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     

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.     

Health Effects of Neighborhood Demolition and Housing Improvement: A Prospective Controlled Study of 2 Natural Experiments in Urban Renewal

Objectives. We took advantage of a 2-intervention natural experiment to investigate the impacts of neighborhood demolition and housing improvement on adult residents’ mental and physical health.Methods. We identified a longitudinal cohort (n = 1041, including intervention and control participants) by matching participants in 2 randomly sampled cross-sectional surveys conducted in 2006 and 2008 in 14 disadvantaged neighborhoods of Glasgow, United Kingdom. We measured residents’ self-reported health with Medical Outcomes Study Short Form Health Survey version 2 mean scores.Results. After adjustment for potential confounders and baseline health, mean mental and physical health scores for residents living in partly demolished neighborhoods were similar to the control group (mental health, b = 2.49; 95% confidence interval [CI] = −1.25, 6.23; P = .185; physical health, b = −0.24; 95% CI = −2.96, 2.48; P = .859). Mean mental health scores for residents experiencing housing improvement were higher than in the control group (b = 2.41; 95% CI = 0.03, 4.80; P = .047); physical health scores were similar between groups (b = −0.66; 95% CI = −2.57, 1.25; P = .486).Conclusions. Our findings suggest that housing improvement may lead to small, short-term mental health benefits. Physical deterioration and demolition of neighborhoods do not appear to adversely affect residents’ health.The quality of residential environments, at both the home and the neighborhood level, is associated with residents’ physical and mental health.1–7 Some longitudinal studies suggest that exposure to poor housing8 or to neighborhood-level deprivation9–18 increases the risk of morbidity or mortality beyond what might be predicted from individual-level socioeconomic factors. A causal association between residential environments and health would have important public health implications: improvements to residential environments might contribute positively to public health goals, and deteriorating residential environments could be harmful.Policymakers expect that improving home and neighborhood environments, particularly in disadvantaged areas, will benefit population health and help reduce health inequalities.19,20 Terms such as urban renewal and regeneration are used to describe a range of interventions, such as home improvement programs, housing clearance and demolition, and neighborhood-level improvements.19Research supports assumptions that housing-led urban renewal benefits residents’ health.21–29 A systematic review found that improvements in respiratory, general, and mental health followed housing improvement, with particularly robust evidence of health benefits relating to warmth-improvement interventions.21,30–32 More recently, an evaluation of a multisite urban renewal program in the United Kingdom found relative improvements in residents’ Medical Outcomes Study 36-item Short Form Health Survey mental health scores and self-reported general health at 10-year follow-up.33However, the evidence base is neither comprehensive nor conclusive, particularly regarding neighborhood-level renewal. Reviews have noted some evidence that such interventions may have unintended consequences.34 A study of neighborhood renewal in the United Kingdom found that self-reported health satisfaction worsened, possibly reflecting the intervention’s failure to deliver sufficient changes to residents’ lives and opportunities.35 A recent series of reviews identified 11 interventions considered to have sufficient evidence of effectiveness to warrant implementation,24–28 only 1 of which was a neighborhood-level intervention (rental vouchers to assist relocations to more desirable areas36). The reviews identified 34 interventions of unknown or inconclusive health effects and 7 that were potentially ineffective.24 Neighborhood-level interventions such as demolishing and revitalizing poor public housing (e.g., HOPE VI37), relocating residents, and various forms of neighborhood redesign yielded too little evidence to draw conclusions.28Some commentators have emphasized the social harms linked to housing clearance and demolition programs.38 Paris and Blackaby note that such programs have “frequently been accused of the ‘destruction of communities.’”39^(p18) This alleged destruction is partly a social phenomenon involving the separation of neighbors and closing down of amenities that may have been used as social hubs (e.g., schools, community centers, cafés). It is also a physical phenomenon that increases the proportion of derelict properties and turns neighborhoods into worksites and buildings into rubble.39,40 Furthermore, large-scale clearances can take years to complete, while residents waiting to be relocated are exposed to steadily worsening neighborhood environments.41 If deteriorating residential environments are harmful to health, then residents who remain in neighborhoods undergoing demolition risk being harmed. However, we have not identified any experimental or quasi-experimental study that focuses on the potentially harmful effects of continued residence in neighborhoods undergoing demolition and clearance.We studied a multifaceted renewal program implemented across the city of Glasgow, United Kingdom. In many neighborhoods, existing properties were improved to meet new government standards. However, some neighborhoods began a long-term process of demolition and rebuilding, and residents often lived for several years in neighborhoods undergoing clearance and demolition while they awaited relocation to better-quality housing.42 We treated housing improvement and the experience of living in a demolition area as 2 distinct natural experiments, and we used quasi-experimental methods to test our hypotheses: (1) residents who spent 2 years living in neighborhoods undergoing clearance and demolition would experience worsening health, and (2) residents who experienced housing improvement (and who did not live in neighborhoods undergoing clearance and demolition) would experience improved physical and mental health.     

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.     

Incarceration and Current Tobacco Smoking Among Black and Caribbean Black Americans in the National Survey of American Life

