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.     

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

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

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.     

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.     

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.     

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.     

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.     

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

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

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

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

The Case for Improving the Health of Ex-Prisoners

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

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

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

Social Branding to Decrease Smoking Among Young Adults in Bars

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

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

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

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.     

Let’s Get Physical: Sexual Orientation Disparities in Physical Activity,Sports Involvement,and Obesity Among a Population-Based Sample of Adolescents

Objectives. We examined sexual orientation disparities in physical activity, sports involvement, and obesity among a population-based adolescent sample.Methods. We analyzed data from the 2012 Dane County Youth Assessment for 13 933 students in grades 9 through 12 in 22 Wisconsin high schools. We conducted logistic regressions to examine sexual orientation disparities in physical activity, sports involvement, and body mass index among male and female adolescents.Results. When we accounted for several covariates, compared with heterosexual females, sexual minority females were less likely to participate in team sports (adjusted odds ratio [AOR] = 0.44; 95% confidence interval [CI] = 0.37, 0.53) and more likely to be overweight (AOR = 1.28; 95% CI = 1.02, 1.62) or obese (AOR = 1.88; 95% CI = 1.43, 2.48). Sexual minority males were less likely than heterosexual males to be physically active (AOR = 0.62; 95% CI = 0.46, 0.83) or to participate in team sports (AOR = 0.26; 95% CI = 0.20, 0.32), but the 2 groups did not differ in their risk of obesity.Conclusions. Sexual orientation health disparities in physical activity and obesity are evident during adolescence. Culturally affirming research, interventions, and policies are needed for sexual minority youths.Obesity is an increasing and serious health problem among adolescents.1,2 This is of major concern because obesity has many health and social consequences and it affects adolescents’ overall well-being.3,4 Obesity among adolescents also has a high likelihood of continuing into adulthood.5 Recent population-based and longitudinal research has demonstrated that there are disparities in obesity between sexual minority and heterosexual adolescents.6–8 Research has also documented sexual orientation disparities in physical activity and sports involvement in adolescence.9,10 Despite this increased attention, the overall empirical base remains limited, and findings also suggest some gender nuances that need further exploration. More population-based research is needed to investigate these disparities, consistent with federal health priorities.7,11There are sexual orientation–based disparities in physical activity and sports involvement among adolescents; however, there are mixed findings for females. One study reported that sexual minority females are less likely than heterosexual females to participate in moderate to vigorous physical activity and team sports,9 whereas another study found no such differences in physical activity.10 Findings are more consistent for sexual minority male adolescents, who are less likely than heterosexual males to engage in moderate to vigorous physical activity, to engage in recommended levels of physical activity, and to participate in team sports.9,10 More research is needed because of the paucity of studies and mixed results. This is especially important given that adolescents’ physical activity has been shown to relieve stress and protect against many mental and physical health conditions, including obesity,12,13 for which sexual minority adolescents are at greater risk.Research on sexual orientation disparities in obesity suggests that there are some gender nuances. Many studies have found that sexual minority female adolescents have higher risk of obesity than heterosexual females (e.g., higher body mass index [BMI], defined as weight in kilograms divided by the square of height in meters).6,8,10,14 These sexual orientation disparities in obesity among adolescent females parallel those among sexual minority adult women.15,16Findings of elevated obesity risk among sexual minority male adolescents are