Parental Incarceration and Child Mortality in Denmark

Objectives. We used Danish registry data to examine the association between parental incarceration and child mortality risk.Methods. We used a sample of all Danish children born in 1991 linked with parental information. We conducted discrete-time survival analysis separately for boys (n = 30 146) and girls (n = 28 702) to estimate the association of paternal and maternal incarceration with child mortality, controlling for parental sociodemographic characteristics. We followed the children until age 20 years or death, whichever came first.Results. Results indicated a positive association between paternal and maternal imprisonment and male child mortality. Paternal imprisonment was associated with lower child mortality risks for girls. The relationship between maternal imprisonment and female child mortality changed directions depending on the model, suggesting no clear association.Conclusions. These results indicate that the incarceration of a parent may influence child mortality but that it is important to consider the gender of both the child and the incarcerated parent.A substantial body of research has found that mortality and morbidity among men is associated with ever being incarcerated, the period of incarceration, and the immediate postrelease period.1–10 In a similar vein, a small but rapidly growing body of research considers how these incarceration experiences might also affect the health of the women who are associated with incarcerated men.11–14Yet the health consequences of imprisonment need not be limited to adults. Recent research demonstrates that the risk of parental imprisonment has increased in lockstep with the risk of imprisonment for men14 and that paternal incarceration is associated with poor child outcomes in a variety of domains,15,16 including increased behavioral problems,17,18 criminality and arrest,19 drug use,20 and educational detainment.21,22 Although many previous studies suggest that paternal incarceration has global negative effects on their children, some research shows that paternal incarceration’s consequences vary by the gender of the child, as paternal incarceration is associated with increases in the aggression of boys but not girls.23 Paternal incarceration is associated with decreases in the aggression of girls, indicating that its effects on girls may be positive, negative, or null. The consequences of maternal imprisonment for children have received less attention.24 Furthermore, findings on the association of maternal incarceration with child well-being are more equivocal, indicating a less clear-cut relationship between maternal incarceration and poor child outcomes.25,26Despite this previous research on parental incarceration and child well-being and a growing body of evidence indicating that other national-level social policies, such as parental leave and antipoverty programs, have important implications for child health outcomes,27–31 little research has considered the relationship between parental incarceration and child health. Indeed, with the exception of 2 studies linking paternal incarceration with elevated risks of infant mortality for all children32 and obesity among young women,33 we know virtually nothing about how parental incarceration shapes child health, which is especially problematic since increasing rates of imprisonment matter not just for adult men but also for their children.14We have extended the literature on the consequences of parental incarceration for child health by considering the relationship between paternal and maternal incarceration and child mortality in Denmark using data from the Danish administrative registers.     

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     

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.     

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     

Gender-Specific Correlates of Incarceration Among Marginally Housed Individuals in San Francisco