Objectives. We examined the relationship between having a history of incarceration and being a current smoker using a national sample of noninstitutionalized Black adults living in the United States.Methods. With data from the National Survey of American Life collected between February 2001 and March 2003, we calculated individual propensity scores for having a history of incarceration. To examine the relationship between prior incarceration and current smoking status, we ran gender-specific propensity-matched fitted logistic regression models.Results. A history of incarceration was consistently and independently associated with a higher risk of current tobacco smoking in men and women. Formerly incarcerated Black men had 1.77 times the risk of being a current tobacco smoker than did their counterparts without a history of incarceration (95% confidence interval [CI] = 1.20, 2.61) in the propensity score-matched sample. The results were similar among Black women (prevalence ratio = 1.61; 95% CI = 1.00, 2.57).Conclusions. Mass incarceration likely contributes to the prevalence of smoking among US Blacks. Future research should explore whether the exclusion of institutionalized populations in national statistics obscures Black–White disparities in tobacco smoking.In the United States, local, state, and national measures first enacted in the 1970s and 1980s under the “war on drugs” and “tough on crime” policies radically changed the criminal justice system as well as the social, economic, and political landscapes.1 As a result, the US incarceration rate soared higher than that of Russia by 2001.2 The overall incarceration rate has increased by more than 400% since 1980, and the incarceration rate associated with felony drug offenses has increased by 1100%.3,4 Black Americans have borne the brunt of these criminal justice policy changes. One in 21 Black men and 1 in 279 Black women are currently incarcerated, and almost one third of Black men will be incarcerated at least once in their lifetime.4 Mass incarceration is thus potentially an important driver of the distribution of disease and ill-being in Black Americans.Tobacco is an integral part of prison culture, serving as a stress reliever, currency, and means of social interaction. Furthermore, the sensory and social deprivation of the prison environment may encourage tobacco use. Until the 1980s, cigarettes were freely distributed to incarcerated individuals as part of their rations and were (and still remain) the currency of choice for underground prison economies.5–7 However, tobacco policy in US prisons has changed radically in the past 25 years, culminating in the Federal Bureau of Prisons’ indoor smoking ban in federal prisons in 2004.8,9 Meanwhile, state and local prison and jail systems also modified their policies. By 2007, 87% of state prisons reported having either a total or indoor smoking ban in place, with none offering free tobacco.5As a population, people who have been incarcerated have a greater likelihood of having problems with substance abuse, psychiatric illness, and stressful or traumatic life events, potentially increasing susceptibility to nicotine addiction, with smoking prevalence in prison estimated at 40% to 80%.10–13 A systematic review of smoke-free policies in US prisons and jails that included 27 studies cited noncompliance with smoke-free policies ranging from 20% to 76% and demonstrated inconsistent implementation and control of contraband as well as the rise of tobacco black markets.14 In essence, if the available data are representative, the influence of underlying smoking norms seems to outweigh institutional policy changes, although the institutional setting may limit access and therefore consumption.In a systematic review, only 6 studies examining smoking postrelease from smoke-free prisons and jails were identified, and it indicated that individuals released went back to their previous smoking behavior almost immediately.14 With fewer constraints on consumption, individuals released from prison and jail may increase their cigarette consumption to achieve previous nicotine levels, especially those undergoing drug treatment or suffering from mental illness (and perhaps taking antipsychotics).15Even less is known about differences in incarceration-related tobacco smoking by race/ethnicity. Research shows that Blacks are less likely to participate and are not sampled in sufficient numbers to allow subgroup analyses.16,17 Controlling for socioeconomic status, Blacks have lower risk trajectories of cigarette smoking from childhood into adulthood than do Whites; they are also less likely to be heavy or regular smokers and more likely to be nonsmokers, initiating smoking later and reaching lower daily cigarette consumption.18–21 Although this lower tobacco consumption is one of the few health behavior advantages for Blacks compared with Whites, Blacks are more vulnerable to the health consequences of smoking (e.g., lung cancer).22 However, the role of incarceration in tobacco smoking prevalence among Blacks in the United States has not been examined.We therefore sought to evaluate the relationship between adult history of incarceration and tobacco smoking using a national sample of noninstitutionalized Black adults living in the United States, while taking account of differential propensity for having a history of incarceration.     

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.     

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.     

Engaging Individuals Recently Released From Prison Into Primary Care: A Randomized Trial

Objectives. Individuals released from prison have high rates of chronic conditions but minimal engagement in primary care. We compared 2 interventions designed to improve primary care engagement and reduce acute care utilization: Transitions Clinic, a primary care–based care management program with a community health worker, versus expedited primary care.Methods. We performed a randomized controlled trial from 2007 to 2009 among 200 recently released prisoners who had a chronic medical condition or were older than 50 years. We abstracted 12-month outcomes from an electronic repository available from the safety-net health care system. Main outcomes were (1) primary care utilization (2 or more visits to the assigned primary care clinic) and (2) emergency department (ED) utilization (the proportion of participants making any ED visit).Results. Both groups had similar rates of primary care utilization (37.7% vs 47.1%; P = .18). Transitions Clinic participants had lower rates of ED utilization (25.5% vs 39.2%; P = .04).Conclusions. Chronically ill patients leaving prison will engage in primary care if provided early access. The addition of a primary care–based care management program tailored for returning prisoners reduces ED utilization over expedited primary care.In the United States, 700 000 individuals are behind prison bars at any point in time; this represents the highest incarceration rate in the world.1 In the past 20 years, states’ correctional costs have risen by 315% to $44 billion annually, constituting the fastest-expanding area of government spending after Medicaid.2 Ninety-five percent of prisoners will eventually be released to the community; more than 500 000 prisoners are released annually.3 There is pressure to release more prisoners because of prison overcrowding, growing correctional health expenditures, and constrained legislative budgets.1,4,5 In October 2011, California began releasing more than 30 000 inmates from its prison system to comply with a Supreme Court ruling citing an unhealthy level of overcrowding.6 Correctional health care systems are constitutionally responsible for health care while patients are incarcerated, but not upon release.Recently released prisoners have low educational attainment; high rates of poverty, unemployment, and homelessness; and high risk of poor health outcomes, including death, upon release.7,8 Eighty percent of released individuals have chronic medical, psychiatric, or substance abuse problems, yet only 15% to 25% report visiting a physician outside of the emergency department (ED) in the first year postrelease.8,9 Most released individuals state that they use the ED as their regular source of care.10 There is little care coordination between prison and community health systems. Few individuals are released with a sufficient supply of chronic medications, primary care follow-up, or health insurance.11,12 There is limited evidence to guide how to provide effective health care to this population after release. More primary care practices are tailoring care to high-risk populations using primary care–based, complex care management (PC-CCM) programs.13 These PC-CCM programs are designed to assist patients in managing medical problems and related psychosocial problems, in an effort to improve care and health system engagement, and to reduce costs.14–16 However, the effectiveness of these PC-CCM programs for recently released prisoners has not been demonstrated.In 2007, we designed and compared 2 interventions to engage recently released prisoners into primary care. We offered individuals returning to San Francisco postincarceration an initial transitional care visit. After this initial visit, we randomly assigned participants to receive (1) ongoing care at Transitions Clinic (TC), a PC-CCM program for formerly incarcerated individuals consisting of primary care from a provider with experience working with this population and care management from a community health worker (CHW) with a personal history of incarceration,17 or (2) an expedited primary care (EPC) appointment at another safety-net clinic. Care management from a CHW included basic case management, as well as chronic disease self-management support, health care navigation, and patient panel management. We compared the effectiveness of TC versus EPC in increasing primary care and reducing acute care utilization. We hypothesized that individuals randomized to TC would have more primary care and fewer ED visits compared with those randomized to EPC.     

