and childhood sexual experience were significantly associated with incarceration history. A history of incarceration was also independently associated with any alcohol and drug use in the past 6 months.Conclusions. The findings highlight an elevated lifetime incarceration history among a geographically diverse sample of BMSM and the need to adequately assess the impact of incarceration among BMSM in the United States.In the United States, an estimated 1.5 million adults are in prisons, 700 000 are in local jails, and an additional 4.8 million are on parole or probation.1 Black Americans are disproportionately affected by incarceration.2–5 In 2011, more than 580 000 Black men and women were in state or federal prisons.2 Both Black men and women were imprisoned at higher rates in all age groups, with the highest imprisonment rate by gender, sex, and age group occurring among Black men aged 25 to 39 years.2 In terms of incarceration history, Black men are also more likely than White men to have a previous history of incarceration. In 2001, almost 17% of Black men had a previous incarceration experience compared with only 2.6% of White men.6 A 31% incarceration history has also been documented in the United States among Black men who have sex with men (BMSM).7Black Americans are also significantly affected by HIV infection. Representing just 14% of the US population, Blacks accounted for almost half (44%) of all new HIV infections as well as almost half of all people living with HIV in 2010.8 Individuals in the correctional system have a higher prevalence of HIV infection than the general US population.9 The 2007 prevalence of AIDS cases among incarcerated individuals in prisons was 2.4 times higher than that in the general population.9 Among individuals in the correctional system, Black men represent the largest proportion of HIV-infected men in state and federal prisons.10 Individuals living with HIV infection are frequently incarcerated during the course of their disease, with an estimated 25% of all Americans living with HIV infection incarcerated at some point during the past year.3,11Incarcerated populations also experience a high prevalence of other conditions that are often related to HIV infection, including elevated sexually transmitted infection (STI) rates,3, 2,5,11–15 prior sexual abuse and assault as a child and as an adult,3,16 mental illness,3,11,17 substance abuse,3,11,18,19 low socioeconomic status,2,16 and a history of survival sex, exchange of sex for money or drugs, and multiple sex partners.3,20,21 Moreover, elevated incarceration and recidivism rates among Black men and women have contributed to a variety of negative health and socioeconomic consequences including high unemployment, reduced opportunities for educational and economic advancement, limited housing, disenfranchisement, poor health, inadequate access to health services, disruption of relationships and family lives, and altered norms related to sexual behavior, concurrency, violence, and drug use.3,4,22–25The impact of incarceration and HIV among Black Americans has been well documented,2–6,8–10,26 but little is known about the relationship between incarceration history, HIV, and demographic and psychosocial characteristics specifically among BMSM, a subgroup that is disproportionately affected by HIV in the United States.7,27–35 We determined lifetime incarceration history among the largest cohort of BMSM to date in the United States and describe the correlates of incarceration history among BMSM enrolled in the HIV Prevention Trials Network (HPTN) 061 study in 6 cities. We focused on the relationship between incarceration history and key demographic and psychosocial characteristics among BMSM that can be used to inform future research and prevention efforts among BMSM.     

Clustering of Midlife Lifestyle Behaviors and Subsequent Cognitive Function: A Longitudinal Study

Objectives. We examined the association between individual and clustered lifestyle behaviors in middle age and later in cognitive functioning.Methods. Middle-aged participants (n = 2430) in the Supplémentation en Vitamines et Minéraux Antioxydant study self-reported their low physical activity, sedentary behavior, alcohol use, smoking, low fruit and vegetable consumption, and low fish consumption. We assessed cognition 13 years later via 6 neuropsychological tests. After standardization, we summed the scores for a composite cognitive measure. We estimated executive functioning and verbal memory scores using principal component analysis. We estimated the mean differences (95% confidence intervals [CIs]) in cognitive performance by the number of unhealthy behaviors using analysis of covariance. We identified latent unhealthy behavior factor via structural equation modeling.Results. Global cognitive function and verbal memory were linearly, negatively associated with the number of unhealthy behaviors: adjusted mean differences = −0.36 (95% CI = −0.69, −0.03) and −0.46 (95% CI = −0.80, −0.11), respectively, per unit increase in the number of unhealthy behaviors. The latent unhealthy behavior factor with low fruit and vegetable consumption and low physical activity as main contributors was associated with reduced verbal memory (RMSEA = 0.02; CFI = 0.96; P = .004). No association was found with executive functioning.Conclusions. Comprehensive public health strategies promoting healthy lifestyles might help deter cognitive aging.Noncommunicable diseases with notable lifestyle components are the leading causes of death worldwide.1,2 There is also growing evidence of the critical role of different midlife health and risk behaviors in cognitive aging.3–7 Because lifestyles are inherently modifiable and no treatment of cognitive decline is available, such findings argue for the paramount importance of prevention.8,9Current data support a deleterious effect of alcohol abstinence or abuse (compared with moderate alcohol consumption),10 smoking,7 low fruit and vegetable intake,11 low fish intake,12 and low physical activity (PA) levels13 on cognitive aging. However, it has been widely documented that lifestyle factors are strongly correlated with each other, forming a cluster of healthy or unhealthy behaviors.14 Traditionally, such interrelations have been accounted for by statistical adjustment; however, it is of major public health interest to consider the cumulative and combined effect of the various lifestyle behaviors on health by using multidimensional strategies.14Research that examines the combined effect of lifestyle factors on mortality is plentiful, and data have been colligated in a recent meta-analysis.15 These authors reported a 66% reduction in mortality risk by comparing adherence to 4 or more healthy lifestyle behaviors versus engagement in any number of unhealthy behaviors.The combined effect of lifestyle factors has also been explored in relation to cardiovascular diseases,16–18 cancer,18–22 diabetes,18,23 memory complaints,24 and dementia25–27; however, very few studies have reported findings regarding cognition.28,29 Despite heterogeneity in the definition of a healthy lifestyle, study design, and residual confounding, available, but scarce, data support a critical, protective role of healthy lifestyles in cognitive health through their beneficial properties via oxidative, inflammatory, vascular, and other neuroprotective pathways.30–33Our objectives in this study were to examine the association between individual and clustered lifestyle behaviors and later cognitive functioning. We employed traditional and innovative techniques (structural equation modeling) in our epidemiological pursuit.     