Objectives. We assessed how different patterns of housing instability affect incarceration and whether correlates of incarceration are gender specific.Methods. We used multivariate logistic regression to assess associations between patterns of housing instability and recent jail stays among a reproducible sample of 1175 marginally housed adults in San Francisco, California.Results. Over the previous year, 71% of men and 21% of women in the sample reported jail stays. Among women, long-term single-room occupancy hotel stays ( > 90 days) were protective for incarceration. Stays in the street were associated with incarceration among both genders, but among men, short-term (i.e., ≤ 90 days) street stays were associated with the highest odds of incarceration, and among women, long-term street stays were most correlated with incarceration. Sex trade increased the odds of incarceration among men only; recent drug use was associated with incarceration among both genders.Conclusions. Correlates of incarceration differed by gender, and patterns of housing instability differentially affected incarceration for men and women. Policies to improve housing options and drug treatment for the urban poor are critical to breaking the cycle of incarceration and homelessness and improving health outcomes.Incarceration rates in the United States have more than quadrupled over the past 3 decades and have increased more rapidly among women than among men.^1–3 Urban poor individuals are at especially high risk for incarceration. A strong body of literature shows bidirectional associations between homelessness and both jail and prison stays in that homelessness is a catalyst for incarceration and incarceration precipitates homelessness by disrupting social networks and employment opportunities.^4–13Incarceration has public health consequences other than decreased housing and employment options; individuals who have been incarcerated in jails or prisons have higher rates of substance abuse, victimization, mental illness, chronic diseases, tuberculosis, HCV, HIV, and other sexually transmitted diseases (STDs) when compared with other low-income individuals.^7,13–26 Among people with HIV, incarceration is associated with worse antiretroviral adherence and worse HIV clinical outcomes than among nonincarcerated individuals.^27,28 Prison and jail stays are also associated with increased risk of needle sharing, unsafe sexual behavior, and drug overdose, which compounds the negative health consequences associated with incarceration.^29–32 Finally, incarceration is associated with high mortality rates compared with the general population, particularly within the first 2 weeks after release.³²In view of the many adverse public health effects of incarceration, it is critical to better understand its correlates. Although we have previously reported that correlates of homelessness differ between men and women,³³ few data indicate whether correlates of incarceration vary by biological sex. This is particularly important because the reasons people are incarcerated in the first place seem to be gender specific (i.e., men are arrested more frequently for nearly every offense category other than prostitution, running away from home, and embezzlement)³⁴ and also because women and men living on the street may experience different vulnerabilities and may have different survival strategies.Another important gap in the literature is that although links between homelessness and incarceration are well established, little is known about whether specific patterns of housing instability are differentially associated with incarceration. We therefore set out to assess gender-specific associations between patterns of homelessness and jail stays among low-income men and women in San Francisco, California.     

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.     

Male Perpetration of Intimate Partner Violence and Involvement in Abortions and Abortion-Related Conflict

Men aged 18 to 35 years (n = 1318) completed assessments of perpetration of intimate partner violence (IPV), abortion involvement, and conflict regarding decisions to seek abortion. IPV was associated with greater involvement by men in pregnancies ending in abortion and greater conflict regarding decisions to seek abortion. IPV should be considered within family planning and abortion services; policies requiring women to notify or obtain consent of partners before seeking an abortion should be reconsidered; they may facilitate endangerment and coercion regarding such decisions.Intimate partner violence (IPV) is a major public health issue that affects the lives and health of approximately 20% to 25% of adolescent and adult US women,^1,2 with women of reproductive age at greatest risk.^3,4 Major reproductive health concerns associated with experiences of IPV include unintended⁵ and rapid repeat pregnancies.^6–8 Given that unintended and unwanted pregnancies are the primary reason for seeking abortion,^7,9 abused women are thought to be more likely to experience abortion than are their nonabused counterparts.^10–12 Recent qualitative research suggests there is a broad role played by abusive male partners in controlling women''s reproductive health,^13–15 including attempts to control abortion-related decisions.^13,15 However, quantitative data on this issue have primarily been collected from women attending abortion services, which therefore precludes comparisons to women with no abortion history.^10–12 Given the increasing recognition of the role of male partners in controlling a woman''s reproductive health and decision-making, coupled with the continuing public debate concerning both women''s access to abortion and the role of family members in decisions regarding abortion (e.g., spousal consent),¹⁶ it is critical to understand to what extent abuse from male partners may relate to both women''s seeking abortion and coercion regarding abortion-related decisions. We examined the association of young adult men''s reports of perpetration of IPV and their participation in pregnancies ending in abortion as well as conflict surrounding abortion-related decisions.     

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.     

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.     

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.     

Childbearing Intentions of HIV-Positive Women of Reproductive Age in Soweto,South Africa: The Influence of Expanding Access to HAART in an HIV Hyperendemic Setting

