Health Disparities and Converging Epidemics in Jail Populations: Protocol for a Mixed-Methods Study

Wildeman C., Wang E.A.

Campbell J.A., Walker R.J., Egede L.E.

Adverse childhood experiences (ACEs) are associated with early mortality and morbidity. This study evaluated the association among ACEs, high-risk health behaviors, and comorbid conditions, as well as the independent effect of ACE components.Data were analyzed on 48,526 U.S. adults from five states in the 2011 Behavioral Risk Factor Surveillance System survey. Exposures included psychological, physical, and sexual forms of abuse as well as household dysfunction such as substance abuse, mental illness, violence, and incarceration. Main outcome measures included risky behaviors and morbidity measures, including binge drinking, heavy drinking, current smoking, high-risk HIV behavior, obesity, diabetes, myocardial infarction, coronary heart disease, stroke, depression, disability caused by poor health, and use of special equipment because of disability. Multiple logistic regression assessed the independent relationship between ACE score categories and risky behaviors/comorbidities in adulthood, and assessed the independent relationship between individual ACE components and risky behaviors/comorbid conditions in adulthood controlling for covariates.A total of 55.4% of respondents reported at least one ACE and 13.7% reported four or more ACEs. An ACE score ≥4 was associated with increased odds for binge drinking, heavy drinking, smoking, risky HIV behavior, diabetes, myocardial infarction, coronary heart disease, stroke, depression, disability caused by health, and use of special equipment because of disability. In addition, the individual components had different effects on risky behavior and comorbidities.In addition to having a cumulative effect, individual ACE components have differential relationships with risky behaviors, morbidity, and disability in adulthood after controlling for important confounders.

Lim S., Nash D., Hollod L., Harris T.G., Lennon M.C., Thorpe L.E.

Objectives Both homelessness and incarceration are associated with housing instability, which in turn can disrupt continuity of HIV medical care. Yet, their impacts have not been systematically assessed among people living with HIV/AIDS (PLWHA). Methods We studied a retrospective cohort of 1,698 New York City PLWHA with both jail incarceration and homelessness during 2001–05 to evaluate whether frequent transitions between jail incarceration and homelessness were associated with a lower likelihood of continuity of HIV care during a subsequent one-year follow-up period. Using matched jail, single-adult homeless shelter, and HIV registry data, we performed sequence analysis to identify trajectories of these events and assessed their influence on engagement in HIV care and HIV viral suppression via marginal structural modeling. Results Sequence analysis identified four trajectories; 72% of the cohort had sporadic experiences of both brief incarceration and homelessness, whereas others experienced more consistent incarceration or homelessness during early or late months. Trajectories were not associated with differential engagement in HIV care during follow-up. However, compared with PLWHA experiencing early bouts of homelessness and later minimal incarceration/homelessness events, we observed a lower prevalence of viral suppression among PLWHA with two other trajectories: those with sporadic, brief occurrences of incarceration/homelessness (0.67, 95% CI = 0.50,0.90) and those with extensive incarceration experiences (0.62, 95% CI = 0.43,0.88). Conclusions Housing instability due to frequent jail incarceration and homelessness or extensive incarceration may exert negative influences on viral suppression. Policies and services that support housing stability should be strengthened among incarcerated and sheltered PLWHA to reduce risk of adverse health conditions.

Ahalt C., Wang E.A., Williams B.

Kaba F., Solimo A., Graves J., Glowa-Kollisch S., Vise A., MacDonald R., Waters A., Rosner Z., Dickey N., Angell S., Venters H.