Socioeconomic Status and Bullying: A Meta-Analysis

We examined whether socioeconomic status (SES) could be used to identify which schools or children are at greatest risk of bullying, which can adversely affect children’s health and life.We conducted a review of published literature on school bullying and SES. We identified 28 studies that reported an association between roles in school bullying (victim, bully, and bully-victim) and measures of SES. Random effects models showed SES was weakly related to bullying roles. Adjusting for publication bias, victims (odds ratio [OR] = 1.40; 95% confidence interval [CI] = 1.24, 1.58) and bully-victims (OR = 1.54; 95% CI = 1.36, 1.74) were more likely to come from low socioeconomic households. Bullies (OR = 0.98; 95% CI = 0.97, 0.99) and victims (OR = 0.95; 95% CI = 0.94, 0.97) were slightly less likely to come from high socioeconomic backgrounds.SES provides little guidance for targeted intervention, and all schools and children, not just those with more socioeconomic deprivation, should be targeted to reduce the adverse effects of bullying.Bullying is defined as repeated, harmful behavior, characterized by an imbalance of power between the victim and perpetrator(s).1 There is compelling evidence that school bullying affects children’s health and well being, with the effects lasting long into adulthood.2,3 Victims of school bullying are at greater risk of physical and mental health problems,4,5 including depression,6,7 anxiety,8,9 psychotic or borderline personality symptoms,10,11 and are more likely to self-harm and attempt suicide.12,13 A small proportion of victims are classified as bully-victims, children who are victimized by their peers, but who also bully other children. Bully-victims are at even greater risk for maladjustment,5 exhibiting attention and behavioral difficulties,4,14 displaying poor social skills,15,16 and reporting increased levels of depression and anxiety through adolescence and into adulthood.2 By contrast, the negative outcomes of bullying perpetration are less clear. Bullies have been found more likely to engage in delinquent or antisocial behavior17,18; however, once other family and childhood risk factors are taken into account, they do not appear to be at any greater risk for poorer health, criminal, or social outcomes in adulthood.3Up to one third of children are involved in bullying, as bully, victim, or bully-victim,19,20 and when considered alongside the damaging effects on physical and mental health, bullying can be seen as a major public health concern.21 Identifying risk factors for bullying aids potential efforts in targeting resources, which can prevent youths from becoming involved in bullying, but also limits the impact it has on their health and well being. Traditional risk factors, such as age and gender, show a clear association22,23; however, there are a range of other potential determinants whose relationship to bullying remain unclear. One such determinant is socioeconomic status (SES), which shows some links to bullying, but at present, research findings are inconsistent regarding roles (i.e., bully, victim, or bully-victim).SES is an aggregate concept comprising resource-based (i.e., material and social resources) and prestige-based (individual’s rank or status) indicators of socioeconomic position, which can be measured across societal levels (individual, household, and neighborhood) and at different periods in time.24 It can be assessed through individual measures, such as education, income, or occupation,25,26 but also through composite measures that combine or assign weights to different socioeconomic aspects to provide an overall index of socioeconomic level. There is no standard measure of SES; indicators are used to measure specific aspects of socioeconomic stratification.26 Accordingly, different measures of SES may show varying effects, which can result from differing causal pathways, or through interactions with other social characteristics, such as gender or race.27 The multifaceted nature of SES has resulted in a lack of consistency in how researchers measure its relationship to bullying, and although several studies provide individual assessments of this relationship, as yet there is no clear consensus over whether roles in bullying are associated with individual socioeconomic measures, or in general, with SES.Currently, the literature suggests some link between low SES and victims or bully-victims at school.28,29 Specifically, being a victim has been reported to be associated with poor parental education,30,31 low parental occupation,32 economic disadvantage,33,34 and poverty.35 In addition, several studies found that bully-victims are also more likely to come from low socioeconomic backgrounds,29,30 including low maternal education28 and maternal unemployment.36 However, others found little or no association between SES and victims or bully-victims.37–39 The type of bullying may matter in relation to SES. Victims of physical and relational bullying have been found to more often come from low affluence families, whereas victims of cyber bullying have not.40Compared with victimization, few studies have explored the link between SES and bullying others. Some studies found bullying others to be associated with low SES, including economic disadvantage,34 poverty,35 and low parental education.30 Additionally, where composite measures have been used, children from low socioeconomic backgrounds have been found to bully others slightly more often.29,41 By contrast, others found no association between bullying perpetration and measures of SES.38,39,42There is a small but growing body of literature that examines the relationship between bullying and SES, and although findings tend to suggest that victims, bully-victims, and bullies are more likely to come from low socioeconomic backgrounds, the results are far from conclusive. First, studies differ in their approach to measuring SES; some use composite measures, combining multiple indicators such as parental education, wealth, and occupation, whereas others concentrate on a single socioeconomic indicator, most often parental education, affluence, or occupation. How bullying relates to SES may differ according to which socioeconomic indicator is used; therefore, in interpreting results, one must consider not only how bullying relates to SES in general, but also which socioeconomic indicator was used, and how this may have influenced the result. Furthermore, although several studies indicate an association between bullying and low SES, the reported effect sizes vary greatly across studies, with some reporting weak and others moderate to strong associations. So far, the associations between bullying and SES have not been quantified across a range of studies in a systematic way. To address this gap in the literature, we conducted a systematic review and meta-analysis that aimed to determine more precisely the exact nature and strength of the relationship between SES and bullying. We systematically investigated the association between the role taken in school bullying (victim, bully, or bully-victim) and measures of SES.     