Mental Health of Prisoners: Identifying Barriers to Mental Health Treatment and Medication Continuity

Objectives. We assessed mental health screening and medication continuity in a nationally representative sample of US prisoners.Methods. We obtained data from 18 185 prisoners interviewed in the 2004 Survey of Inmates in State and Federal Correctional Facilities. We conducted survey logistic regressions with Stata version 13.Results. About 26% of the inmates were diagnosed with a mental health condition at some point during their lifetime, and a very small proportion (18%) were taking medication for their condition(s) on admission to prison. In prison, more than 50% of those who were medicated for mental health conditions at admission did not receive pharmacotherapy in prison. Inmates with schizophrenia were most likely to receive pharmacotherapy compared with those presenting with less overt conditions (e.g., depression). This lack of treatment continuity is partially attributable to screening procedures that do not result in treatment by a medical professional in prison.Conclusions. A substantial portion of the prison population is not receiving treatment for mental health conditions. This treatment discontinuity has the potential to affect both recidivism and health care costs on release from prison.Mental health disorders among prisoners have consistently exceeded rates of such disorders in the general population, and correctional facilities in the United States are often considered to be the largest provider of mental health services.1–3 Despite court mandates for access to adequate health care in prisons (these mandates are even further limited to “severe” and “serious” mental illness treatment requirements in prison settings), inmate access to health and mental health care has been sporadic.4,5 Treatment decisions often depend on the limited available resources, public support of correctional treatment, and correctional management decision-making.4,5 Some studies report that at least half of male inmates and up to three quarters of female inmates reported symptoms of mental health conditions in the prior year (compared with 9% or fewer in the general population).3,6–8 These rates underscore the importance of access to mental health treatment for inmates, because lack of access to treatment can have important policy implications, particularly when financial resources are limited for correctional intervention and treatment.Individuals with untreated mental health conditions may be at higher risk for correctional rehabilitation treatment failure and future recidivism on release from prison.2,9,10 In fact, Baillargeon et al.10 found that after release from prison, former inmates who received a professional diagnosis of any Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, mental health disorder were 70% more likely to return to prison at least once than were those who were not given a diagnosis. Furthermore, among those who have been previously incarcerated, the rates of recidivism are between 50% and 230% higher for persons with mental health conditions than for those without any mental health conditions, regardless of the diagnosis.The limited treatment options in many prison settings are directly reflected in the greater number of disciplinary problems, rule violations, and physical assaults among those who have mental health disorders,11 often compounded by the resulting solitary confinement as punishment for these behaviors.1 Although all prisons are required to provide some level of health care, we know very little about whether mental health treatment is actually available to inmates on a case-by-case basis.3,9 In fact, Wilper et al. found that most prisoners, even those who have chronic medical conditions (such as diabetes or hypertension), had limited access to health care in prison.3 Therefore, we used a nationally representative sample of US prisoners to assess whether all persons with a history of mental health conditions were screened and evaluated by a medical professional for these conditions and whether medication use was continuous from the community setting to the prison setting.Mental health conditions represent a different level of need when compared with physical health needs among prisoners. For instance, tuberculosis transmission is a physical health hazard to all inmates and staff. Therefore, correctional administrators ensure that individuals suspected of having tuberculosis obtain proper assessment and subsequent access to health care. Symptoms inherent to many mental health disorders, however, may be less obvious to prison staff, especially without assessment by trained mental health professionals. In addition, a report on mental health care in prison emphasized the need for screening and treatment of mental health conditions among inmates from both a legal and a humanitarian perspective.12 Specifically, several US Supreme Court decisions have supported the rights of prisoners to receive health care, including mental health care (see Bowring v Godiva, 551 F2d 44 [4th Cir 1977]; Laamon v. Helgemoe, 437 F Supp 269 [DNH 1977]; and Ruiz v Estelle, 503 F Supp 1265 [SD Tex 1980]). To date, however, a great deal of variation remains in screening for and treatment of mental health disorders in prison settings.13,14 The use of pharmacotherapy, in conjunction with counseling and self-help groups, to treat mental health conditions in correctional settings has been largely accepted in the correctional community; however, many medications are expensive and, therefore, not offered widely within institutions.4,12,13,15Several practical issues might explain why an individual in the correctional system would have difficulty receiving (or continuing to receive) pharmacotherapy for mental health conditions. First, psychologists and psychiatrists who may properly diagnose disorders are in short supply,12 and the screening tools that are typically used in prison settings are not diagnostic tests. Instead, the purpose of these tools is to gauge the security risk of a new inmate at the institution.4 Second, the continuously declining correctional budget may limit treatment access to those with only the most serious mental health conditions.5 In an ideal situation in which a licensed professional properly diagnoses inmates, specialized treatment programs (rarely located inside of prison facilities) are available. Unfortunately, the use of these outside treatment programs is limited, because correctional budgets do not have the extensive resources necessary to manage inmates enrolled in off-site treatment or to handle the logistics (such as secure transport) involved.15The incarceration experience itself poses a challenge to mental health treatment. Untreated mental health (and physical health) conditions are known to result in poor adjustment to life in prison.12 Furthermore, crowded living quarters, lack of privacy, increased risk of victimization, and solitary confinement within the institution have been identified as strong correlates for self-harm and adaptation challenges for those with mental health conditions in prison settings.16,17Given the strong relation between mental health and criminal behavior,18 the public health system has a great deal to gain from better mental health treatment among inmates, particularly in reducing the costs associated with high recidivism rates.5,10,19 Therefore, this study extends previous research on prisoner health conducted by Wilper et al.3 by assessing the continuity of pharmacotherapy (e.g., medication used to treat a mental health condition in prison), beyond the prevalence rates of pharmacotherapy in prison. Furthermore, we examined potential explanations for both continuity and discontinuity of treatment in the inmate population. Specifically, this study will contribute to the literature by evaluating 3 specific aims: (1) to assess medication continuity for a mental health condition since admission to prison; (2) to assess the correlates of medication continuity, medical screening, and receipt of examinations by medical personnel; and (3) to assess the degree to which medication continuity is predicted by screening prisoners for mental health conditions at intake to prison.     

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.     

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.     