Objectives. We investigated whether the intention to have children varied according to HIV status and use of highly active antiretroviral therapy (HAART) among women in Soweto, South Africa.Methods. We used survey data from 674 women aged 18 to 44 years recruited from the Perinatal HIV Research Unit in Soweto (May through December 2007); 217 were HIV-positive HAART users (median duration of use = 31 months; interquartile range = 28, 33), 215 were HIV-positive and HAART–naive, and 242 were HIV negative. Logistic regression models examined associations between HIV status, HAART use, and intention to have children.Results. Overall, 44% of women reported intent to have children, with significant variation by HIV status: 31% of HAART users, 29% of HAART-naive women, and 68% of HIV-negative women (P < .001). In adjusted models, HIV-positive women were nearly 60% less likely to report childbearing intentions compared with HIV-negative women (for HAART users, adjusted odds ratio [AOR] = 0.40; 95% confidence interval [CI] = 0.23, 0.69; for HAART-naive women, AOR = 0.35; 95% CI = 0.21, 0.60), with minimal differences according to use or duration of HAART.Conclusions. Integrated HIV, HAART, and reproductive health services must be provided to support the rights of all women to safely achieve their fertility goals.In sub-Saharan Africa, women of childbearing age comprise 61% of people living with HIV, accounting for over 12 million women.¹ In many regions, HIV incidence is increasing most dramatically among young women aged 18 to 30 years,^1,2 which coincides with their peak reproductive years.³ Globally, a plethora of evidence indicates that many women living with HIV continue to desire children,^4–8 become pregnant,^5,6,9 and give birth^5,6,10 after knowing their HIV-positive status.Childbearing decision making can be complex regardless of HIV seropositivity¹¹; among HIV-infected women, however, reproduction introduces additional personal, public health, and clinical care issues.¹² The vast majority of conceptions occur without the use of reproductive technologies such as sperm washing and artificial insemination.¹³ Thus, the unprotected sexual activity required for conception carries a risk of HIV transmission to uninfected sexual partners.¹⁴ Reproduction among HIV-positive women also carries a risk of vertical transmission during pregnancy and labor and through breastfeeding.^15,16 Moreover, HIV-positive women have a lower life expectancy than HIV-negative women,¹⁷ increasing the risk of maternal orphanhood.¹⁸ In light of these concerns, early reproductive guidelines for people living with HIV were dissuasive,¹⁹ and HIV-positive women who express a desire to have children continue to encounter the disapproval of the community and of health care workers.^4,20Nonetheless, although the potential health risks may have dampened the fertility intentions of some HIV-positive women, stigma associated with childlessness in many societies²¹ and the strong personal desires for biological parenthood⁴ remain potent drivers of childbearing intentions, despite an HIV-positive status. Indeed, in some cultural contexts, remaining childless can be a violation of societal norms more stigmatizing than the HIV infection itself.^4,22Expanding access to highly active antiretroviral therapy (HAART) is changing the landscape of childbearing decision making for people living with HIV.²³ HAART increases life expectancy,^24–26 decreases morbidity,^25,27 and dramatically reduces the risks of vertical²⁸ and horizontal^29,30 transmission. In this era of expanding access to HAART, the significant reduction in health risks and barriers to reproduction among people living with HIV has coincided with increased calls for a rights- and evidenced-based approach to reproduction.^31,32 Since childbearing intentions are among the strongest predictors of eventual childbearing,³³ creating effective and responsive sexual and reproductive health services for HIV-positive women in the context of expanding access to HAART requires a clear understanding of expressed childbearing intentions.Existing evidence concerning the influence of expanding access to HAART on childbearing intentions is largely incomplete. Although recent regional studies have shown that HAART use is associated with higher childbearing intentions, these studies neglected to consider the duration of HAART use^6,7 and tended only to compare the childbearing intentions of HIV-positive women without conducting a comparison with HIV-negative women from the same community.^6–8 Moreover, the lack of an HIV-negative control group precludes the opportunity to assess whether HAART users begin to resemble HIV-negative women in their childbearing intentions, particularly as HIV is increasingly recognized as a manageable chronic disease.Given the high HIV prevalence among women of reproductive age in Soweto, South Africa,¹ we aimed to assess the prevalence of childbearing intentions and to determine whether they varied according to HIV status and HAART use among women. We hypothesized that HIV-positive women would have lower childbearing intentions than would HIV-negative women. In addition, we hypothesized that HIV-positive women receiving HAART would have higher childbearing intentions than would HIV-positive HAART-naive women, with increasing duration of HAART treatment associated with incrementally higher childbearing intentions. Overall, we hypothesized that HAART use would narrow the measurable differences in childbearing intentions between HIV-positive and HIV-negative women.²³     

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.     