Correlates of incarceration among young methamphetamine users in Chiang Mai, Thailand

Objectives. We examined correlates of incarceration among young methamphetamine users in Chiang Mai, Thailand in 2005 to 2006.Methods. We conducted a cross-sectional study among 1189 young methamphetamine users. Participants were surveyed about their recent drug use, sexual behaviors, and incarceration. Biological samples were obtained to test for sexually transmitted and viral infections.Results. Twenty-two percent of participants reported ever having been incarcerated. In multivariate analysis, risk behaviors including frequent public drunkenness, starting to use illicit drugs at an early age, involvement in the drug economy, tattooing, injecting drugs, and unprotected sex were correlated with a history of incarceration. HIV, HCV, and herpes simplex virus type 2 (HSV-2) infection were also correlated with incarceration.Conclusions. Incarcerated methamphetamine users are engaging in behaviors and being exposed to environments that put them at increased risk of infection and harmful practices. Alternatives to incarceration need to be explored for youths.Over the past decade, methamphetamine use has increased exponentially and reached epidemic proportions, particularly in North America¹ and Southeast Asia.² The methamphetamine epidemic has been concentrated among adolescents and young adults and has significant public health implications² because methamphetamine use has been associated with high-risk behaviors including multiple sexual partners, contractual sex, polydrug use, and aggression.^3,4Thailand has experienced a steadily increasing methamphetamine epidemic since 1996.⁵ By 2003, an estimated 3 500 000 Thais had ever used methamphetamines.⁶ In 1996, Thailand criminalized methamphetamines, treating the trafficking, possession, and use of methamphetamines with the same severity as heroin-related offenses.⁷ In 2003 the government began a “war on drugs” in an attempt to control the epidemic.^8,9 In combination, these events led to a doubling in the number of incarcerated individuals between 1996 and 2004.^7,10 In 2005, 64% of Thai inmates were drug offenders,¹¹ and in 2006, 75% of drug-related arrests and charges were related to methamphetamines.¹² Treatment for methamphetamine use is limited. Institutional management of methamphetamine users includes the use of rehabilitation centers, military-style boot camps, compulsory drug treatment centers, and prisons.¹¹A history of incarceration has been associated with negative health outcomes, including sexually transmitted infections (STIs) and blood-borne viruses, particularly syphilis,¹³ herpes,¹⁴ HIV,^10,15,16 hepatitis b (HBV),^17,18 and HCV.^18–21 The prevalence of these pathogens has been found to be much higher in prisons than in the general population.^22–26 Although these infections may be a result of a high-risk lifestyle leading to incarceration, it is also clear that the prison system exposes individuals to environments and behaviors that increase their risk of acquiring these infections, such as tattooing,^{10,18,21,27–29} unprotected sex as a result of limited condom availability,²⁷ and using shared needles to inject drugs.^27,30,31With so many young methamphetamine users entering the judicial system, it is important to understand the characteristics of this group so that appropriate public health interventions can be designed. Young methamphetamine users need to be diverted away from the judicial system to decrease high-risk behaviors that may impact their own well-being and that of the community.As part of a randomized controlled trial to reduce the risks associated with methamphetamine use among youths in Chiang Mai, Thailand, we investigated behavioral and viral correlates of incarceration among a sample of 1189 young adults aged 18 to 25 years.     