mixed. Some studies show that sexual minority males, specifically bisexual males, have higher odds of obesity than heterosexuals,14 whereas other studies have documented no differences.10 By contrast, some studies have found that heterosexual males have increases in BMI during adolescence compared with sexual minority males.6,8 These mixed findings for sexual minority males might be attributed to physical maturation and developmental changes in adolescence that some of the cross-sectional studies could not examine.10,14 Specifically, one study found that sexual minority males had higher obesity risk than heterosexual males in early adolescence, but their risk of obesity became lower than for heterosexual males later in adolescence.6 The authors postulated that, compared with heterosexual males, sexual minority males reach puberty maturation earlier in adolescence but make less substantial weight gains later in adolescence.6Sexual orientation health disparities have been explained through the minority stress model: sexual minority youths experience unique stressors and stigma related to their sexual identity (e.g., homophobic bullying), which lead to poorer health.17 Sexual minority adolescents might therefore be less likely to be physically active or involved in team sports because of potential minority stressors that they often experience at school, especially bias and heightened discrimination experienced in the context of sports or in their communities.18–20 More recently, the negative effects of minority stress and stigma on physical health disparities have been documented,21,22 including their effects on obesity for sexual minority women.23 However, the minority stress model is not sufficient in explaining how sexual minority adolescent females, but not males, are at greater risk for obesity compared with their heterosexual peers.Another potential explanation of these obesity disparities is related to cultural norms and sexual minority females’ experiences of internalizing ideals for femininity and appearance8 and sexual minority males’ ideals for muscularity and body image.24 For instance, compared with heterosexual women, sexual minority women are more likely to be satisfied with their bodies and attracted to women with greater body mass,25,26 whereas sexual minority men are less likely to be satisfied with their bodies compared with heterosexual men and are more likely to be attracted to muscular men.25,27 Therefore, these 2 groups might engage (or not engage) in differing body weight management and dieting behaviors compared with their heterosexual peers; concomitantly, these behaviors might render differing risks for obesity.Sexual minority adolescents’ lack of physical activity and sports involvement might be influenced by traditional gender norms associated with athleticism and sports, which has implications for their athletic self-esteem and involvement. For adolescent males, team sports are a means to define masculinity28; however, adolescent males often engage in homophobic banter to prove their masculinity and heterosexuality and to enforce traditional gender norms.29,30 Sexual prejudice is pervasive in athletic settings,19,20 making sports contexts unwelcoming and unsafe for many sexual minority males. Traditional feminine gender norms and homophobia also affect sexual minority females’ involvement in sports.31 However, sexual minority adolescent females have unique gendered experiences in relation to sports. Because women’s athleticism can be a stereotype for being a lesbian,32 sexual minority females might avoid sports involvement. Expecting or experiencing exclusion in sports settings might also affect sexual minority adolescents’ athletic self-esteem, consequently preventing them from engaging in future sports or physical activity.9 In fact, athletic self-esteem has been found to contribute to sexual orientation disparities in sports involvement and physical activity.9Emerging evidence of sexual orientation disparities in physical activity, sports involvement, and obesity among adolescents, in addition to potential gender nuances in these disparities, points to the need for more population-based research in this area. We therefore examined sexual orientation disparities among a large adolescent population-based sample and tested for gender differences. While accounting for variables commonly associated with physical activity and obesity among adolescents,4,33 we hypothesized that sexual minority adolescents would be less likely to report physical activity and sports involvement than would their heterosexual peers. We also hypothesized that sexual minority females would be at higher risk for being overweight and obese than their heterosexual peers. Because of mixed findings in existing sexual orientation disparities research among adolescent males, we hypothesized that sexual minority males would be at equal risk for being overweight and obese than their heterosexual male peers.     