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     

Assessment of Hepatitis C Risk Factors and Infection Prevalence in a Jail Population

Objectives. We sought to validate previous reports of HCV prevalence in jails, identify HCV risk factors prevalence, and identify risk factors associated with HCV infection in this population.Methods. Inmates at the Buzz Westfall Justice Center (BWJC) in St. Louis, Missouri, were offered risk factor screening for HCV and anti-HCV antibody testing from December 2012 through May 2013. Demographic and risk factor information were assessed for significant associations with positive HCV antibody results. Risk factors that were significantly associated in univariate analysis were assessed using binary logistic regression to model the relationship between positive HCV results and the risk factors and demographics.Results. Fifty of 304 inmates were positive for HCV, with a prevalence of 16.4%. The risk factors significantly associated with increased risk for positive HCV antibody were age (odds ratio [OR] = 1.09; 95% confidence interval [CI] = 1.04, 1.15 for each year), injection drug use (OR = 53.87; 95% CI = 17.78, 163.21), sex with HCV-positive partner (OR = 7.35; 95% CI = 1.41, 38.20), and tattoos by a nonlicensed provider (OR = 2.62; 95% CI = 1.09, 6.33). Prevalence for women was 3 times that of men (38% vs 12%).Conclusions. Prevalence of HCV at BWJC was similar to previous jail studies, which is lower than reported prison rates and higher than the general population.HCV infection is one of the most common and deadly blood-borne infectious diseases in the United States.1–3 National Health and Nutrition Examination Survey (NHANES) data estimate that 1.6% of the US population, or about 4.1 million people are infected with HCV.2 This NHANES estimate is likely an underestimation because it did not sample several high prevalence populations; the true prevalence may be conservatively closer to 2% (5.2 million) or potentially as high as 2.8% (7.1 million).4 In 2010, approximately 17 000 new infections occurred with an incidence rate of 0.3 cases per 100 000 persons in the United States.5 Incidence rates have decreased significantly from 1992, but have been holding fairly steady over the past decade.3 Some authors predict the incidence will likely increase slightly with recent increases in injection drug use. The incidence of complications associated with HCV is expected to continue to increase as well.3,6HCV infection is associated with significant morbidity, mortality, and cost. It is the most common chronic liver disease associated with hepatocellular carcinoma, present in close to half of all cases.7,8 It is the leading indication for liver transplantation in the United States, with a rate nearly double that of the second cause.9 HCV infection was listed as an underlying or contributing cause of more than 15 000 deaths in 2007.10 Patients who do not go on to develop cirrhosis or those in the 20- to 30-year window between infection and development of cirrhosis can also suffer social, emotional, and physical complications; experience a decreased quality of life; and require hospitalization.3,11,12 The yearly total health care costs associated with HCV infection were calculated to be $6.5 billion in 2007 and are predicted to peak at $9.1 billion in 2024 based on current trends and excluding the cost of antiviral treatments.6In the general US population, the risk factors most associated with HCV infection are injection drug use (IDU), sexual contact with HCV-positive partners, receipt of blood and blood products prior to 1992, and needle sticks.2,5 According to data from NHANES, men have a higher prevalence of HCV infection than women (2.1% vs 1.1%), and non-Hispanic Blacks have a higher prevalence than non-Hispanic Whites or Mexican Americans (3%, 1.5%, and 1.3% respectively).2 The Centers for Disease Control and Prevention has recently added a recommendation to test all patients born between 1945 and 1965, as this birth cohort has a HCV prevalence rate of 3.25% and accounts for approximately 75% of HCV infections in the general US population.13 One recent analysis found that among those with a history of IDU, any past incarceration was significantly associated with HCV infection with an adjusted odds ratio (OR) of 2.6 (95% confidence interval [CI] = 1.2, 6.1).14As prevalent as HCV infection is in the general population, it is nearly 10-fold higher in the incarcerated population. The prevalence of HCV infection in incarcerated individuals is estimated to be 23.1% to 41.2%.4 Individuals who are incarcerated are more likely to participate in high-risk behavior for HCV infection, including IDU, tattoos from nonlicensed providers, and prostitution. In addition to their increased risk prior to incarceration, inmates are also at higher risk for becoming infected during incarceration, mostly from tattoos received in prison and continued use of injection drugs while incarcerated. With increasing rates of IDU in the United States, rates of incarceration and HCV infection are predicted to increase as well.3Although there is a significant amount of literature assessing HCV in the general population and incarcerated populations as a whole, most of the literature assessing incarcerated populations deals specifically with prison populations rather than jail populations. Jails are more dynamic environments than prisons and include people being released from custody in a short period of time as well as those destined to be imprisoned. Studies relating to HCV infection in a jailed population are much more limited. Only 1 previous study has specifically assessed only jailed populations.15 This study assessed the prevalence of HCV infection from a random sample of stored blood samples from 3 city jails and did not include any risk factor assessment directly from inmates, although it did link results to demographic information, previous incarceration status, hepatitis B virus (HBV) infection, and HIV infection status. This evaluation found the weighted prevalence of HCV to be 13% overall with 10% prevalence in San Francisco, California; 14% in Chicago, Illinois; and 15% in Detroit, Michigan. The study was not able to assess whether inmates were previously aware of their HCV infection.15 Another study assessed both jail and prison populations in Maryland.16 This study also assessed HCV rates on stored samples and was linked to demographic information, reasons for incarceration, syphilis infection, HBV infection, and HIV infection. Those enrollees labeled as “detainees,” meaning presentencing, had an HCV prevalence of 31.1%, higher than that in the prison population at 26.4%.As pointed out in a 2012 editorial, jails may represent an ideal location to institute widespread screening programs for HCV.17 Jails may represent a higher-risk group than the general population. Identifying those at high risk for HCV infection in a jail could lead to education on risk reduction to those not already infected and could lead to earlier detection for those infected with HCV who did not previously know of their infection status. This detection could prevent the spread within communities for those jail inmates who are released from custody shortly after incarceration and could decrease the spread of HCV within prisons for those who are sentenced. In addition to slowing or preventing the spread of HCV, the detection of an infection in jails could lead to more frequent and earlier treatment, improving the health of the infected inmate and decreasing the morbidity and costs associated with late-stage HCV infections. This article also correctly points out, however, that the cost savings that may be realized because of early screening and intervention for HCV are unlikely to be realized directly by the same payers as the initial direct screening costs. Finding ways to better target testing expenditures would enable jails to provide a public health benefit without the costs associated with testing all those incarcerated.The current project was undertaken to add to and validate previous reports of HCV prevalence in jailed populations, identify the HCV risk factors present in this population, and identify the risk factors most associated with HCV infection in the population.     