Objectives. To better understand jail mental health services entry, we analyzed diagnosis timing relative to solitary confinement, nature of diagnosis, age, and race/ethnicity. Methods. We analyzed 2011 to 2013 medical records on 45 189 New York City jail first-time admissions. Results. Of this cohort, 21.2% were aged 21 years or younger, 46.0% were Hispanic, 40.6% were non-Hispanic Black, 8.8% were non-Hispanic White, and 3.9% experienced solitary confinement. Overall, 14.8% received a mental health diagnosis, which was associated with longer average jail stays (120 vs 48 days), higher rates of solitary confinement (13.1% vs 3.9%), and injury (25.4% vs 7.1%). Individuals aged 21 years or younger were less likely than older individuals to receive a mental health diagnosis (odds ratio [OR] = 0.86; 95% confidence interval [CI] = 0.80, 0.93; P < .05) and more likely to experience solitary confinement (OR = 4.99; 95% CI = 4.43, 5.61; P < .05). Blacks and Hispanics were less likely than Whites to enter the mental health service (OR = 0.57; 95% CI = 0.52, 0.63; and OR = 0.49; 95% CI = 0.44, 0.53; respectively; P < .05), but more likely to experience solitary confinement (OR = 2.52; 95% CI = 1.88, 3.83; and OR = 1.65; 95% CI = 1.23, 2.22; respectively; P < .05). Conclusions. More consideration is needed of race/ethnicity and age in understanding and addressing the punishment and treatment balance in jails.

Bai J.R., Befus M., Mukherjee D.V., Lowy F.D., Larson E.L.

This study estimated the prevalence of chronic medical conditions and risk predictors of 759 newly admitted inmates in two New York State maximum-security prisons. The most prevalent conditions were respiratory (34.1%), cardiovascular (17.4%), and sexually transmitted diseases (STD; 16.1%); least prevalent were HIV (3.6%), cancer (1.7%), and kidney disease (1.7%). Results of the multivariable logistic regression showed that females had higher risk for all conditions except cardiovascular and liver disease; individuals aged 40 years and older had significantly higher risk for all conditions except asthma and STD; non-Hispanic Black inmates had higher risk for respiratory disease and STD; cigarette smoking was associated with asthma; and obesity was significantly associated with diabetes, asthma, and cardiovascular conditions. These findings highlight the heavy burden of chronic illnesses among newly admitted inmates and the need to address adequate screening, prevention, and treatment services.

Boyd A.T., Song D.L., Meyer J.P., Altice F.L.

Release from short-term jail detention is highly destabilizing, associated with relapse to substance use, recidivism, and disrupted health care continuity. Little is known about emergency department (ED) use, potentially a surrogate for medical, psychiatric, or social instability, by people living with HIV/AIDS (PLWHA) leaving jails. All ED visits were reviewed from medical records for a cohort of 109 PLHWA in the year following release from county jail in Connecticut, between January 1, 2008 and December 31, 2010. Primary outcomes were frequency and timing of ED visits, modeled using multivariate negative binomial regression and Cox proportional hazards regression, respectively. Demographic, substance use, and psychiatric disorder severity factors were evaluated as potential covariates. Overall, 71 (65.1 %) of the 109 participants made 300 unique ED visits (2.75 visits/person-year) in the year following jail-release. Frequency of ED use was positively associated with female sex (incidence rate ratios, IRR 2.40 [1.36–4.35]), homelessness (IRR 2.22 [1.15–4.41]), and recent substance use (IRR 2.47 [1.33–4.64]), and inversely associated with lifetime drug severity (IRR 0.01 [0–0.10]), and being retained in HIV primary care (IRR 0.80 [0.65–0.99]). Those in late or sustained HIV care used the ED sooner than those not retained in HIV primary care (median for late retention 16.3 days, median for sustained retention 24.9 days, median for no retention not reached at 12 months, p value 0.004). Using multivariate modeling, those who used the ED earliest upon release were more likely to be homeless (HR 1.98 [1.02–3.84]), to be retained in HIV care (HR 1.30 [1.04–1.61]), and to have recently used drugs (HR 2.51 [1.30–4.87]), yet had a low lifetime drug severity (HR 0.01 [0.00–0.14]). Among PLWHA released from jail, frequency of ED use is high, often soon after release, and is associated with social and drug-related destabilizing factors. Future interventions for this specific population should focus on addressing these resource gaps, ensuring housing, and establishing immediate linkage to HIV primary care after release from jail.