Longitudinal Predictors of Human Papillomavirus Vaccination Among a National Sample of Adolescent Males

Objectives. We conducted a longitudinal study to examine human papillomavirus (HPV) vaccine uptake among male adolescents and to identify vaccination predictors.Methods. In fall 2010 and 2011, a national sample of parents with sons aged 11 to 17 years (n = 327) and their sons (n = 228) completed online surveys. We used logistic regression to identify predictors of HPV vaccination that occurred between baseline and follow-up.Results. Only 2% of sons had received any doses of HPV vaccine at baseline, with an increase to 8% by follow-up. About 55% of parents who had ever received a doctor’s recommendation to get their sons HPV vaccine did vaccinate between baseline and follow-up, compared with only 1% of parents without a recommendation. Fathers (odds ratio = 0.29; 95% confidence interval = 0.09, 0.80) and non-Hispanic White parents (odds ratio = 0.29; 95% confidence interval = 0.11, 0.76) were less likely to have vaccinated sons. Willingness to get sons HPV vaccine decreased from baseline to follow-up among parents (P < .001) and sons (P = .003).Conclusions. Vaccination against HPV remained low in our study and willingness to vaccinate may be decreasing. Physician recommendation and education about HPV vaccine for males may be key strategies for improving vaccination.Quadrivalent human papillomavirus (HPV) vaccine against types 6, 11, 16, and 18 is approved to protect against genital warts (caused mostly by HPV types 6 and 111) and anal cancer (caused mostly by HPV types 16 and 182) in males.3 About 4% of men in the United States report a previous diagnosis of genital warts,4 and about 2250 new cases of anal cancer occur annually among males in the United States.5 Given the high levels of HPV concordance among sexual partners,6 vaccinating males may also have indirect health benefits for their partners.7 United States guidelines began including HPV vaccine for males in October 2009.8 The Advisory Committee on Immunization Practices first provided a permissive recommendation, recommending the 3-dose quadrivalent vaccine series for males aged 9 to 26 years but not making it part of their routine vaccination schedule.8 In October 2011, the Advisory Committee on Immunization Practices updated its stance on HPV vaccine for males and recommended routine vaccination of boys aged 11 to 12 years with catch-up vaccination for males aged 13 to 21 years.9 The updated recommendation continues to allow HPV vaccine to be given to males aged as young as 9 years and up to 26 years.9Although numerous studies have examined HPV vaccine uptake among females,10 data on HPV vaccine uptake among males are sparse. Despite mostly encouraging early levels of parental acceptability of the vaccine for males,11–13 initial estimates found that only about 2% of male adolescents in the United States had received any doses of HPV vaccine by the end of 2010.14,15 Recent data suggest that this increased to about 8% by the end of 2011.16 We are not aware of any studies that have examined predictors of vaccine uptake among males.Our study addresses several important gaps in the existing literature. We provide the first longitudinal examination of HPV vaccination among males and identify predictors of vaccine uptake. In doing so, we used data from both parents and their adolescent sons because many adolescents are involved in vaccination decisions.17 We also examined longitudinal changes in vaccine acceptability among parents and sons and parents’ reasons for not getting their sons HPV vaccine, because these data may provide valuable insight about future HPV vaccine uptake among males.     