Intergenerational Social Networks and Health Behaviors Among Children Living in Public Housing

Objectives. In a survey of families living in public housing, we investigated whether caretakers’ social networks are linked with children’s health status.Methods. In 2011, 209 children and their caretakers living in public housing in suburban Montgomery County, Maryland, were surveyed regarding their health and social networks. We used logistic regression models to examine the associations between the perceived health composition of caretaker social networks and corresponding child health characteristics (e.g., exercise, diet).Results. With each 10% increase in the proportion of the caretaker’s social network that exercised regularly, the child’s odds of exercising increased by 34% (adjusted odds ratio = 1.34; 95% confidence interval = 1.07, 1.69) after the caretaker’s own exercise behavior and the composition of the child’s peer network had been taken into account. Although children’s overweight or obese status was associated with caretakers’ social networks, the results were no longer significant after adjustment for caretakers’ own weight status.Conclusions. We found that caretaker social networks are independently associated with certain aspects of child health, suggesting the importance of the broader social environment for low-income children’s health.Health inequalities often endure across several generations.1,2 Studies have linked grandparental and parental childhood exposures,3,4 social class,5 educational attainment,6,7 and health behaviors8 to offspring health. Neighborhood environments have been postulated to play an important role in the persistence of intergenerational inequalities. Research conducted by Sharkey has shown that children whose parents grew up in disadvantaged, segregated neighborhoods are highly likely to themselves live in disenfranchised neighborhoods as adults.1 Although social scientists have noted the important contributions of neighborhood social processes to health outcomes,9 the question of whether social networks play a role in connecting neighborhood environments to intergenerational inequality remains unresolved.Understanding how social networks influence health behaviors and outcomes is an evolving area of research in public health.10,11 Studies have linked the likelihood of particular health-related behaviors and attributes among adults, such as smoking, alcohol consumption, obesity, and poor mental health, to the characteristics of their friends and relations.11–14 Research also has shown associations between children’s peer networks and aspects of their health, including physical activity, weight, and substance use.15–21 Despite growing interest in social networks and health, little is known about intergenerational social networks or how the social networks of one generation may affect the health and well-being of the next.Caretaker social networks may be related to child health through at least 2 mechanisms. First, the adults in a caretaker’s social network may shape a child’s health directly by serving as adult role models, modeling behaviors and conveying social norms.22 Second, a caretaker’s social network may have an indirect effect, mediated by the caretaker, on a child’s health.22 In this formulation, the caretaker may select network members with similar health beliefs and behaviors, given the tendency for individuals with shared characteristics to establish ties (a phenomenon known as homophily),23 or social network members with different characteristics may influence caretakers to express new norms or behaviors (termed induction).13 By reinforcing or shaping the caretaker’s attitudes and behaviors, caretaker social networks may, in turn, influence children. It is widely recognized that caretakers play a critical role in their children’s health by providing food, shelter, and care; teaching children about healthy eating; creating opportunities for physical activity; and molding children’s understanding of health and related behavioral norms.24–28We examined associations between caregivers’ social ties and children’s health among families living in suburban subsidized housing. Specifically, we assessed whether relationships exist between caregivers’ social networks and their children’s health and whether these associations are independent of caretakers’ own health characteristics.We focused on suburban families living in subsidized housing for several reasons. First, although subsidized housing programs provide important benefits to residents,29–31 the physical and mental health of these populations is often poor.32–35 Second, suburban neighborhoods, on average, now house more poor residents than do central US cities, and the number of families in suburban public housing continues to grow.36,37 Third, families receiving housing assistance are at the bottom of the income distribution, with most such households earning less than $20 000 annually.38 Fourth, caretakers’ social networks may play important roles among families living in certain types of public housing in which friends and neighbors serve as informal caretakers by watching one another’s children.39 This may be particularly important in single-parent households, which made up the majority of households in our study.Studies of public housing residents have shown that their social networks may be affected by neighborhood context.39–42 Using data from Montgomery County, Maryland, we previously found that adults living in wealthier communities had more socioeconomically diverse and, to a limited extent, healthier social networks.41,43 Similarly, research from the Moving to Opportunity experiment revealed that participants who received housing vouchers to move to low-poverty neighborhoods (from high-poverty neighborhoods) were more likely to have at least 1 college-educated friend than those who remained in public housing developments in high-poverty neighborhoods.44 Given the well-documented relationship between income and health and the evidence of limited intergenerational mobility among children who grow up in poor households and neighborhoods,45,46 determining the extent to which associations exist between caretakers’ social networks and children’s health allows consideration of whether caretakers’ relationships may maintain or disrupt intergenerational inequalities known to affect factors critical to health.     

Self-Reported Experience of Racial Discrimination and Health Care Use in New Zealand: Results From the 2006/07 New Zealand Health Survey

