Past incarceration linked to worse health outcomes

Adults with a history of incarceration had a higher risk for developing chronic diseases and geriatric syndromes than those who were never incarcerated, highlighting a need for targeted interventions, according to researchers.

While previous research has established that incarcerated individuals face higher rates of geriatric syndromes and chronic disease, Ilana R. Garcia-Grossman, MD, a board-certified primary care internist and current Veterans Affairs fellow at the University of California, San Francisco, National Clinician Scholars Program, and colleagues wrote in JAMA Network Open that it is unclear if older adults who have a history of incarceration also face these risks.

“There is a profound lack of data about U.S. adults with a criminal legal history,” the researchers wrote, adding there is “a critical need to improve data collection and transparency to generate accurate estimates of lifetime incarceration in the U.S.”

Garcia-Grossman and colleagues conducted a cross-sectional study to better understand the connections between incarceration history and health outcomes in older age. They used population-based data from 13,462 adults aged 50 years or older who completed the 2012 or 2014 Health and Retirement Study (HRS), which is a nationally representative survey.

Of the participants, 946 adults with a mean age of 62.4 years had experienced incarceration, yielding a prevalence rate of 7.6%. Those with a history of incarceration were more likely to be men — 83% vs. 42.8% — in the lowest quartile of wealth — 44.1% vs. 21.4%.

“We found that at least one in 15 adults ... had experienced incarceration during their lifetime,” the researchers wrote. “This is likely an underestimate of the actual experience of older U.S. adults since the HRS does not include people who were unhoused, did not have a telephone or were incarcerated at the time of study enrollment.”

There were no associations between a history of incarceration and diabetes or cardiovascular conditions, but the researchers found a 20% to 80% higher risk for all geriatric syndromes, including hearing impairment (RR = 1.22; 95% CI, 1.04-1.44) and activities of daily living impairment (RR = 1.62; 95% CI, 1.4-1.88) after adjusting for age, sex, race and ethnicity, wealth, educational attainment and uninsured status.

“We found that health outcomes associated with a history of incarceration had a positive linear trend in our unadjusted analysis; longer incarceration periods were associated with higher disease prevalence for many health outcomes,” Garcia-Grossman and colleagues wrote.

In addition, prior incarceration was also linked to higher risks for some chronic diseases, including:

• chronic lung disease (RR = 1.56; 95% CI, 1.27-1.91);
• heavy alcohol use (RR = 2.13; 95% CI, 1.59-2.84); and
• mental health conditions (RR = 1.8; 95% CI, 1.55-2.08).

“These findings are consistent with prior research demonstrating a high prevalence of chronic health conditions and geriatric syndromes at relatively young ages among older adults who were currently incarcerated (rather than living in the community) and support the notion of accelerated aging in this population,” Garcia-Grossman and colleagues wrote.

Although the study was not meant to evaluate “underlying causal pathways between incarceration and poor health,” the researchers offered several potential explanations:

• people who experience incarceration could face worse baseline health that persists throughout their lives;
• facing incarceration could worsen poor health outcomes because of the variable access to physical activity, healthy food and high-quality health care, or because of “exposure to trauma and violence, acute and chronic stress from living in dehumanizing conditions;”
• incarceration may also lead to “downstream barriers to other social determinants of health,” like housing and employment, which also contribute to worse health outcomes; and
• connections between incarceration and worse health outcomes could be “the result of unaccounted confounders, suggesting the need for a longitudinal cohort study of people following release from incarceration.”

“Regardless of the underlying etiology, our results support that a history of incarceration is an important marker for risk of poor health outcomes and thus should be considered by clinicians, public health professionals, and policy makers,” they wrote.

Policymakers and health care professionals should consider the health implications of incarceration for older adults, according to Garcia-Grossman and colleagues.

“Our findings indicate that incarceration is so prevalent in the US that an older adult’s likelihood of having a history of incarceration is higher than their lifetime risk of developing colorectal cancer,” they wrote. “Yet, despite the ubiquity of criminal legal system involvement in the U.S., there has been relatively little funding and research dedicated to understanding the downstream health outcomes and needs of this population.”

The researchers also noted that the evidence regarding long-term health consequences from incarceration is key as policymakers look at methods to “reduce the footprint of mass incarceration in the U.S.”

“Given that incarceration is differentially experienced by racial and ethnic minority individuals in the U.S., there is a need for additional research to evaluate whether involvement in the criminal legal system contributes to health disparities seen in these populations,” they wrote. “Health care professionals may benefit from enhanced training, for example, about the effects of incarceration on individuals and communities or the existence and implications of accelerated aging in this population.”