1. The Health of Prisoners In
Iowa
from a Public Health
Perspective
Findings from a cross-sectional data analysis 2015
1
Tala Al- Rousan, MD MPH candidate
Practicum Project
Robert Wallace, MD MSc
Professor of Epidemiology and Internal
Medicine
The University of Iowa
College of Public Health
Linda Rubenstein, PhD
Senior Biostatistician
2. “Health is a state of complete physical,
mental and social well-being and not
merely the absence of disease or infirmity”
― WHO definition of Health
2
3. Public Health Approach to Incarceration
• More than 3 million Americans are incarcerated, more than
anywhere else in the world
• The impact of imprisonment is clear on those imprisoned and
their families and communities
• A national trend of increasing mental illnesses is seen in prisons
all over the U.S.
3
4. Public Health Approach to Incarceration
• Outbreaks of scabies, MRSA, TB and Hepatitis are on the rise
in many prisons.
• Prevalence of chronic conditions, and contrasting numbers
inside prisons with those outside prison, are not fully
understood
4
5. 5
• As a science of prevention and health promotion,
public health is positioned to mitigate risks and
promote healthy living within one’s environment
• It is essential to strengthen multidisciplinary
linkages to deal with the challenges of mass
incarceration
6. • ICON- Medical data is an important source of information
that could tell us how prisoners are doing
• We requested a set of variables to look at data at one point
in time
• Data were received on February 7, 2015 and analyzed by an
experienced biostatistician using specialized software
Data Source for Today’s Talk
6
7. Research Questions:
1. What are the general characteristics of Iowa’s prisoners?
2. What is the prevalence of chronic conditions among prisoners?
Does it differ between younger and older prisoners?
3. Can we better understand the burden of mental illnesses in
prisons?
4. Are there areas that need to be improved and policy
recommendations from a public health perspective?
7
8. 9, 9%
91%
Female Male
26.9, 27%
7.1, 7%
62.9, 63%
3, 3%
Race
Black
Hispanic
White
Other
Gender
Demographics of Inmates
Blacks and Hispanics are overrepresented and female prisoners are growing in numbers
8
9. 83%
17%
Age Distribution
Younger
OlderN= 7107
N= 1467
Younger
inmates
• Total Number of Prisoners = 8574
• Total Number of younger prisoners 49 Years old or less =
7107
• Total Number of older prisoners 50 Years or older =
1467
• Mean age for younger prisoners = 32.4 ± 8.4
• Mean age for older prisoners = 57.2 ± 6.8
• Mean age for all prisoners = 36.7 ± 12.4
Data from February 2015
9
10. 0
5
10
15
20
25
30
35
40
A felony B felony C felony D felony Aggravated
misdemeanor
Other classes
Conviction Class
Younger 2015 Older 2015 Younger 2006 Older 2006
Younger
Older
Conviction Class:
• A felony = Life in prison
• B felony = 25- 50 years
• C felony = 10 years
• D felony = 5 years
• Aggravated misdemeanor = 2 years
• Other classes = Irregular penalties,
others
Comparing
10
11. 93.3 96.5
Younger Older
Supervision Status
Prison Work release
23.9
44.4
22
6.8
2.8
16.2
64
9.9
7.7
2.2
Drug Violent Public order Property Other
Crime Type
Younger Older
Demographics
11
12. 17
13.5
69.4
Married Single Divorced/widowed
Marital status
2.3
18.8
76
2.1
0.8
0 10 20 30 40 50 60 70 80
Other
Less than high school
High school/ equivalent
Some college
College graduate
Highest Level of Education
Demographics
12
13. 54
38.1
51.2
0
10
20
30
40
50
60
Hx of Tobacco use
HISTORY OF SMOKING
Younger AllOlder
About half the prisoners have a positive history of smoking with a mean of 16.1 packs/year. The
documented data on older prisoners may be under-representative
13.3
34.9
16.1
0
5
10
15
20
25
30
35
40
Younger Older All prisoners
Mean pack.year (smokers
only)
History of Smoking at Admission
13
14. Body Mass Index and Diagnosis of Obesity
Underweight Normal Overweight Obese
BMI by Age
Younger Older
0
10
20
30
40
50
60
Underweight Normal Overweight Obese
BMI by Gender
Females Males
But the rate of ICD-9 diagnosis of obesity was only 4.3%!
Energy intake, programs and atypical antipsychotic
medications may explain disparities in BMI and gender? 14
16. 8.2
0.6
0.4
45.3
11.3
3.9
31.5
9.8
8.5
5
3
6.3
1.6
0.3
1.4
17.9
3.5
1.7
38.9
8.1
8.2
62
37.9
15.1
16.7
5.5
23.2
13.2
0.9
3.2
Infectious and parasitic diseases
Neoplasms
Diseases of the blood and blood-forming organs
Mental diseases
Endocrine, nutritional and metabolic diseases
Diseases of the nervous system
Diseases of the sense organs
Diseases of the circulatory system
Diseases of the respiratory system
Diseases of the digestive system
Diseases of the skin and subcutaneous tissue
Diseases of the musculoskeletal system and…
Diseases of the genitourinary system
Congenital malformations
Injury, poisoning and other consequences of…
Older prisoners Younger prisoners
Prevalence Rates of Diagnostic Categories by Age
Groups
16
Sense organs ICD-9:360-
390 (includes vision codes
that are not really
diseases
17. Comparing Prevalence of Chronic Conditions to the 2006
study studying the prisoners population
0
10
20
30
40
50
60
Hepatitis Hypertension Hyperlipidemia Diabetes II Coronary artery disease
Comparison Between 2006 and 2015 in Older and Younger prisoners
Younger 2006 Younger 2015 Older 2006 Older 2015
Increase in rates of diagnosis
inmates or real increase in
prevalence?
