The National Heart, Lung, and Blood Institute convened a Working Group (WG), in Bethesda, Maryland, to discuss Cardiovascular Diseases in the Inmate and Released Prison Population.
The large size of the prison population in the United States and the fact that many prisoners are at a health disadvantage even before they enter prison as a result of their social and economic circumstances make the health of this population an important priority for health care and public health systems. Conditions specific to prisons may also increase risk for cardiovascular disease (CVD) and a range of other diseases and conditions. Although there has been some research on the health of incarcerated populations, the focus on chronic diseases, and in particular CVD, has been limited. In addition, the prison population is at highest risk of adverse health outcome during times of transition from prison to the general population.
Data collected in our national databases help to develop public health policy and direct health programs and services in the U.S. ("National Health and Nutrition Examination Survey ", 2016). However, the estimate of true prevalence of diseases in the U.S. is limited, since health information about prisoners is excluded from these national databases. Inaccurate representation of disease prevalence in both civilian and non-civilian populations may adversely affect funding, especially if decisions are based on an underrepresentation of the true need.
This has important implications for communities and the public healthcare system, since nearly 95% of prisoners are eventually released back to communities at a rate of 700,000 annually. A disproportionately high number of prisoners suffer from infectious diseases, chronic diseases (including asthma, diabetes, and hypertension), and mental illness compared with the rest of the nation’s population (Gostin, 2007). In addition, the U.S. prison population is older than the overall U.S. population, and their release will have an impact on health care resources in communities faced with integrating a growing number of older, former inmates (Williams, et al, 2012).
Several themes were discussed during the workshop that centered on the magnitude of CVD burden in the general population and the impact of excluding the incarcerated population when estimating prevalence, trends, and health disparities. Based on the data presented, incarcerated populations may have many known risk factors for CVD, such as poor diet, lack of exercise, co-morbidities (HIV/AIDS and drug addiction), and stress, in addition to incarceration-specific factors, such as exposure to the prison environment that may increase the risk of CVD.
Diagnosis, prevention, and treatment of CVD in the incarcerated population are complex, and improvement of cardiovascular health may require individual changes such as behavioral and stress reduction as well as system changes. System changes include structural changes to how health care is delivered within a prison system to improve access to care and encourage self-management of chronic diseases, and provider training to change the attitude and awareness of CVD prevention and treatment. Long-term management of CVD in the prison and the released populations requires care coordination to ensure continuous access to health care, as well as social support and services, including obtaining health insurance and navigating the healthcare systems. Logistical and ethical issues remain a barrier to CVD data access in the incarcerated population and pose a challenge to conducting research on CVD in this population. The conceptualization of prison as a punitive vs. rehabilitative environment also has implications for what can be accomplished regarding CVD prevention and the prevention of other health conditions, such as diabetes and HIV infection.
Working Group Recommendations
- Gather longitudinal data regarding prevalence of CVD and risk factors in people exposed to the criminal justice system (e.g., prison, jail, probation, parole, etc.) in a manner that is identical or similar to how information is collected for other national surveys of health for non-institutionalized populations (e.g. NHANES).
- Characterize CVD burden in incarcerated populations by building on existing surveys conducted through the Bureau of Justice Statistics (BJS), focusing on incarcerated and released prisoners with CVD risk factors.
- Add survey questions on incarceration history and intensity onto existing and future national health survey and epidemiological studies.
- Include incarcerated populations in community-based surveys and interventions (which currently exclude incarcerated populations).
- Develop compatible surveys between the criminal justice system and general population.
- Establish new prospective epidemiological studies to understand the magnitude and etiology of CVD in populations exposed to the criminal justice system (e.g., prison, jail, probation, parole, etc.).
- Incorporate health information technology and common standards in data collection to allow for data-sharing for research purposes and for providing continuous care.
- Study the impact of incarceration on the health of family members, women in particular, who are bearing most of the health-care responsibility.
- Leverage existing NIH and other federal investment through collaborative work with other institutes and agencies to build infrastructure (training, resources, network), and share best practices.
- Adapt community-based CVD prevention and reduction strategies to incarcerated and recently released populations, evaluate short-term and long-term effects, and ensure continuity of care across the transition.
- Organize a teleconference with stakeholders including BJS, Substance Abuse and Mental Health Services Administration (SAMHSA), NIH, and local health departments to discuss potential collaborations and sharing of resources.
- Develop resources and networks to facilitate the interaction of CVD investigators with the criminal justice (CJ) system.
- Provide training opportunities for CVD investigators to learn the CJ health care and health data management system.
- Work with regulatory bodies and CJ staff to reduce or eliminate barriers to conducting research in the CJ population while continuing to ensure that this vulnerable population is adequately protected.
- Intervene at the criminal justice system and clinical provider levels to improve the health service (for example, design and test educational-normative or knowledge sessions on “healthy heart” diet and lifestyle for correctional officers, and if successful, implement as a standard protocol for CJ system).
- Engage stakeholders, including inmates, staff, and administrators of the CJ system (for example, discuss how self-management of CVD can be tailored to the correctional health care service without compromising safety).
- Include economic measurements (e.g. cost-effectiveness) and public safety aspects in CVD studies in the incarcerated population to demonstrate potential benefits of CVD prevention/intervention for the CJ system.
The working group plans to prepare a manuscript for publication in a peer-reviewed journal.
Erin Iturriaga, BS, MSN
Paul Sorlie, PhD
Jue Chen, MS, PhD
Susan Shero, RN, MS
Working Group Participants
Ana V. Diez Roux, MD, PhD, MPH
George A. Mensah, MD, FACC
Becky Pettit, PhD
Nicole Redmond, MD, PhD, MPH
Emily Wang, MD, MAS
Laura Maruschak, MA
Marc Stern, MD, MPH
Cheryl Dennison-Himmelfarb, RN, ANP, PhD, FAAN
Dina Passman, MPH, PMP
Joneigh Khaldun, MD, MPH
Faye Taxman, PhD
Tisha Wiley, PhD
Denise Juliano-Bult, MSW
Jennifer Alvidrez. PhD
Participants from other NIH Institutes and other Agencies:
Derrick Tabor, PhD
National Institute on Minority Health and Health Disparities (NIMHD)
Teresa Jones, MD
National Institute of Digestive and Kidney Diseases (NIDDK)
Marcel Salive, MD, MPH
National Institutes on Aging (NIA)
Shoba Srinivasan, PhD
National Cancer Institute (NCI)
Ann Carson, PhD
Statistician, Bureau of Justice Statistics (BJS)
Department of Justice (DOJ)
Gostin, L. O. (2007). Changing Demographics and Health Issues. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK19877/?report=printable#
National Health and Nutrition Examination Survey. (2016, November 06). Retrieved from http://www.cdc.gov/nchs/nhanes/about_nhanes.htm
Williams, B. A., Goodwin, J. S., Baillargeon, J., Ahalt, C., & Walter, L. C. (2012). Addressing the Aging Crisis in U.S. Criminal Justice Health Care. Journal of the American Geriatrics Society, 60(6), 1150-1156.