Life-Course Accumulation of Neighborhood Disadvantage and Allostatic Load: Empirical Integration of Three Social Determinants of Health Frameworks

Objectives. We examined if the accumulation of neighborhood disadvantages from adolescence to mid-adulthood were related to allostatic load, a measure of cumulative biological risk, in mid-adulthood, and explored whether this association was similar in women and men.Methods. Data were from the participants in the Northern Swedish Cohort (analytical n = 818) at ages 16, 21, 30, and 43 years in 1981, 1986, 1995, and 2008. Personal living conditions were self-reported at each wave. At age 43 years, 12 biological markers were measured to operationalize allostatic load. Registered data for all residents in the cohort participants’ neighborhoods at each wave were used to construct a cumulative measure of neighborhood disadvantage. Associations were examined in ordinary least-squares regression models.Results. We found that cumulative neighborhood disadvantage between ages 16 and 43 years was related to higher allostatic load at age 43 years after adjusting for personal living conditions in the total sample (B = 0.11; P = .004) and in men (B = 0.16; P = .004), but not in women (B = 0.07; P = .248).Conclusions. Our findings suggested that neighborhood disadvantage acted cumulatively over the life course on biological wear and tear, and exemplified the gains of integrating social determinants of health frameworks.Different frameworks relevant to social determinants of health have been introduced, developed, and applied to research during the last 2 decades. We specifically aimed to empirically integrate the allostatic load,1 neighborhoods and health,2 and life-course epidemiology3 frameworks by examining whether the life-course accumulation of neighborhood disadvantage was related to allostatic load in mid-adulthood.The allostatic load model4,5 was developed within the stress physiology field and was introduced as a general framework for the cumulative “wear and tear” the body eventually experiences across multiple interrelated physiological systems because of repeated stressor exposures during the life course. Allostatic load (or cumulative biological risk) has been proposed as a biological link that explains socioeconomic disparities in morbidity and mortality6,7; empirical studies have demonstrated that allostatic load is patterned by social determinants (e.g., ethnicity, education, and income)8–11 and prospectively predicts mortality as well as cognitive and physical decline.12–14Studying the importance of the area of residence—defined, for example, by parishes, wards, or neighborhoods—for health represents a more contextual perspective on social determinants of health. For example, socioeconomic status aggregated at the neighborhood level is related to cardiovascular health beyond individual-level socioeconomic conditions.2,15 Such effects have been attributed to several possible pathways, including (1) indirect-cognitive paths, where the effects are mediated by conscious responses such as health-damaging behaviors, and (2) direct-contextual paths, which include differential chronic stressor exposure and the potential development of allostatic load.16 Cross-sectional studies in recent years have demonstrated that various neighborhood characteristics, such as socioeconomic disadvantages,17 poverty,11 lack of affluence,18 and perceived neighborhood conditions,19 are related to allostatic load. However, most studies within the field use cross-sectional or short-term prospective designs20,21; conceptual and empirical elaborations of how social context affects health in the long term are lacking.21However, such a long-term temporal perspective emphasizes life-course epidemiology, which focuses on how and when exposures over the life course affect adult health outcomes, a question that is guided by conceptual life-course models.3 The cumulative risk model, which posits that the most important aspect for health effects is the accumulation of exposures across the life course, is the model with the most consistent empirical support (e.g., socioeconomic disadvantages and cardiovascular outcomes).22Although the few recent register-based studies on area effects on health over the life course found only a small proportion of variance in adult morbidity and mortality to be attributable to the area of residence at specific life-course periods,23 mortality risk clustered at the area of residence seemed to accumulate over the life course, corresponding to a cumulative risk life-course model.24 The cumulative risk model is also the model that most closely corresponds to the allostatic load framework, which emphasizes the gradual accumulation of physiological dysregulation over the life course.6 Empirical studies demonstrated that the life-course accumulation of individual socioeconomic disadvantages and of adversity from childhood or adolescence to mid-adulthood were related to allostatic load.25–27In summary, despite the unique contributions of research on the social determinants of health offered by allostatic load, neighborhoods and health, and the life-course epidemiology frameworks, empirical efforts to integrate them are at an early stage. To advance this task, the cumulative risk life-course model appears to be a promising focal point.The present 27-year prospective cohort study specifically aimed to examine whether socioeconomic disadvantages of the residence neighborhood at 4 time points during the life course were cumulatively related to allostatic load in mid-adulthood, when taking the life-course accumulation of disadvantageous personal living conditions into account. Previous research hypothesized that women were more embedded in their communities, and because of this, could be more exposed to neighborhoods stressors and health effects.28 Therefore, our secondary aim explored this cumulative effect on allostatic load separately in women and men.     

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

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

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

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