Objectives. We investigated whether reported experience of racial discrimination in health care and in other domains was associated with cancer screening and negative health care experiences.Methods. We used 2006/07 New Zealand Health Survey data (n = 12 488 adults). We used logistic regression to examine the relationship of reported experience of racial discrimination in health care (unfair treatment by a health professional) and in other domains (personal attack, unfair treatment in work and when gaining housing) to breast and cervical cancer screening and negative patient experiences adjusted for other variables.Results. Racial discrimination by a health professional was associated with lower odds of breast (odds ratio [OR] = 0.37; 95% confidence interval [CI] = 0.14, 0.996) and cervical cancer (OR = 0.51; 95% CI = 0.30, 0.87) screening among Maori women. Racial discrimination by a health professional (OR = 1.57; 95% CI = 1.15, 2.14) and racial discrimination more widely (OR = 1.55; 95% CI = 1.35, 1.79) were associated with negative patient experiences for all participants.Conclusions. Experience of racial discrimination in both health care and other settings may influence health care use and experiences of care and is a potential pathway to poor health.Racism is increasingly recognized as an important determinant of health and driver of ethnic health inequalities.1 Regardless of its health effects, racism breaches fundamental human rights and is morally wrong. It is important to understand how racism operates as a health risk to develop interventions that reduce ethnic inequalities in health within a context of eliminating racism.2Racism is an organized system that categorizes racial/ethnic groups and structures opportunity, leading to inequities in societal goods and resources and a racialized social order.3–5 Racism operates via institutional and individual practices (racial discrimination) and varies in form and type.6,7 The pathways whereby racism leads to poor health are also multiple, with direct and indirect mechanisms such as race-based assaults and violence, physiological and psychological stress mechanisms, differential exposures to health risk factors, differential access to and experiences of health care, and differential access to goods, resources, and power in society.6,8–10Research on racism and health, particularly self-reported racism, has increased. Self-reported experience of racism has been linked to multiple health measures (including mental and physical health outcomes and health risk factors) across a variety of countries and for different ethnic groups.10–12 Research on how self-reported experience of racism may negatively affect health has largely focused on racism as a stressor with mental and physical health consequences.10,13 Comparatively less evidence is available on how experience of racism may influence health service use,10 although this is another potentially important pathway to poor health.14,15Studies on the association between self-reported racism and health care experience and use have included racism experienced within the health care system, outside of the health care system, or both.16–19 Health care measures have included use of specific services such as cancer screening19–24 and receipt of optimal care,20,25 measures of unmet need,16,26 measures of adherence to care,17,27,28 and measures of satisfaction and experiences with care.18,29–31Various mechanisms have been suggested to explain how the experience of racism may negatively affect health care use, experiences of health care, and subsequent poor health. Experiences of racism within the health care system may influence health by shaping decision making of both providers and patients and influencing future health behaviors, including future health care use behaviors and potential disengagement from the health care system.14,18,26 Experiences of racism in wider society also may lead to general mistrust and avoidance of dominant culture institutions, including health care systems.15,30 This is supported by evidence that both experiences of racism and general discrimination within and outside of health care have been associated with negative health care use measures.15,16,19,22New Zealand has a population of approximately 4.4 million people, with the major ethnic groupings being Maori (indigenous peoples, 15% of the population), European (77%), Pacific (7%), and Asian (10%).32 Ethnic inequalities in health and socioeconomic status persist, with racism a potentially important contributor to these inequalities.33 Previous research in New Zealand has shown reported experience of racial discrimination by a health professional to be higher among non-European ethnic groups with experiences of racial discrimination in different settings associated with multiple health outcomes and risk factors.34In this study, we focused on the relationship between racial discrimination and health service use and experience, an area not previously examined in New Zealand. We provide important information on how racial discrimination may affect health care use as a possible pathway to poor health outcomes and ethnic health inequalities in New Zealand. In addition, our study contributes to the limited evidence on racial discrimination and health care internationally.Primary health care in New Zealand is available to all residents and is usually provided at general practices. Costs of visits are universally subsidized by government to enable lower patient copayments with additional limited provision for extra funding based on high need.35 Currently, 2 publicly funded national cancer screening programs are available.36 Breast cancer screening is free to all eligible women through BreastScreen Aotearoa. Cervical cancer screening usually incurs a fee and is available through patients’ usual primary care provider or specific cervical cancer screening providers.We specifically examined the association between self-reported experience of racial discrimination and the use of health care in 2 domains—cancer screening and negative patient perceptions of health care encounters. We hypothesized that experience of racial discrimination both within and outside the health care system may negatively affect how individuals use and experience health care.     

Neighborhood Social Capital,Neighborhood Attachment,and Dental Care Use for Los Angeles Family and Neighborhood Survey Adults

Objectives. We tested the hypothesis that neighborhood-level social capital and individual-level neighborhood attachment are positively associated with adult dental care use.Methods. We analyzed data from the 2000–2001 Los Angeles Family and Neighborhood Survey that were linked to US Census Bureau data from 2000 (n = 1800 adults aged 18–64 years across 65 neighborhoods). We used 2-level hierarchical logistic regression models to estimate the odds of dental use associated with each of 4 forms of social capital and neighborhood attachment.Results. After adjusting for confounders, the odds of dental use were significantly associated with only 1 form of social capital: social support (adjusted odds ratio [AOR] = 0.85; 95% confidence interval [CI] = 0.72, 0.99). Individual-level neighborhood attachment was positively associated with dental care use (AOR = 1.05; 95% CI = 1.01, 1.10).Conclusions. Contrary to our hypothesis, adults in neighborhoods with higher levels of social capital, particularly social support, were significantly less likely to use dental care. Future research should identify the oral health–related attitudes, beliefs, norms, and practices in neighborhoods and other behavioral and cultural factors that moderate and mediate the relationship between social capital and dental care use.Oral health is an indicator of general health and social justice.1,2 Common dental diseases such as tooth decay and gum disease are linked to chronic health conditions, including cardiovascular disease, stroke, diabetes, obesity, and kidney disease.3–7 When left untreated, dental diseases can lead to difficulties chewing food, pain, systemic infections, hospitalization, and, in rare cases, death. Less visible are the social consequences of poor oral health, such as lost work hours,8 functional limitations,9,10 and poor quality of life.11A comprehensive strategy for optimal oral health involves exposure to topical fluorides (e.g., in optimally fluoridated water, toothpaste), limited fermentable carbohydrate intake, tobacco use prevention, and regular dental visits.12 Professional dental care is particularly important because dentists have opportunities to assess a patient’s risk level for oral health problems, provide diagnostic and preventive care as well as needed restorative care, deliver patient-centered anticipatory guidance, and screen for systemic health conditions.13–16 However, not all individuals in the United States have equal access to dental care.17Most dental utilization studies focus on children younger than 18 years and seniors aged 65 years and older, even though data from the National Health and Nutrition Examination Survey indicate a decline in dental care use for US adults aged 18 to 64 years.18 Between 1988 and 1994 and 1999 and 2004, there were significant drops in the proportions of adults who had an annual dental visit for those aged 20 to 34 years (from 63.5% to 54.6%) and those aged 35 to 49 years (from 69.0% to 62.5%).18 The factors related to these declines are unknown.The 2008 World Health Organization report Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health calls for policies and interventions targeting the social determinants of health to reduce and eliminate health disparities.19 Social determinants of health are the structural and environmental conditions that shape human welfare and well-being,20 with health inequalities attributed to unequal distribution of and access to power, money, and resources.21 Although social factors contribute to disparities in dental care use,22 relevant studies focus mostly on individual-level determinants.23–37 There has been less emphasis on the area-level social determinants of adult dental care use.Social capital is an important health determinant38–41 and is defined as the material, affective, and informational resources inherent in social networks. Most health research has focused on social capital in neighborhoods. Neighborhood-based social capital can be operationalized into 4 forms: (1) social support (provisions that help residents cope with everyday challenges), (2) social leverage (sharing information on health- and non–health-related issues), (3) informal social control (maintenance of safety and norms), and (4) neighborhood organization participation (organized efforts that address community quality of life and personal well-being).42 Social capital has direct and interactive associations with a range of positive and negative health-related outcomes.43,44 In some cases, these resources may not help individuals pursue a desirable health outcome or may inhibit an individual’s efforts through negative influences in the community.45Although investigators have examined social capital and access to health care services,46 fewer oral health–related studies have focused on social capital. In 2 multilevel studies of elderly persons in Japan, number of teeth was positively associated with higher levels of neighborhood friendship networks47 and a higher prevalence of neighborhood peer group activities.48 Neighborhood social capital also moderated the relationship between income inequality and self-reported oral health but not the number of teeth present among the Japanese elderly.49 A study of Japanese students aged 18 to 19 years found that poor self-reported oral health was associated with lower levels of neighborhood trust and with higher levels of neighborhood informal social control.50 Among Brazilians aged 14 to 15 years, a 5-dimension measure showed that social capital (social trust, social control, empowerment, neighborhood security, and political efficacy) was inversely associated with odds of dental injury.51Although social capital was not the primary focus, there are 2 relevant US publications. The first reported positive associations between neighborhood social capital and self-reported oral health for children younger than 18 years.52 In the second, neighborhood social capital was identified as a potential source of oral health disparities between Black children and White children aged 3 to 17 years (measured as having a dental problem and poor self-reported oral health) but not for disparities in preventive dental care use.53 Collectively, these studies suggest that neighborhood social capital is an important determinant of oral health.54–56 However, they have 2 main limitations: (1) none of the operationalizations of social capital considered the extent of neighborhood social ties, the resources linked to these ties, or unequal access to resources42; and (2) none focused on dental care use for adults aged 18 to 64 years, a US population subgroup that has exhibited declines in dental care use.18We addressed previous limitations by adopting a multilevel conceptual model of social capital42,43,45 to examine how neighborhood social capital is associated with dental care use for US adults (Figure 1). We operationalized neighborhood-level social capital as the 4 forms identified earlier (social support, social leverage, informal social control, and neighborhood organization participation). Individual-level neighborhood attachment is the extent to which an individual knows and socializes with neighbors42–44; this moderates the effects of social capital.57 On the basis of this model, we tested 3 hypotheses: (1) higher levels of each form of neighborhood social capital are associated with greater odds of dental use, (2) neighborhood attachment is associated with greater odds of dental care use, and (3) there are interactions between social capital and neighborhood attachment. This study represents an important first step in understanding the social determinants of an important oral health behavior. Our long-term goal is to develop and test neighborhood-based interventions and policies aimed at improving the oral health of individuals at greatest risk for disparities in dental care use.Open in a separate windowFIGURE 1—Conceptual model and proposed study hypotheses tested using data from the Los Angeles Family and Neighborhood Survey, 2000–2001.Note. H1 = hypothesis 1 (there is a direct relationship between the 4 social capital forms and adult dental care use); H2 = hypothesis 2 (there is a direct relationship between neighborhood attachment and adult dental care use); H3 = hypothesis 3 (in modeling adult dental care use, there is an interaction between the four forms of social capital and neighborhood attachment).     