Silva N.M.

Sommers B.D., Musco T., Finegold K., Gunja M.Z., Burke A., McDowell A.M.

On the basis of data from the Gallup–Healthways Well-Being Index, a survey of a national sample of adults, the authors estimate that the rate of uninsured nonelderly adults declined by about 5 percentage points after the Affordable Care Act's initial open-enrollment period.

Chodos A.H., Ahalt C., Cenzer I.S., Myers J., Goldenson J., Williams B.A.

Objectives. We examined older jail inmates’ predetainment acute care use (emergency department or hospitalization in the 3 months before arrest) and their plans for using acute care after release. Methods. We performed a cross-sectional study of 247 jail inmates aged 55 years or older assessing sociodemographic characteristics, health, and geriatric conditions associated with predetainment and anticipated postrelease acute care use. Results. We found that 52% of older inmates reported predetainment acute care use and 47% planned to use the emergency department after release. In modified Poisson regression, homelessness was independently associated with predetainment use (relative risk = 1.42; 95% confidence interval = 1.10, 1.83) and having a primary care provider was inversely associated with planned use (relative risk = 0.69; 95% confidence interval = 0.53, 0.89). Conclusions. The Affordable Care Act has expanded Medicaid eligibility to all persons leaving jail in an effort to decrease postrelease acute care use in this high-risk population. Jail-to-community transitional care models that address the health, geriatric, and social factors prevalent in older adults leaving jail, and that focus on linkages to housing and primary care, are needed to enhance the impact of the act on acute care use for this population.

Heidari E., Dickson C., Newton T.

This article is the first in a series of four, which explore the oral and dental health of male prisoners in the United Kingdom. The series comprises: an overview of the general and oral health status of male prisoners, a discussion on how multi-disciplinary team working can be used to benefit the care of patients in prison environments and a description of the future planning of dental services for male prisoners. The oral health of prisoners is linked to their general health status, due in part to the presence of common risk factors such as smoking, drinking alcohol and in some cases use of recreational drugs, poor dietary and poor oral hygiene habits. Barriers to healthcare services can all have an effect on oral disease in this group. This paper highlights some of the common medical problems that oral healthcare providers face when treating prisoners in male UK prison establishments.

Morgan O., Kuramoto F., Emmet W., Stange J.L., Nobunaga E.

Boutwell A.E., Freedman J.

People who have served time in US prisons and jails have high rates of undiagnosed chronic and infectious diseases, behavioral health conditions, and trauma. Because a large portion of this population are young men-a demographic previously underrepresented in Medicaid rolls-who have been uninsured, Medicaid payers and the managed care plans they contract with have little experience serving this population. To meet the Affordable Care Act's policy objectives of cost-efficient and effective care through improved and expanded access, health plans need to understand the epidemiology and care-seeking patterns of this population. Plans also need to develop outreach, communications, and engagement strategies and create service models designed to address these individuals' health care needs. Corrections departments and health plans should exchange information about the medical histories of people entering and leaving prisons and jails, promote models of peer support, and advocate for suspension rather than termination of Medicaid benefits during incarceration, so inmates can quickly regain coverage once they are released.

Koester K.A., Morewitz M., Pearson C., Weeks J., Packard R., Estes M., Tulsky J., Kang-Dufour M., Myers J.J.

HIV-infected individuals leaving jails, facilities typically used to confine accused persons awaiting trial or to incarcerate persons for minor offenses, often face barriers to engagement with medical and social-support services. Patient navigation is a model that may ease these barriers by supporting individuals in negotiating fragmented and highly bureaucratic systems for services and care. While there is evidence linking navigation to a reduction in health disparities, little is known about the mechanisms by which the model works. We present findings of an ethnographic study of interactions between navigators and their clients: HIV-infected men and women recently released from jails in San Francisco, California. We conducted 29 field observations of navigators as they accompanied their clients to appointments, and 40 in-depth interviews with clients and navigators. Navigators worked on strengthening clients' abilities to engage with social-services and care systems. Building this strength required navigators to gain clients' trust by leveraging their own similar life experiences or expressing social concordance. After establishing meaningful connections, navigators spent time with clients in their day-to-day environments serving as mentors while escorting clients to and through their appointments. Intensive time spent together, in combination with a shared background of incarceration, HIV, and drug use, was a critical mechanism of this model. This study illustrates that socially concordant navigators are well positioned to facilitate successful transition to care and social-services engagement among a vulnerable population.