Health and Health Risks Among Sexual Minority Women: An Examination of 3 Subgroups

We used 2001–2010 National Health and Nutrition Examination Survey data to examine insurance status, source of routine care, cigarette and alcohol use, and self-rated health among lesbian, bisexual, and heterosexual women who have sex with women, compared with heterosexual women who do not have sex with women. We found higher risks of being uninsured among lesbian and bisexual women, worse self-rated health among bisexual women, higher alcohol use among bisexual and heterosexual women who have sex with women, and higher smoking across all subgroups.Sexual minority women (SMW), whether defined by sexual identity (e.g., lesbian or bisexual) or sexual behavior (i.e., same-sex sexual activity), face numerous health risks, including substance use,1–3 mental health disorders,4–6 and poorer physical health,7–10 as well as barriers to quality health care,11,12 compared with sexual nonminority women. Little research, however, has examined the health of different subpopulations of SMW.13 Studies often combine lesbian and bisexual women in analysis, obscuring meaningful differences.14–17 Research also frequently overlooks heterosexual women who have sex with women (WSW), who may experience distinct health risks.18–21In this study, we used information about sexual behavior and sexual identity to further understand differences among SMW. Specifically, we examined health and health risks among 3 subgroups of women: lesbian, bisexual, and heterosexual WSW, compared with heterosexual women who do not have sex with women.     

Impact of individual-, environmental-, and policy-level factors on health care utilization among US farmworkers

Objectives. We examined individual-, environmental-, and policy-level correlates of US farmworker health care utilization, guided by the behavioral model for vulnerable populations and the ecological model.Methods. The 2006 and 2007 administrations of the National Agricultural Workers Survey (n = 2884) provided the primary data. Geographic information systems, the 2005 Uniform Data System, and rurality and border proximity indices provided environmental variables. To identify factors associated with health care use, we performed logistic regression using weighted hierarchical linear modeling.Results. Approximately half (55.3%) of farmworkers utilized US health care in the previous 2 years. Several factors were independently associated with use at the individual level (gender, immigration and migrant status, English proficiency, transportation access, health status, and non-US health care utilization), the environmental level (proximity to US–Mexico border), and the policy level (insurance status and workplace payment structure). County Federally Qualified Health Center resources were not independently associated.Conclusions. We identified farmworkers at greatest risk for poor access. We made recommendations for change to farmworker health care access at all 3 levels of influence, emphasizing Federally Qualified Health Center service delivery.US farmworkers face significant disease burden¹ and excessive mortality rates for some diseases (e.g., certain cancers and tuberculosis) and injuries.² Disparities in health outcomes likely stem from occupational exposures and socioeconomic and political vulnerabilities. US farmworkers are typically Hispanic with limited education, income, and English proficiency.³ Approximately half are unauthorized to work in the United States.³ Despite marked disease burden, health care utilization appears to be low.^1,4–9 For example, only approximately half of California farmworkers received medical care in the previous year.⁶ This rate parallels that of health care utilization for US Hispanics, of whom approximately half made an ambulatory care visit in the previous year, compared with 75.7% of non-Hispanic Whites.¹⁰ Disparities in dental care have a comparable pattern.^6,8,11,12 However, utilization of preventive health services is lower for farmworkers^5,7,13,14 than it is for both US Hispanics and non-Hispanic Whites.^15,16Farmworkers face numerous barriers to health care^1,4,17: lack of insurance and knowledge of how to use or obtain it,^6,18 cost,^{5,6,12,13,18–20} lack of transportation,^{6,12,13,19–21} not knowing how to access care,^6,18,20,21 few services in the area or limited hours,^12,20,21 difficulty leaving work,¹⁹ lack of time,^5,13,19 language differences,^6,8,18–20 and fear of the medical system,¹³ losing employment,⁶ and immigration officials.²¹ Few studies have examined correlates of health care use among farmworkers. Those that have are outdated or limited in representativeness.^5,7,14,22,23 Thus, we systematically examined correlates of US health care use in a nationally representative sample of farmworkers, using recently collected data. The sampling strategy and application of postsampling weights enhance generalizability. We selected correlates on the basis of previous literature and the behavioral model for vulnerable populations.²⁴ The behavioral model posits that predisposing, enabling, and need characteristics influence health care use.²⁵ The ecological model, which specifies several levels of influence on behavior (e.g., policy, environmental, intrapersonal),²⁶ provided the overall theoretical framework. To our knowledge, we are the first to extensively examine multilevel correlates of farmworker health care use. We sought to identify farmworkers at greatest risk for low health care use and to suggest areas for intervention at all 3 levels of influence so that farmworker service provision can be improved.     