Incarcerated Youths’ Perspectives on Protective Factors and Risk Factors for Juvenile Offending: A Qualitative Analysis

Objectives. We sought to understand incarcerated youths’ perspectives on the role of protective factors and risk factors for juvenile offending.Methods. We performed an in-depth qualitative analysis of interviews (conducted October–December 2013) with 20 incarcerated youths detained in the largest juvenile hall in Los Angeles.Results. The adolescent participants described their homes, schools, and neighborhoods as chaotic and unsafe. They expressed a need for love and attention, discipline and control, and role models and perspective. Youths perceived that when home or school failed to meet these needs, they spent more time on the streets, leading to incarceration. They contrasted the path through school with the path to jail, reporting that the path to jail felt easier. All of them expressed the insight that they had made bad decisions and that the more difficult path was not only better but also still potentially achievable.Conclusions. Breaking cycles of juvenile incarceration will require that the public health community partner with legislators, educators, community leaders, and youths to determine how to make success, rather than incarceration, the easier path for disadvantaged adolescents.With 2 million juveniles arrested and over 60 000 detained annually, the United States incarcerates a larger proportion of youths than any other developed country.1–3 Incarcerated adolescents represent a high-risk, vulnerable population with disproportionately high rates of unmet physical, developmental, social, and mental health needs, and higher mortality.4–7 Juvenile offending predicts a higher likelihood of chronic adult offending, as well as adverse adult outcomes such as poor health, substance use, and increased mortality.8 Further, significant disparities exist. African American youths are approximately 5 times more likely, and Latino and American Indian adolescents are 3 times more likely, to be detained than their White counterparts.3 Additionally, adolescents from socially disadvantaged neighborhoods are at higher risk for incarceration.9 These inequities perpetuate future incarcerations. Prior incarceration places youths at greater risk for repeat offending throughout adolescence and adulthood.10 Within 3 years of release, approximately 75% of adolescents are rearrested.2Identification of protective and risk factors for juvenile offending can inform programs and policies to disrupt youths’ pathways to jail. Quantitative studies identify low school achievement, poor mental health, substance use, parental incarceration, large family size, single-parent families, poor parental supervision, delinquent peer groups, and residing in high-crime neighborhoods as risk factors for juvenile offending.11,12 The modest literature on protective factors for juvenile incarceration highlights the importance of supportive family relationships, prosocial peers, academic achievement, reading ability, and psychological factors such as self-esteem and empathy.13–15Qualitative research to identify underlying mechanisms for these associations is needed. For effective implementation, predictive factors need to be understood in the context of youths’ situations, goals, and ideas about pathways to jail within their communities. Yet adolescent voices on pathways to jail are notably lacking in this literature. To date, only 1 published study has examined incarcerated youths’ perspectives on protective and risk factors for incarceration. The study, which focused on barriers and protective factors during community reentry after juvenile incarceration, identified social connectedness and having a future-oriented perspective as the main predictors of success.16 Adolescents’ views of the pathways to jail across the entire trajectory of juvenile offending—from initiation of delinquency and entry into the juvenile justice system, to repeat arrests and, ultimately, their expected endpoints for these trajectories—remain unknown.To address these gaps, we interviewed incarcerated youths to elucidate their perspectives on pathways to jail across the trajectory of juvenile offending. We explored their perceptions of protective and risk factors in their communities, with the ultimate goal of strengthening programs that prevent juvenile offending and disrupt cycles of incarceration.     