Vaughn M.G., Salas-wright C.P., Delisi M., Piquero A.R.

A burgeoning criminological literature has identified important intersections between public health, crime, and antisocial behavior. This study is based on public-use data collected between 2006 and 2010 as part of the National Survey on Drug Use and Health (NSDUH) and an analytical sample of men ( N = 84,054) and women ( N = 95,308) between the ages of 18 and 64. Latent class analysis (LCA) identified three classes: a large normative group, a small drug-involved group, and a criminal-justice-involved group. Chronic health conditions that are more closely associated with longer term medical problems and perhaps cumulative stress such as heart disease and diabetes are not linked to criminal-justice-system-involved or drug-involved offenders. Medical problems that are more closely related to an antisocial lifestyle such as sexually transmitted diseases, pancreatitis, and hepatitis were found to be more prevalent among antisocial subgroups in this sample.

Schumacher J.E., Ahsan A., Simpler A.H., Natoli A.P., Cain B.J.

Abstract Background Conducting research within a carceral health care context offers a unique view into the nature of drug use among arrestees with potential to identify and prevent drug use consequences. The purpose of this study was to characterize the nature and extent of drug use among first-time jail arrestees to inform detection and treatment. Methods This study utilized a naturalistic research design to collect de-identified urine drug screens (UDS), jail characteristics, and arrestee demographic variables among arrestees indicating drug use from 25 jails across the United States in 2023 through a confidential data sharing agreement with NaphCare, Inc. using its proprietary electronic health record operating system. Descriptive statistics were used to detail the features of the dataset, Pearson’s chi-square tests of independence were performed to statistically analyze associations between UDS results and jail characteristics and arrestee demographics, and significant chi-square test results were further investigated by examining standardized residuals to clarify the nature and significance of within-group differences in proportions. Results Of the 43,553 UDS cases comprising the final sample (28.8% of total arrestees), 74.8% (32,561) were positive for one or more drugs, and 25.2% of UDS cases were negative for all drugs. Among those who tested positive, 69.0% were positive for cannabis, 54.8% for stimulants, 29.6% for opioids, and 12.4% for sedatives. Arrestees were positive for multiple drugs half the time, with combinations of cannabis, stimulants, and opioids most common. Significant associations between drug use and both jail characteristics and arrestee demographics were found. Conclusions Though drug use is not a recent phenomenon, the lethality potential of the drugs being used today is relatively new. Arrestees with positive urine drug screens are at heightened risk of adverse outcome due to sudden cessation of substance use. Findings highlight the need for objective clinical data to guide acute treatment of individuals at risk of withdrawing while detained.

Petreca, PhD, DNP, PMHNP-BC V.G., Flanagan, PhD, ANP-BC, FAAN J., S. Lyons, PhD, FGSA K., W. Burgess, DNSC, APRN, FAAN A.

Skinner-Osei P.

Suh M.I., Robinson M.D.