The Long-Term Health Consequences of Relationship Violence in Adulthood: An Examination of Low-Income Women From Boston, Chicago, and San Antonio

Objectives. We examined the long-term health consequences of relationship violence in adulthood.Methods. Using data from the Welfare, Children, and Families project (1999 and 2001), a probability sample of 2402 low-income women with children living in disadvantaged neighborhoods in Boston, Massachusetts; Chicago, Illinois; and San Antonio, Texas, we predicted changes in the frequency of intoxication, psychological distress, and self-rated health over 2 years with baseline measures of relationship violence and a host of relevant background variables.Results. Our analyses showed that psychological aggression predicted increases in psychological distress, whereas minor physical assault and sexual coercion predicted increases in the frequency of intoxication. There was no evidence to suggest that relationship violence in adulthood predicted changes in self-rated health.Conclusions. Experiences with relationship violence beyond the formative and developmental years of childhood and adolescence can have far-reaching effects on the health status of disadvantaged urban women.Over the past 2 decades, numerous studies have examined the long-term health consequences of relationship violence during childhood. This body of research suggests that physical and sexual abuse in early life can be devastating to health in adulthood, contributing to poor mental^1–6 and physical health^3–5,7 and to higher rates of substance abuse.^5,6,8,9 These patterns are remarkably consistent across studies and notably persistent through the life course. In a recent study of more than 21 000 older adults, Draper et al.³ reported that physical and sexual abuse before 15 years of age is associated with poor mental and physical health well into late life.Although previous research has made significant contributions to our understanding of the lasting effects of abuse in early life, few studies have considered the long-term health consequences of relationship violence in adulthood. Our review of the literature revealed 5 longitudinal studies of relationship violence and health in adulthood. Not surprisingly, research suggests that women who experience relationship violence in adulthood are vulnerable to poor health trajectories, including increases in depressive symptoms,^10–12 functional impairment,^10,12 and alcohol consumption.^13,14Relationship violence is an important issue in all segments of society; however, studies consistently show that women of low socioeconomic status exhibit higher rates of intimate partner victimization than do their more affluent counterparts.^15–17 For example, Tolman and Raphael¹⁷ reported that between 34% and 65% of women receiving welfare report having experienced some form of relationship violence in their lifetime, and between 8% and 33% experience some form of relationship violence each year, levels that surpass those for women overall.¹⁸ Research also shows that residence in disadvantaged neighborhoods^19,20 and the presence of children in the household^21,22 may elevate the odds of relationship violence. Given their high violence-risk profile, attention must be directed to the patterns and health consequences of intimate partner victimization in the lives of disadvantaged urban women with children.^23–25Building on previous research, we used data collected from a large probability sample of low-income women with children living in low-income neighborhoods in Boston, Massachusetts, Chicago, Illinois, and San Antonio, Texas, to predict changes in the frequency of intoxication, psychological distress, and self-rated health over 2 years with measures of relationship violence in early life and adulthood and a host of relevant background variables. In accordance with previous research, we expected that intimate partner victimization in adulthood would predict increases in psychological distress and the frequency of intoxication and decreases in self-rated health over the study period.     