Social Branding to Decrease Smoking Among Young Adults in Bars

Objectives. We evaluated a Social Branding antitobacco intervention for “hipster” young adults that was implemented between 2008 and 2011 in San Diego, California.Methods. We conducted repeated cross-sectional surveys of random samples of young adults going to bars at baseline and over a 3-year follow-up. We used multinomial logistic regression to evaluate changes in daily smoking, nondaily smoking, and binge drinking, controlling for demographic characteristics, alcohol use, advertising receptivity, trend sensitivity, and tobacco-related attitudes.Results. During the intervention, current (past 30 day) smoking decreased from 57% (baseline) to 48% (at follow-up 3; P = .002), and daily smoking decreased from 22% to 15% (P < .001). There were significant interactions between hipster affiliation and alcohol use on smoking. Among hipster binge drinkers, the odds of daily smoking (odds ratio [OR] = 0.44; 95% confidence interval [CI] = 0.30, 0.63) and nondaily smoking (OR = 0.57; 95% CI = 0.42, 0.77) decreased significantly at follow-up 3. Binge drinking also decreased significantly at follow-up 3 (OR = 0.64; 95% CI = 0.53, 0.78).Conclusions. Social Branding campaigns are a promising strategy to decrease smoking in young adult bar patrons.Tobacco companies1 and public health authorities2–5 recognize young adulthood as a critical time when experimenters either quit or transition to regular tobacco use. Young adults are also aspirational role models for youths.1,6,7 Tobacco companies devote considerable resources to reaching young adults to encourage tobacco use,1,8–11 and young adults have a high prevalence of smoking.12 In California in 2011, young adults had the highest smoking prevalence of any age group, and the Department of Health estimated that 32% of California smokers started smoking between the ages of 18 and 26 years.13 Although they are more likely to intend to quit and successfully quit than older adults,14–17 young adults are less likely to receive assistance with smoking cessation.18,19 Although there are few proven interventions to discourage young adult smoking,20 cessation before age 30 years avoids virtually all of the long-term adverse health effects of smoking.21Tobacco companies have a long history of using bars and nightclubs to reach young adults and to encourage smoking.1,6,9–11,22–24 Bar attendance and exposure to tobacco bar marketing is strongly associated with smoking.25 The 1998 Master Settlement Agreement and Food and Drug Administration regulations that limit tobacco advertising to youths, explicitly permit tobacco marketing in “adult only” venues, including bars and nightclubs.26,27Aggressive tobacco marketing may actually be more intensive in smoke-free bars: a 2010 study of college students attending bars found that students in the community with a smoke-free bar law were more likely to be approached by tobacco marketers, offered free gifts, and to take free gifts for themselves than in communities without a smoke-free bar law.28 Bars and nightclubs also attract young adults who are more likely to exhibit personality traits such as sensation seeking,29 increasing their risk30 independently of receptivity to tobacco advertising; tobacco promotional messages resonate with these personality traits.8,31 Tobacco marketing campaigns are tailored to specific segments of the population defined by psychographics (e.g., values, attitudes, shared interests, such as tastes in music and fashion, and friend groups) and demographic criteria, and they aim to create positive smoker images, identities, and social norms for smoking.1,8 Tobacco marketing campaigns also focus on young adult trendsetters to leverage peer influence to promote smoking.6,10In contrast to the tobacco companies’ efforts, most young adult health interventions take place in colleges or health centers rather than social environments.32–39 Bars and nightclub venues represent an opportunity to reach those at highest risk for long-term smoking morbidity and mortality.40 We evaluated the effectiveness of an intervention to decrease cigarette smoking by countering tobacco industry marketing strategies targeting young adults attending bars and nightclubs in the San Diego, California, “hipster” scene. Because tobacco and alcohol use are strongly linked,41,42 we also examined the effects of the intervention on alcohol use and among binge drinkers. We found a significant decrease in smoking in the community where the intervention took place, including significant decreases among nondaily smokers and binge drinkers, as well as a significant decrease in binge drinking.     

The Case for Improving the Health of Ex-Prisoners

The global prison population exceeds 10 million and continues to grow; more than 30 million people are released from custody annually. These individuals are disproportionately poor, disenfranchised, and chronically ill.There are compelling, evidence-based arguments for improving health outcomes for ex-prisoners on human rights, public health, criminal justice, and economic grounds. These arguments stand in stark contrast to current policy and practice in most settings.There is also a dearth of evidence to guide clinicians and policymakers on how best to care for this large and growing population during and after their transition from custody to community. Well-designed longitudinal studies, clinical trials, and burden of disease studies are pivotal to closing this evidence gap.The world prison population is more than 10.75 million and is growing at a rate in excess of population growth.1 Although in the United States there is a distinction between prisoners (felony offenders incarcerated in state and federal prisons) and jail detainees (mostly misdemeanor offenders), this distinction is not made in most countries. Here we use the term prisoner to refer to both prisoners and jail detainees. Because of the rapid turnover of custodial populations, it has been estimated that globally, more than 30 million people move through prisons each year.2 Incarceration rates vary markedly within and between countries, and are heavily influenced by public policy decisions, such as the criminalization of drug users3 and the de-institutionalization of the mentally ill.4 The United States has the highest incarceration rate in the world (743 per 100 000 population) and accounts for more than one fifth of the world’s prisoners, with approximately 2.2 million people in custody on any one day.1 Of these, 1.5 million are held in state and federal prisons, and spend on average three years in custody before returning to the community; more than 700 000 are held in local jails, where the average stay is less than seven days. Given the large incarcerated population and rapid turnover of jail detainees, in excess of 11 million persons pass through US correctional facilities each year—more than in any other country.5–7Prisoners globally are characterized by complex and multifaceted health problems.8 Although imprisonment confers its own unique health risks,9,10 health usually improves in custody, where stable accommodation and regular meals are provided at little or no cost, illicit drugs are less readily available, and high-intensity health services are routinely provided.11,12 Unfortunately, these health gains are often rapidly lost after return to the community, where many ex-prisoners experience poor health-related outcomes, including poorly controlled disease,13 elevated rates of life-threatening drug overdose,14,15 preventable hospitalization,16,17 and mortality.18,19 Key to improving these outcomes is increased access to health care for ex-prisoners,20 but this has proven difficult to achieve. Despite recent encouraging research findings,21 the greater challenge has been translating promising pilot programs into policy, at scale and in a sustainable way. Here we make the case for improving the health of ex-prisoners, in the hope that this will provide a platform for evidence-based advocacy to improve the health of this profoundly marginalized, challenging, and underserved population.     