In the wake of the social unrest in the summer of 2020, many academic medical centers in the United States issued statements about their commitment to health equity and eliminating health care disparities. However, the discussion has been notably silent on the care of patients who are incarcerated, a vulnerable population with complex social, ethical, and medical considerations. In the absence of recognition and education around incarcerated patients, a hidden curriculum has been allowed to flourish.In the United States, about half of the 2.2 million incarcerated people, defined as those awaiting trial in jails or those serving sentences in prisons, report a chronic health condition.1 Additionally, during the COVID-19 pandemic, the incarcerated population has had greater than 5 times the infection rate and triple the mortality rates of the general public.2 This population's second most common source of health care are academic medical centers,3 which commonly have guidelines regarding the care of the incarcerated patient. However, these guidelines are often narrowly focused on resident safety, only outlining security requirements and not acknowledging patient vulnerabilities.4 While resident safety is paramount, it is a disservice to both residents and patients if the nuances of working with a vulnerable population are not explicitly addressed.Previous studies have shown that learners are exposed to negative moral judgments by attendings and staff about patients who are incarcerated, as well as comments about secondary gain and malingering.5,6 Additionally, learners exposed to this population without a formal curriculum perform poorly on attitude and knowledge tests.7 By its very nature, the hidden curriculum is not found in a course syllabus or clerkship objectives but rather taught through perceptions, modeling, and workplace culture and norms.8 We propose that these coalesce to form a hidden curriculum against incarcerated patients that teaches trainees to distrust them, have deference to other loyalties, and disregard incarcerated patient rights. As a result, we argue this negatively impacts patient evaluation, care, and outcomes.The hidden curriculum teaches learners to view incarcerated patients as less trustworthy. For example, at our institution, a resident recently presented an incarcerated patient's severe chest pain as “incarceritis,” a term describing patients thought to be faking symptoms to avoid incarceration, despite the patient having had coronary stents placed 2 months prior. This diagnostic skepticism was not taught in any preclinical foundation course but rather through a hidden curriculum that teaches learners to view patients in custody as often having secondary gain when reporting their medical symptoms, as has been established in other studies and articles.6,9,10 The resident learned via the hidden curriculum to evaluate the patient's chest pain through the lens of his incarceration status rather than through the lens of his recent stents. Furthermore, racism in both the health care and the criminal legal systems cause both distrust and disproportionate incarceration, doubly disadvantaging incarcerated Black and Latinx populations needing health care.11-13Second, residents learn through the hidden curriculum to have deference to other loyalties, such as perceived or real obligations to the state and carceral system.14 While all physicians experience dual loyalties, such as hospital administrators pushing for a premature discharge of a patient with unmet social needs, the conflict is starker when a patient is in custody. For example, an adolescent presented from jail with flexor tenosynovitis and needed an urgent washout of his hand. However, the accompanying guard withheld the parent's contact information and prevented proper consent from being obtained, citing the theoretical danger to staff should the parent present to the hospital in a disruptive manner. The residents deferred to the guard, even though this was in direct violation of hospital policy, ethical principles of informed consent with a minor, and the standard of care. If residents had been taught an ethical framework through an explicit curriculum, they would have been empowered to obtain parental consent for the operation and maintain a singular loyalty to the patient. One framework suggests explicitly identifying dual loyalty situations when they arise, using independent judgment to maintain loyalty to the patient, relying on standard of care, being knowledgeable about relevant guidelines and policies, and resisting pressure to change decisions.15Third, despite clear case law establishing rights for incarcerated patients, in practice the hidden curriculum rationalizes infringement on patients' rights.16-18 Specifically, trainees routinely perform substandard history taking and physical examinations due to indiscriminate shackling and the presence of guards who are actually nonclinical observers outside of the care team.17 This is the norm due to a lack of formal instruction regarding incarcerated patients' privacy rights and areas of vulnerability. These lapses in care delivery can have serious clinical ramifications. A detained patient in our institution required urgent chemotherapy but was deemed to lack capacity due to his unwillingness to discuss treatment options. During a private moment in the CT scanner, away from the guards, he revealed that he was unwilling to talk about his diagnosis in front of the guards, as he thought it may negatively impact his immigration case. Another patient with cirrhotic ascites and abdominal pain could not receive a diagnostic paracentesis because the guards refused to reposition his shackles. A formal curriculum would teach learners to be aware of institutional policies and that patients in custody have a right to privacy, including from guards.18-20 Although shackling and constant attendance by guards is presented as a way to avoid violence toward health care workers, there is a dearth of evidence establishing a higher rate of patient violence in the incarcerated population than in the general population. In fact, altered mental status associated with delirium, dementia, mental illness, and intoxication has consistently been found to be the top risk factor in incidents of workplace violence.21We call for a radical shift in the approach to the care of the patient who is incarcerated. First, academic medical centers must include carceral health in the discussions about equity and social determinants of health. While some institutions have begun to examine their relationship to mass incarceration, these are often trainee-led efforts and thus serve to highlight a lack of institutional curricula.22,23 Curricula should include explicit training regarding the rights of patients who are incarcerated, as well as a code of conduct for learners participating in the care of incarcerated patients.Second, the Accreditation Council for Graduate Medical Education (ACGME) should take a leading role in offering guidance for programs that provide care for the patient who is incarcerated. To start, ACGME competency IV.B.1 already calls for respect for patient privacy and responsiveness to diverse patient populations—adding incarceration status to the current examples of patient characteristics would be a small but meaningful change.24 Additionally, the ACGME should encourage specialties to develop educational standards for academic medical centers affiliated with correctional facilities and programs that routinely take care of patients who are incarcerated. Education should include, but not be limited to, the context of mass incarceration in the United States, ethical frameworks for complex situations, addressing diagnostic skepticism, antibias training, and institutional policies regarding incarcerated patients. Our hope is that more robust curriculums will equip residents to provide equitable care to patients who are incarcerated. Further work will need to be done to include faculty development for physicians who have completed their formal training.Third, more effort is necessary to establish the disparities facing patients who are incarcerated, as well as the impact of specific policies regarding their rights and treatment in hospitals. In an effort to protect this vulnerable population from exploitation, the pendulum has swung too far, and the dearth of data allows misinformation to flourish.25,26 Institutional review boards should work with correctional health experts to ensure that research is noncoercive and safe for this population rather than halting research altogether. Additionally, as academic medical centers seek to improve patient satisfaction and implement quality improvement projects, incarcerated patients should be considered for these initiatives.Lastly, academic medicine must change the way it treats vulnerable populations. Too often, patients who are in custody are treated as opportunities for advanced pathology and learner autonomy.6 As these marginalized populations have no other recourse for medical care, we must approach their care not only as a benefit to trainees but also as a chance to learn what it means to deliver the best care possible in challenging circumstances. As academic medical centers undergo a transformation in how they approach vulnerable populations, we must combat hidden curriculums by providing explicit and equitable training in the care of patients who are incarcerated.