Racial/Ethnic and Socioeconomic Differences in Short-Term Breast Cancer Survival Among Women in an Integrated Health System

Objectives. We examined the combined influence of race/ethnicity and neighborhood socioeconomic status (SES) on short-term survival among women with uniform access to health care and treatment.Methods. Using electronic medical records data from Kaiser Permanente Northern California linked to data from the California Cancer Registry, we included 6262 women newly diagnosed with invasive breast cancer. We analyzed survival using multivariable Cox proportional hazards regression with follow-up through 2010.Results. After consideration of tumor stage, subtype, comorbidity, and type of treatment received, non-Hispanic White women living in low-SES neighborhoods (hazard ratio [HR] = 1.28; 95% confidence interval [CI] = 1.07, 1.52) and African Americans regardless of neighborhood SES (high SES: HR = 1.44; 95% CI = 1.01, 2.07; low SES: HR = 1.88; 95% CI = 1.42, 2.50) had worse overall survival than did non-Hispanic White women living in high-SES neighborhoods. Results were similar for breast cancer–specific survival, except that African Americans and non-Hispanic Whites living in high-SES neighborhoods had similar survival.Conclusions. Strategies to address the underlying factors that may influence treatment intensity and adherence, such as comorbidities and logistical barriers, should be targeted at low-SES non-Hispanic White and all African American patients.Breast cancer is the most common cancer among women in the United States, and it is the second leading cause of cancer death.1 Despite significant improvements in breast cancer survival from 1992 to 2009,1,2 racial/ethnic and socioeconomic survival disparities have persisted.3,4 African American women have consistently been found to have worse survival after breast cancer,3,5–11 Hispanic women have worse or similar survival,3,9,11,12 and Asian women as an aggregated group have better or similar survival3,9,11,12 than do non-Hispanic White women. Underlying factors thought to contribute to these racial/ethnic disparities include differences in stage at diagnosis,8,12,13 distributions of breast cancer subtypes,14–16 comorbidities,12,13,17 access to and utilization of quality care,13,18 and treatment.12,13Numerous studies also have found poorer survival after breast cancer diagnosis among women residing in neighborhoods of lower socioeconomic status (SES).6,9,19,20 Research has shown that inadequate use of cancer screening services, and consequent late stage diagnosis and decreased survival, contribute to the SES disparities.21,22 Similar to racial/ethnic disparities, SES disparities have been attributed to inadequate treatment and follow-up care and comorbidities.18 Previous population-based studies have continued to observe racial/ethnic survival disparities after adjusting for neighborhood SES, but these studies have not considered the combined influence of neighborhood SES and race/ethnicity.3,9,11,12,23 These disparities may remain because information on individual-level SES, health insurance coverage, comorbidities, quality of care, and detailed treatment regimens have typically not been available.3,8,9,11,13 Even among studies using national Surveillance Epidemiology and End Results–Medicare linked data, in which more detailed information on treatment and comorbidities are available among some patients aged 65 years and older, survival disparities have remained.12,23,24 However, not all data on medical conditions and health care services are captured in Medicare claims, including data on Medicare beneficiaries enrolled in HMOs (health maintenance organizations).25,26Using electronic medical records data from Kaiser Permanente Northern California (KPNC) linked to data from the population-based California Cancer Registry (CCR), we recently reported that chemotherapy use followed practice guidelines but varied by race/ethnicity and neighborhood SES in this integrated health system.27 Therefore, to overcome the limitations of previous studies and address simultaneously the multiple social28 and clinical factors affecting survival after breast cancer diagnosis, we used the linked KPNC–CCR database to determine whether racial/ethnic and socioeconomic differences in short-term overall and breast cancer–specific survival persist in women in a membership-based health system. Our study is the first, to our knowledge, to consider the combined influence of neighborhood SES and race/ethnicity and numerous prognostic factors, including breast cancer subtypes and comorbidities, thought to underlie these long-standing survival disparities among women with uniform access to health care and treatment.     

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.     

Effect of health care system distrust on breast and cervical cancer screening in Philadelphia, Pennsylvania