The Impact of School Water,Sanitation, and Hygiene Interventions on the Health of Younger Siblings of Pupils: a Cluster-Randomized Trial in Kenya

Objectives. We examined the impact of school water, sanitation, and hygiene (WASH) interventions on diarrhea-related outcomes among younger siblings of school-going children.Methods. We conducted a cluster-randomized trial among 185 schools in Kenya from 2007 to 2009. We assigned schools to 1 of 2 study groups according to water availability. Multilevel logistic regression models, adjusted for baseline measures, assessed differences between intervention and control arms in 1-week period prevalence of diarrhea and 2-week period prevalence of clinic visits among children younger than 5 years with at least 1 sibling attending a program school.Results. Among water-scarce schools, comprehensive WASH improvements were associated with decreased odds of diarrhea (odds ratio [OR] = 0.44; 95% confidence interval [CI] = 0.27, 0.73) and visiting a clinic (OR = 0.36; 95% CI = 0.19, 0.68), relative to control schools. In our separate study group of schools with greater water availability, school hygiene promotion and water treatment interventions and school sanitation improvements were not associated with differences in diarrhea prevalence between intervention and control schools.Conclusions. In water-scarce areas, school WASH interventions that include robust water supply improvements can reduce diarrheal diseases among young children.Diarrhea accounts for 700 000 deaths per year among children younger than 5 years,1 or 10.5% of total under-5 mortality.2 These deaths are largely preventable. An estimated 85% of diarrhea mortality is attributed to unsafe drinking water, inadequate sanitation, and substandard hygiene practices.3 A recent meta-analysis calculated reductions in diarrhea associated with hand-washing promotion, water quality improvements, and improvements in excreta disposal of 48%, 17%, and 36%, respectively.4 These estimates have been widely adopted in the international health community.5,6 Although some studies have found limited evidence of health impact associated with water supply improvements,7 emerging research suggests that relationships between water supply and diarrhea may be mediated by several factors, including collection time and distance to source.8,9Estimates of the health impact of water, sanitation, and hygiene (WASH) interventions on children younger than 5 years are derived from interventions that promote or improve services and practices in domestic environments.4 The impact of WASH improvements at institutions—such as schools—on child diarrhea remains underexplored. WASH interventions in schools can influence diarrheal outcomes among children younger than 5 years who themselves are not attending school through 2 primary pathways. First, these interventions may result in the diffusion of improved practices and behaviors to domestic environments and the broader community. Studies have documented both the transfer of knowledge about proper hygiene and point-of-use water treatment practices from school-based10,11 and clinic-based12 interventions. Second, interventions may interrupt pathogen transmission within the public sphere, reducing transmission to and exposures in domestic environments.13 Water supply improvements in schools may also serve broader community needs, resulting in changes in both domestic and public settings. The potential for domestic or public WASH improvements to reduce disease burden depends on several factors, including background disease burden and baseline WASH access.14School WASH interventions have been associated with improvements in educational outcomes11,15,16 and reductions in absence caused by illness17,18 and diarrhea19 among school-aged children. Because the majority of the WASH-attributable disease burden involves children younger than 5 years,20,21 it is important to understand the extent to which school interventions affect younger children. We analyzed data from a cluster-randomized trial in Kenya to quantify the impact of school WASH improvements on parent-reported diarrhea and clinic visits for gastrointestinal symptoms among children younger than 5 years living in households within the catchment areas of study schools.     