Camplain R., Hale L., Camplain C., Stageman R., Baldwin J.A.

To investigate sleep quality among individuals incarcerated in a rural county jail, by housing status before incarceration.Using cross-sectional survey methods, 194 individuals incarcerated in jail reported sleep quality prior to and during incarceration on a Likert scale and pre-incarceration housing status (ie, house, apartment, motel, group living, or homeless). Prevalence ratios (PR) were estimated using log binomial regression to determine associations between housing status before incarceration and changes in sleep quality.Participants in non-permanent housing before incarceration had a lower prevalence of worsening sleep quality while incarcerated (compared to stable or improving) compared to those in permanent housing before incarceration (PR = 1.69, 95% CI: 1.03, 2.77).Pre-incarceration housing is associated with change in sleep quality among individuals incarcerated in jail. Jail may be an important point of intervention to improve sleep quality during incarceration and through connecting individuals to more stable living conditions.

Talbert R.D., Macy E.D.

A large body of research has documented the far-reaching health consequences of mass incarceration in the United States. Yet, less scholarship has examined the relationship between former incarceration and oral health, a key reflection of health and disease occurring within the rest of the body. Using data extracted from the National Survey of American Life (n = 3343), this study examines associations among former incarceration status, duration of detention, and self-reported oral health among African American women and men. Results from gender-stratified ordered logistic models reveal that formerly incarcerated African American men and women experience significantly poorer oral health than their never incarcerated counterparts even after controlling for important social determinants of health. Furthermore, oral health is curvilinearly associated with the length of time that men are incarcerated such that odds of poor health decrease as detention duration increases up to approximately 15 years incarcerated. After 15 years of detainment, the odds of poor health tend to increase as duration increases. Findings extend research identifying gendered spillover health consequences of contact with the criminal legal system. Health professionals and policymakers should be conscious of incarceration as an important deleterious experience for the immediate and long-term condition of people’s teeth, mouth, and gums.