Objectives. We investigated whether health care system distrust is a barrier to breast and cervical cancer screening and whether different dimensions of distrust—values and competence—have different impacts on cancer screening.Methods. We utilized data on 5268 women aged 18 years and older living in Philadelphia, Pennsylvania, and analyzed their use of screening services via logistic and multinomial logistic regression.Results. High levels of health care system distrust were associated with lower utilization of breast and cervical cancer screening services. The associations differed by dimensions of distrust. Specifically, a high level of competence distrust was associated with a reduced likelihood of having Papanicolaou tests, and women with high levels of values distrust were less likely to have breast examinations within the recommended time period. Independent of other covariates, individual health care resources and health status were associated with utilization of cancer screening.Conclusions. Health care system distrust is a barrier to breast and cervical cancer screening even after control for demographic and socioeconomic determinants. Rebuilding confidence in the health care system may improve personal and public health by increasing the utilization of preventive health services.Cancer is a leading cause of death in the United States. Approximately 1.5 million Americans are diagnosed with cancer per year and 1 in 4 deaths are attributed to cancer.¹ Among women, an estimated 192 000 breast and 11 000 cervical cancer cases are detected each year, and in 2009 more than 40 000 women died of breast cancer and approximately 4000 of cervical cancer.¹ To effectively reduce the morbidity and mortality resulting from breast and cervical cancer, efforts need to be made to increase the proportion of women who comply with screening recommendations²; according to a recent report, a third of women are not in compliance with screening guidelines for breast cancer, and more than a fifth are not in compliance for cervical cancer.³ Our goal was to investigate whether health care system distrust (hereafter referred to as distrust) is a barrier to breast and cervical cancer screening.The late 20th century saw many changes in the theoretical underpinnings of research on health in general and women''s health in particular. The prevailing biomedical model was criticized for ignoring social determinants of health, such as social class, gender roles, and poverty,⁴ and health determinants models that incorporated multiple social, economic, and demographic dimensions were embraced.^5–7 The multiple determinants of health perspective emphasizes the relationships between socioeconomic factors and health outcomes,⁴ but the role of psychological factors (i.e., depression and distrust) in cancer screening has only recently been recognized.^8–11 Relatively little is known about whether distrust affects health outcomes, and specifically whether it influences cancer screening behaviors among women.¹¹Americans’ overall confidence in their health care system has declined markedly in recent decades. In 2010, only 34% of adults reported “a great deal” of confidence in the health system, down from over 70% in 1966.¹² More than 80% of Americans, however, held high levels of trust in their personal physicians or providers,¹³ a paradox that has been widely documented in the literature.^14–17 Previous studies suggest that trust in physicians is associated with seeking timely medical care, maintaining appropriate health care, and adhering to medical advice,^18–20 but it is unclear whether trust or its converse, distrust, affects the adoption of preventive health services among women.¹¹The emerging distrust research in health care shows that distrust is a multidimensional concept.^21–23 For example, Shea et al. used focus groups, pilot testing, and a telephone survey to develop a highly reliable 9-item distrust scale that includes 2 subscales: competence distrust and values distrust.²² Competence distrust is expected to be high when the quality of service fails to meet patient expectations and does not improve health. Values distrust is expected to be high when the integrity of the health care system is questioned (e.g., ethical issues, financial priorities, transparency of care). Although dimensions of distrust may influence the use of preventive health services in different ways, little research has addressed this issue explicitly.A range of individual characteristics has been found to be associated with the use of breast and cervical cancer screening, including age,^5,24 race/ethnicity,^11,25 socioeconomic factors,^5,24 marital status,^5,11,24 and availability and utilization of health care resources.^11,24 Access to insurance and health care providers is associated with higher likelihood of interaction with the health care system and has been hypothesized to be related to levels of distrust and to individuals’ health-related behaviors.²⁶ Personal health status has been found to be related to levels of distrust,²⁷ although the underlying causal mechanisms have not been well documented. Evidence concerning the association of health status with use of preventive health services is inconclusive.¹¹ An important contribution of our study is the investigation of the association of distinct aspects of distrust—values distrust and competence distrust—with receipt of 2 preventive health services for adult women: the Papanicolaou (Pap) test for cervical cancer and clinical breast examination to screen for breast cancer. We tested the following 2 hypotheses: after we controlled for individual socioeconomic and demographic characteristics, (1) high levels of distrust are associated with low utilization of cancer screening services and (2) the negative relationship between distrust and cancer screening utilization holds for the values and competence dimensions of distrust.     