Correlates of Sexual Risk Among Sexual Minority and Heterosexual South African Youths

We explored psychosocial correlates of sexual risk among heterosexual and sexual minority youths (SMYs) in Johannesburg, South Africa. Young people 16 to 18 years old (n = 822) were administered surveys assessing demographic characteristics, sexual behaviors, mental health, and parent–child communication. Adjusted multivariate regressions examining correlates of sexual risk revealed that SMYs had more sexual partners than heterosexual youths (B = 3.90; SE = 0.95; P < .001) and were more likely to engage in sex trading (OR = 3.11; CI = 1.12-8.62; P < .05). South African SMYs are at increased risk relative to their heterosexual peers.South Africa has the highest burden of HIV in the world; 9.2% of young persons aged 15 to 19 years living in the country are infected with HIV.1,2 Few studies have examined multilevel sexual risk factors (e.g., individual, partner, family) among sexual minority youths (SMYs)3 in South Africa, despite their increased vulnerability.4–8 Research has shown that rates of sexual risk behavior are high among adult men who have sex with men (MSM) in sub-Saharan Africa,5,9 and South African SMYs may be especially vulnerable given the transitional nature of adolescence, fear of discrimination, and lack of cultural acceptance of homosexuality.4,7,10Our analyses were guided by theories of syndemics (i.e., collective risk or co-occurring epidemics)11–13 and minority group stress.14 These theories posit that young MSM experience psychosocial disparities in numerous areas (substance use, abuse and victimization, mental health problems, risk taking)15–18 and that SMYs are at increased risk for poor mental health, sexual vulnerability, substance use, and violence.19,20 Moreover, stigma creates stressful environments, another cause of mental health problems among SMYs.14 This situation is especially salient in South Africa, where same-sex behavior is so highly stigmatized that even normative adolescent sexual exploration would likely be denounced.7We hypothesized that South African SMYs would be at increased sexual risk relative to heterosexual youths. To our knowledge, this is one of the first investigations to examine risk and protective factors associated with sexual risk in this population.     

Health Among Caregivers of Children With Health Problems: Findings From a Canadian Population-Based Study

Objectives. We used population-based data to evaluate whether caring for a child with health problems had implications for caregiver health after we controlled for relevant covariates.Methods. We used data on 9401 children and their caregivers from a population-based Canadian study. We performed analyses to compare 3633 healthy children with 2485 children with health problems. Caregiver health outcomes included chronic conditions, activity limitations, self-reported general health, depressive symptoms, social support, family functioning, and marital satisfaction. Covariates included family (single-parent status, number of children, income adequacy), caregiver (gender, age, education, smoking status, biological relationship to child), and child (age, gender) characteristics.Results. Logistic regression showed that caregivers of children with health problems had more than twice the odds of reporting chronic conditions, activity limitations, and elevated depressive symptoms, and had greater odds of reporting poorer general health than did caregivers of healthy children.Conclusions. Caregivers of children with health problems had substantially greater odds of health problems than did caregivers of healthy children. The findings are consistent with the movement toward family-centered services recognizing the link between caregivers'' health and health of the children for whom they care.Caring for a child with health problems can entail greater than average time demands,^1,2 medical costs,^3,4 employment constraints,^5,6 and childcare challenges.^6–8 These demands may affect the health of caregivers, a notion supported by a variety of small-scale observational studies that have shown increased levels of stress, distress, emotional problems, and depression among caregivers of children with health problems.^1,2,5,9–12Whether these problems are caused by the additional demands of caring for children with health problems or by confounding variables is difficult to answer definitively. The literature reports the identification of a variety of factors purported to be associated with caregiver health, including contextual factors such as socioeconomic status^13–17; child factors such as level of disability,^{1,11,13,18–21} presence of behavior problems,^22–25 and overall child adjustment²⁶; and caregiver-related characteristics such as coping strategies^11,22,27 and support from friends and family.^15,17,28,29 In general, this work has been based on small clinic-based samples^9,30 or specific child populations (e.g., cerebral palsy,^5,25 attention-deficit/hyperactivity disorder^31,32), and typically has been hampered by limited generalizability and a lack of careful, multivariate analysis. Furthermore, most studies have focused on caregivers'' psychological health,^1,2,5,9–12 although physical health effects may also exist among caregivers.^5,19,25,33One of the few studies to involve large-scale, population-based data compared the health of 468 caregivers of children with cerebral palsy to the health of a population-based sample of Canadian parents.⁵ The study showed that caregivers of children with cerebral palsy had poorer health on a variety of physical and psychological health measures. Furthermore, the data were consistent with a stress process model,^5,25 which proposes that additional stresses associated with caring for a child with cerebral palsy directly contribute to poorer caregiver health. However, these findings were based on a specific subpopulation of caregivers and univariate comparisons that could not control for potentially important confounders such as variation in caregiver education, income, and other demographic factors.We used population-based data to test the hypothesis that the health of caregivers of children with health problems would be significantly poorer than that of caregivers of healthy children, even after we controlled for relevant covariates. Our approach of using large-scale, population-based data representing a broad spectrum of childhood health problems³⁴ makes 4 key contributions to the current literature. First, our use of population-based data rather than small-scale, clinic-based studies yielded results that are potentially generalizable to a wide group of caregivers caring for children with health problems. Second, our examination of children with and without health problems allowed us to examine caregiver health effects across a wide variety of caregiving situations. Third, consideration of physical health outcomes (in addition to more regularly studied psychological outcomes) increased our knowledge of the breadth of caregiver health issues. Finally, controlling for relevant covariates allowed us to rule out a number of alternative explanations for caregiver health effects.     