Abderhalden F.P., Moule R.K.

Mommaerts K., Lopez N.V., Camplain C., Keene C., Hale A.M., Camplain R.

Purpose Using a seven-day cycle menu and commissary items at a rural county jail, this study aims to describe provisions of micronutrients known to be associated with mental health disorders and if they meet dietary guidelines. Design/methodology/approach The nutritional content of a seven-day cycle menu and four available commissary food packs were evaluated using NutritionCalc® Plus software (McGraw-Hill Education version 5.0.19) and compared to Dietary Reference Intakes (DRI). Findings Menu mean values of Vitamin B6, Vitamin B12, Vitamin C and zinc met DRI recommendations. However, Vitamin D (for men and women), magnesium (for men only) and omega-3s (for men only) did not meet the DRI recommendations. Originality/value As deficits of Vitamin D, magnesium and omega-3s are known to exacerbate bipolar disorder, anxiety and depression, small changes to food would increase the offerings and potential intake of nutrients that may improve mental health.

Abderhalden F.P.

Zottola S.A., Duhart Clarke S.E., Desmarais S.L.

Bail is the practice of using money or property as an assurance that a person charged with a criminal offense will return for their scheduled court dates and not engage in criminal activity during the pretrial period. However, there is limited evidence supporting bail as an intervention in these ways, despite the steady increase in both the use and amount of bail since the late 1980s. Instead, bail is widely criticized for emphasizing resource-based decisions that have unnecessarily increased rates of pretrial detention in the United States and have contributed to cumulative and disproportionate disadvantage for people of color and low-income people involved in the American legal system. Consequently, there is widespread agreement that bail reform is needed and, yet, what this means in policy and practice is widely contested. In this chapter, we review bail decision-making practices, their impact overall and for marginalized groups, and bail reform efforts over time, including ongoing challenges or concerns.

Camplain R., Pinn T.A., Becenti L., Williamson H.J., Pro G., Luna C., Bret J.

The physical and mental health benefits of physical activity in all populations are well established. In 2019, incarcerated women at a Southwest county jail were observed during "recreation time," a time when physical activity is encouraged, to identify the proportion of women who participated in recreation time and their physical activity levels. During observed recreation times, 28% of women attended; 56% were sedentary, 4% engaged in vigorous physical activity, and approximately 40% walked or performed similarly moderate physical activity. Future research should identify barriers to being physically active while incarcerated, leading to targeted interventions to promote physical activity.

Camplain R., Lininger M.R., Baldwin J.A., Trotter R.T.

We aimed to estimate the prevalence of cardiovascular risk factors, including hypertension, diabetes, high cholesterol, cigarette smoking, alcohol consumption, and obesity among a sample of individuals incarcerated in an Arizona county jail and compare prevalence estimates to a matched non-institutionalized population. From 2017–2018, individuals housed at a county jail completed a cross-sectional health survey. We estimated the prevalence of hypertension, diabetes, cholesterol, overweight/obesity, cigarette smoking, binge drinking, and self-reported health among individuals incarcerated. We compared prevalence estimates of cardiovascular risk factors to a matched sample of 2017–2018 NHANES participants. Overall, 35.9%, 7.7%, and 17.8% of individuals incarcerated in jail self-reported hypertension, diabetes, and high cholesterol, respectively. Of individuals incarcerated, 59.6% were overweight or obese and 36.8% self-reported fair or poor general health. Over half of individuals incarcerated reported ever smoking cigarettes (72.3%) and binge drinking (60.7%). Compared to a matched sample of NHANES participants, individuals incarcerated in jail had a statistically higher prevalence of cigarette smoking and binge drinking. Screening of cardiovascular risk factors and providing preventive measures and interventions, such as healthy eating, physical activity, or pharmacological adherence interventions, while individuals are incarcerated may contribute to the prevention and management of cardiovascular risk factors and, eventually, cardiovascular disease.