17
18. Older offenders have more modifiable risk factors for
developing chronic conditions than younger offenders like
smoking and obesity
Older offenders are more likely to have: CAD,
Hypertension, Hyperlipidemia, vision problems, Hep. C and
cancer than younger offenders 18
Summary of Chronic Conditions
19. Summary of Chronic Conditions
There is an increase in the prevalence of all chronic
conditions since 2006 for all offenders
Obesity is a big problem and females have higher rates of
obesity
Younger offenders have more substance abuse than older
offenders 19
20. 26.1
14.8
14.2
10.1
8.1
7.8
6.8
4.8
2.9
1.4
0.9
0.6
0.3
0.1
0.1
0
0 5 10 15 20 25 30
Substance abuse
Depression and major depressive disorders
Anxiety, general anxiety and panic disorders
Personality disorders
Psychosis and psychotic disorders
Developmental disabilities
Bipolar
Post-Traumatic Stress Disorder (PTSD)
Schizophrenia
Impulse control disorders
Dysthymia/ neurotic depression
Dementia
Sleep, movement and eating disorders
Pervasive developmental disorders
Sexual disorders/ Paraphelias
Somatization disorders
All prisoners
Prevalence of Mental Illnesses in All Inmates using DSM- 5 and ICD-9
codes
20
22. Diagnosis of Mental Disorders During Incarceration by
Gender
22
0
10
20
30
40
50
60
70
80
Substance
abuse
Schizophrenia Bipolar Depression and
major
depressive
disorders
Psychosis and
psychotic
disorders
Post-Traumatic
Stress Disorder
(PTSD)
Diagnosed Documented During Incarceration
Females Males
23. Diagnosis of Mental Disorders During Incarceration by Gender
23
0
10
20
30
40
50
60
70
80
Anxiety,
general anxiety
and panic
disorders
Dysthymia/
neurotic
depression
Personality
disorders
Sleep,
movement and
eating disorders
Impulse control
disorders
Developmental
disabilities
Diagnosis Documented During Incarceration
Females Males
24. Almost half of the mental illness diagnoses are not noted
during initial screening? This is slightly more common in
younger inmates
24
0
10
20
30
40
50
60
70
80
90
100
Substance
abuse
Dementia Schizophrenia Bipolar Depression and
major
depressive
disorders
Psychosis and
psychotic
disorders
Pervasive
developmental
disorders
Diagnosed During Incarceration
Younger Older All
Diagnosis During Incarceration by Age
25. 25
Diagnosis During Incarceration by Age
0
20
40
60
80
100
120
Post-Traumatic
Stress Disorder
(PTSD)
Anxiety, general
anxiety and
panic disorders
Dysthymia/
neurotic
depression
Personality
disorders
Sexual
disorders/
Paraphelias
Sleep,
movement and
eating disorders
Impulse control
disorders
Developmental
disabilities
Younger Older
All
26. 26.1
14.8 14.2
6.8
4.8
0.9
18 17
6.7
1.1
8.6
2.8
0
5
10
15
20
25
30
Substance abuse Depression and
major depressive
disorders
Anxiety, general
anxiety and panic
disorders
Bipolar Post-Traumatic
Stress Disorder
(PTSD)
Dysthymia/
neurotic
depression
Comparison to National Numbers
Prisoners Community
These are crude rates and we may need to adjust for age, gender and other
variables
Comparing Mental Health Prevalence Rates to National Data Using The
National Comorbidity Study*
Reference: The National Institute for Mental Health (NIMH) Collaborative Psychiatric Epidemiology Surveys (CPES):
http://www.hcp.med.harvard.edu/ncs/
26
27. Summary of Mental Illnesses
• About half the offenders have a mental illness diagnosis
• Substance abuse is the most common disorder and rates are higher
than community rates
• Depression, anxiety, psychosis and personality disorders come next
• Mental illnesses are a problem in both younger and older offenders
• Generally, most of the mental illnesses are diagnosed during
incarceration and may be not noted at initial screening 27
28. Suggested Interventions
Evidence-base interventions to prevent relapse to smoking (Rhode Island DOC example: counseling
and CBT while in prison six weeks prior to release)
Health education and health promotion for chronic diseases in all prisons
Dietary modification (energy intake, percentage energy intake as fat, sodium intake monitoring)
Promote physical activity and evidence-base wellness programs
Substance abuse: A recent meta-analysis showed that motivational interviewing, psychotherapy and
pharmacological interventions during imprisonment have a positive result
Mental illness: Psychotherapy, skills training during imprisonment, music and yoga therapy, showed
positive effects.
Infectious diseases: Hep B vaccination, HCV dried blood spot testing during incarceration
28
29. References
1. Kouyoumdjian, F. G., McIsaac, K. E., Liauw, J., Green, S., Karachiwalla, F., Siu, W., ... & Hwang, S. W.
(2015). A Systematic Review of Randomized Controlled Trials of Interventions to Improve the Health of
Persons During Imprisonment and in the Year After Release. Journal Information, 105(4).
2. Gates, M. L., & Bradford, R. K. (2015). The Impact of Incarceration on Obesity: Are Prisoners with
Chronic Diseases Becoming Overweight and Obese during Their Confinement?. Journal of
Obesity, 2015.
3. van den Berg, J. J., Bock, B., Roberts, M. B., Stein, L. A., Friedmann, P. D., Martin, S. A., & Clarke, J.
G. (2014). Cigarette smoking as an expression of independence and freedom among inmates in a
tobacco-free prison in the United States. nicotine & tobacco research, 16(2), 238-242.
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