Prevalence of HCV Infection Among Clients in Community-Based Health Settings in Hawaii, 2002–2010: Assessing Risk Factors

Objectives. We sought to determine the prevalence of HCV infection and identify risk factors associated with HCV infection among at-risk clients presenting to community-based health settings in Hawaii.Methods. Clients from 23 community-based sites were administered risk factor questionnaires and screened for HCV antibodies from December 2002 through May 2010. We performed univariate and multivariate logistic regression analyses.Results. Of 3306 participants included in the analysis, 390 (11.8%) tested antibody positive for HCV. Highest HCV antibody prevalence (17.0%) was in persons 45 to 64 years old compared with all other age groups. Significant independent risk factors were current or prior injection drug use (P < .001), blood transfusion prior to July 1992 (P = .002), and having an HCV-infected sex partner (P = .03). Stratification by gender revealed sexual exposure to be significant for males (P = .001).Conclusions. Despite Hawaii’s ethnic diversity, high hepatocellular carcinoma incidence, and a statewide syringe exchange program in place since the early 1990s, our HCV prevalence and risk factor findings are remarkably consistent with those reported from the mainland United States. Hence, effective interventions identified from US mainland population studies should be generalizable to Hawaii.Hepatitis C is the most prevalent chronic blood-borne viral infection in the United States, with an estimated 1.3% of the population chronically infected.1 Chronic HCV infection is often asymptomatic; approximately 75% of infected persons may be unaware that they are infected.2 Transmission is mainly through direct blood-to-blood contact, and the most common risk factor in the United States is the sharing of injection drug use equipment.1,2 Complications from HCV infection include cirrhosis, hepatocellular carcinoma (HCC), and end-stage liver disease; more than one third of liver transplants in the United States can be attributed to HCV.3 There is currently no vaccine,4 and until recently, standard therapy with pegylated interferon and ribavirin achieved a sustained virologic response in only 40% to 50% of patients.5,6In May 2011, the US Food and Drug Administration approved 2 new HCV-specific protease inhibitors for the treatment of chronic genotype 1 HCV infections: boceprevir7,8 and telaprevir.9,10 In combination with standard therapy, these drugs have achieved significantly higher rates of sustained virologic response: up to 67% to 75%.7,10 Achieving sustained virologic response is key to reducing mortality, HCC, and other comorbidities.11,12 With such a large percentage of HCV-infected individuals unaware of their status and new successful treatments available, there is now increased rationale for health providers to screen their clients for chronic HCV infection.The population of Hawaii differs from that of the mainland United States on a number of key factors related to HCV and HCC. Hawaii has the highest incidence of HCC nationally.13 Asian/Pacific Islanders have the highest incidence of HCC in the United States,13 and 57% of the Hawaii’s population is Asian, either alone or in combination with other ethnic groups.14 The high HCC incidence among Asian/Pacific Islanders is attributed in large part to chronic hepatitis B virus (HBV) infection,13,15 and the identification and treatment of persons with chronic HBV or HCV infection is an important public health priority in Hawaii. In addition, Hawaii implemented a statewide syringe exchange program in the early 1990s, the first state to do so.16 The risk factor demonstrating the strongest association with HCV infection in the United States is injection drug use,1,17 and syringe exchange programs have demonstrated efficacy in reducing HCV infection among injection drug users.18,19To our knowledge, only 3 HCV prevalence studies have been conducted in Hawaii; however, each focused on a specific well-defined subgroup population: patients with HCC,20 HIV-infected persons enrolled in a state drug assistance plan,21 and adults from a homeless shelter.22The Adult Viral Hepatitis Prevention Program of the Hawaii State Department of Health, which offers risk-based HCV antibody testing based on reported national risk factors,1,23 has been collecting data on persons undergoing screening since 2002. We investigated the prevalence of HCV antibody positivity among at-risk clients of community-based health programs in Hawaii and identified demographic characteristics and independent risk factors associated with HCV infection.