Eaves E.R., Camplain R.L., Lininger M.R., Trotter II R.T.

Purpose The purpose of this paper is to characterize the relationship between adverse childhood experiences (ACEs) and substance use among people incarcerated in a county jail. Design/methodology/approach A questionnaire was administered to 199 individuals incarcerated in a Southwest county jail as part of a social-epidemiological exploration of converging comorbidities in incarcerated populations. Among 96 participants with complete ACEs data, the authors determined associations between individual ACEs items and a summative score with methamphetamine (meth), heroin, other opiates and cocaine use and binge drinking in the 30 days prior to incarceration using logistic regression. Findings People who self-reported use of methamphetamine, heroin, other opiates or cocaine in the 30 days prior to incarceration had higher average ACEs scores. Methamphetamine use was significantly associated with living with anyone who served time in a correctional facility and with someone trying to make them touch sexually. Opiate use was significantly associated with living with anyone who was depressed, mentally ill or suicidal; living with anyone who used illegal street drugs or misused prescription medications; and if an adult touched them sexually. Binge drinking was significantly associated with having lived with someone who was a problem drinker or alcoholic. Social implications The findings point to a need for research to understand differences between methamphetamine use and opiate use in relation to particular adverse experiences during childhood and a need for tailored intervention for people incarcerated in jail. Originality/value Significant associations between methamphetamine use and opiate use and specific ACEs suggest important entry points for improving jail and community programming.

Camplain R., Pinn T.A., Williamson H.J., Pro G., Becenti L., Bret J., Luna C., Baldwin J.A.

Over 9 million people are incarcerated in jail each year, but physical activity has not been assessed among incarcerated populations. Measuring physical activity in the jail setting is complicated as current physical activity measurement tools are not designed for use inside jail facilities. Therefore, we adapted an evidence-based physical activity measurement tool, the System for Observing Play and Recreation in Communities (SOPARC), to assess physical activity within a jail facility. SOPARC was designed to obtain observational information on physical activity of individuals. The study team created a protocol for SOPARC for use in jail facilities. Unlike the original SOPARC, access to recreation time in jail required prior scheduling. Target areas were unnecessary as recreation spaces were enclosed. The adapted SOPARC protocol for jails included start and end times, the number of individuals that attended, and recreation time users’ physical activity levels, footwear, outerwear, uniform color, and use of mobility assistive devices. The use of SOPARC in the jail setting requires adaptation to adequately capture physical activity data among incarcerated individuals. Accurately measuring physical activity among incarcerated individuals and the environment in which they are active may allow for future development and testing of physical activity interventions in jail facilities.

Camplain R., Warren M., Baldwin J.A., Camplain C., Fofanov V.Y., Trotter R.T.

Each year, 9 million individuals cycle in and out of jails. The under-characterization of incarceration as an exposure poses substantial challenges to understanding how varying levels of exposure to jail may affect health. Thus, we characterized levels of jail incarceration including recidivism, number of incarcerations, total and average number of days incarcerated, and time to reincarceration.We created a cohort of 75,203 individuals incarcerated at the Coconino County Detention Facility in Flagstaff, Arizona, from 2001 to 2018 from jail intake and release records.The median number of incarcerations during the study period was one (interquartile range [IQR] = 1-2). Forty percent of individuals had >1 incarceration. The median length of stay for first observed incarcerations was 1 day (IQR = 0-5). The median total days incarcerated was 3 (IQR = 1-23). Average length of stay increased by number of incarcerations. By 18 months, 27% of our sample had been reincarcerated.Characteristics of jail incarceration have been largely left out of public health research. A better understanding of jail incarcerations can help design analyses to assess health outcomes of individuals incarcerated in jail. Our study is an early step in shaping an understanding of jail incarceration as an exposure for future epidemiologic research. See video abstract at, http://links.lww.com/EDE/B536.