Revisiting the Role of the Urban Environment in Substance Use: The Case of Analgesic Overdose Fatalities

Objectives. We examined whether neighborhood social characteristics (income distribution and family fragmentation) and physical characteristics (clean sidewalks and dilapidated housing) were associated with the risk of fatalities caused by analgesic overdose.Methods. In a case-control study, we compared 447 unintentional analgesic opioid overdose fatalities (cases) with 3436 unintentional nonoverdose fatalities and 2530 heroin overdose fatalities (controls) occurring in 59 New York City neighborhoods between 2000 and 2006.Results. Analgesic overdose fatalities were less likely than nonoverdose unintentional fatalities to have occurred in higher-income neighborhoods (odds ratio [OR] = 0.82; 95% confidence interval [CI] = 0.70, 0.96) and more likely to have occurred in fragmented neighborhoods (OR = 1.35; 95% CI = 1.05, 1.72). They were more likely than heroin overdose fatalities to have occurred in higher-income (OR = 1.31; 95% CI = 1.12, 1.54) and less fragmented (OR = 0.71; 95% CI = 0.55, 0.92) neighborhoods.Conclusions. Analgesic overdose fatalities exhibit spatial patterns that are distinct from those of heroin and nonoverdose unintentional fatalities. Whereas analgesic fatalities typically occur in lower-income, more fragmented neighborhoods than nonoverdose fatalities, they tend to occur in higher-income, less unequal, and less fragmented neighborhoods than heroin fatalities.Rates of fatal overdoses caused by analgesic opioids have increased dramatically in the United States, particularly over the past 5 years.1–3 The prevalence of nonmedical analgesic drug abuse is second only to that of marijuana abuse, and currently the number of fatal overdoses attributed to opioid analgesics, such as oxycodone, hydrocodone, and codeine, is greater than the number attributed to heroin and cocaine combined.4Urban areas have long been associated with elevated risks of substance abuse and subsequent mortality from unintentional drug poisoning. From 1997 to 2002, the number of overdose deaths involving opioid analgesics increased 97% in urban areas during a time when the rate of overdose from all drugs increased 27%.5 From a public health burden standpoint, understanding the determinants of analgesic overdose mortality in large urban areas is critical to help stem the tide of mortality from analgesics, as all available data suggest that analgesic overdose mortality in these areas will continue to increase in the coming years.6Extant epidemiological research in the area has predominantly been concerned with the role of individual characteristics in explaining the prevalence of analgesic overdose throughout the United States.5,7–12 Analgesic opiate overdose decedents have been reported to be primarily White, male, and adult (ranging in age from 25 to 54 years) and to exhibit a high prevalence of concurrent psychotherapeutic drug use.5,7–10 However, several organizing frameworks in the field (principally rooted in ecosocial theory) suggest that environments operate jointly with individual factors to influence the risk of substance use.13–15In addition to individual characteristics such as psychiatric morbidity, genetic vulnerability, gender, and age,16–20 these frameworks suggest that interconnected components of influence shape drug use. These components include social policies and regulations that affect the allocation of social and health resources21–26; social and physical features of the neighborhood environment that structure the availability of drugs, influence norms around use, and generate sources of stress that contribute to drug use13,14,27–37; and interpersonal characteristics, such as social support and social networks, that mediate the relationship between the neighborhood environment and drug use.28,31,38–42 Despite this conceptual orientation, few studies have attempted to provide an understanding of the contextual factors that may explain the geographic distribution of analgesic overdose in an urban environment.Of particular interest in the urban context are the features of neighborhoods that can shape drug overdose. Established conceptual frameworks suggest 2 such features: primary determinants of infrastructure, employment, education, and health care resources, including residential segregation, income distribution, and neighborhood deprivation, and secondary determinants that are consequences of these fundamental conditions and may mediate their impact on drug use, including the quality of the built environment, social norms around drug use, and family fragmentation.15 Drawing on this framework, we examined 3 features of the neighborhood environment that have been previously linked with drug overdose: income distribution, quality of the built environment, and family fragmentation.35,37,43,44First, neighborhood income distribution has been consistently linked to drug abuse or overdose fatalities.27,35,44,45 For example, research has shown that in New York City neighborhoods with more unequal income distributions, drug overdoses are more likely than other causes to lead to unintentional deaths.35,44 The erosion of social capital and greater mistrust of authority found in more unequal neighborhoods may lead to a greater reluctance to seek medical help in cases of overdose.46 Furthermore, underinvestment in health and social resources could contribute to longer response times on the part of paramedics and limited access to substance abuse treatment. It is plausible that these same processes may drive a higher risk for analgesic opiate overdose in more unequal neighborhoods.Second, studies have shown a positive association between poor quality of the built environment (dilapidated buildings, vandalism of public property, and littering) and risk of drug overdose.43,44,46 Deterioration of the built environment has been linked with higher levels of distress.47 In turn, people with higher levels of distress may be more vulnerable to drug abuse and overdose than people low in distress.48,49 Moreover, reduced social capital reflected in a vandalized and littered built environment may discourage neighborhood residents from interacting with each other and from developing relationships that would enable to them to intervene to prevent the development of drug distribution networks in the neighborhood.50Third, family fragmentation (e.g., a high prevalence of divorced, separated, or single-parent families) represents a social mechanism through which neighborhoods may influence analgesic overdose. Disruption of the neighborhood social fabric may manifest in personal forms of disorganization within adult relationships.51,52 Studies of crime have shown that family disruption influences the collective ability of local residents to promote adult and youth conformity to local norms and laws.53–55 A high prevalence of fragmented families in a neighborhood reduces the neighborhood’s ability to monitor young people and respond to delinquency and crime.56 Such disorganization may have direct consequences in terms of access to and consumption of analgesics, given that the formation of drug-selling and drug-consuming networks may be more likely in neighborhoods where residents do not monitor delinquent activity consistently.57Furthermore, disrupted families may be less likely to exert informal control over the abuse of analgesics by other family members.57 Given that consumption of analgesics occurs most frequently at home,58 the absence of a family support and control net is particularly problematic.This study had 2 aims. First, we examined the roles that the 3 features of the neighborhood social and physical environment just described—income distribution, the quality of the built environment, and family fragmentation—play in the risk of unintentional death from analgesic overdose in New York City. Second, we examined whether analgesic opiate overdoses in New York City are driven by distinct neighborhood factors than heroin overdose, the historically most prevalent form of illicit opiate overdose in urban areas.59,60