Walking and Cycling to Health: A Comparative Analysis of City, State, and International Data

Objectives. We sought to determine the magnitude, direction, and statistical significance of the relationship between active travel and rates of physical activity, obesity, and diabetes.Methods. We examined aggregate cross-sectional health and travel data for 14 countries, all 50 US states, and 47 of the 50 largest US cities through graphical, correlation, and bivariate regression analysis on the country, state, and city levels.Results. At all 3 geographic levels, we found statistically significant negative relationships between active travel and self-reported obesity. At the state and city levels, we found statistically significant positive relationships between active travel and physical activity and statistically significant negative relationships between active travel and diabetes.Conclusions. Together with many other studies, our analysis provides evidence of the population-level health benefits of active travel. Policies on transport, land-use, and urban development should be designed to encourage walking and cycling for daily travel.Many nations throughout the world have experienced large increases in obesity rates over the past 30 years.^1,2 The World Health Organization estimates that more than 300 million adults are obese,³ putting them at increased risk for diseases such as diabetes, hypertension, cardiovascular disease, gout, gallstones, fatty liver, and some cancers.^4,5 Several studies have linked the increase in obesity rates to physical inactivity^6–8 and to widespread availability of inexpensive, calorie-dense foods and beverages.^1,9The importance of physical activity for public health is well established. A US Surgeon General''s report in 1996, Physical Activity and Health,¹⁰ summarized evidence from cross-sectional studies; prospective, longitudinal studies; and clinical investigations. The report concluded that physical inactivity contributes to increased risk of many chronic diseases and health conditions. Furthermore, the research suggested that even 30 minutes per day of moderate-intensity physical activity, if performed regularly, provides significant health benefits. Subsequent reports have supported these conclusions.^11–13The role of physical activity in prevention of weight gain is well documented.¹⁴ Strong evidence from cross-sectional studies has established an inverse relationship between physical activity and body mass index.^15,16 In addition, longitudinal studies have shown that exercisers gain less weight than do their sedentary counterparts.^6,8 Thus, the obesity epidemic may be explained partly by declining levels of physical activity.^1,17,18A growing body of evidence suggests that differences in the built environment for physical activity (e.g., infrastructure for walking and cycling, availability of public transit, street connectivity, housing density, and mixed land use) influence the likelihood that people will use active transport for their daily travel.^19,20 People who live in areas that are more conducive to walking and cycling are more likely to engage in these forms of active transport.^21–25 Walking and cycling can provide valuable daily physical activity.^26–30 Such activities increase rates of caloric expenditure,³¹ and they generally fall into the moderate-intensity range that provides health benefits.^32–35 Thus, travel behavior could have a major influence on health and longevity.^29,30,36,37Over the past decade, researchers have begun to identify linkages between active travel and public health.^38–40 Cross-sectional studies indicate that walking and cycling for transport are linked to better health. The degree of reliance on walking and cycling for daily travel differs greatly among countries.^39,41 European countries with high rates of walking and cycling have less obesity than do Australia and countries in North America that are highly car dependent.²⁶ In addition, walking and cycling for transport are directly related to improved health in older adults.⁴² The Coronary Artery Risk Development in Young Adults Study found that active commuting was positively associated with aerobic fitness among men and women and inversely associated with body mass index, obesity, triglyceride levels, resting blood pressure, and fasting insulin among men.^26,39,41,43Further evidence of the link between active commuting and health comes from prospective, longitudinal studies.⁴⁴ Matthews et al. examined more than 67 000 Chinese women in the Shanghai women''s health study and followed them for an average of 5.7 years.³⁷ Women who walked (P < .07) and cycled (P < .05) for transport had lower rates of all-cause mortality than did those who did not engage in such behaviors. Similarly, Andersen et al. observed that cycling to work decreased mortality rates by 40% among Danish men and women.³⁶ A recent analysis of a multifaceted cycling demonstration project in Odense, Denmark, reported a 20% increase in cycling levels from 1996 to 2002 and a 5-month increase in life expectancy for males.⁴⁵We analyzed recent evidence from a variety of data sources that supports the crucial relationship between active travel, physical activity, obesity, and diabetes. We used city- and state-level data from the United States and national aggregate data for 14 countries to determine the magnitude, direction, and statistical significance of each relationship.