Using decision tree models and comprehensive statewide data to predict opioid overdoses following prison release.

PURPOSE: Identifying predictors of opioid overdose following release from prison is critical for opioid overdose prevention. METHODS: We leveraged an individually linked, state-wide database from 2015-2020 to predict the risk of opioid overdose within 90 days of release from Massachusetts state prisons. We developed two decision tree modeling schemes: a model fit on all individuals with a single weight for those that experienced an opioid overdose and models stratified by race/ethnicity. We compared the performance of each model using several performance measures and identified factors that were most predictive of opioid overdose within racial/ethnic groups and across models. RESULTS: We found that out of 44,246 prison releases in Massachusetts between 2015-2020, 2237 (5.1%) resulted in opioid overdose in the 90 days following release. The performance of the two predictive models varied. The single weight model had high sensitivity (79%) and low specificity (56%) for predicting opioid overdose and was more sensitive for White non-Hispanic individuals (sensitivity = 84%) than for racial/ethnic minority individuals. CONCLUSIONS: Stratified models had better balanced performance metrics for both White non-Hispanic and racial/ethnic minority groups and identified different predictors of overdose between racial/ethnic groups. Across racial/ethnic groups and models, involuntary commitment (involuntary treatment for alcohol/substance use disorder) was an important predictor of opioid overdose.

Identifying structural risk factors for overdose following incarceration: a concept mapping study.

BACKGROUND: Currently, there are more than two million people in prisons or jails, with nearly two-thirds meeting the criteria for a substance use disorder. Following these patterns, overdose is the leading cause of death following release from prison and the third leading cause of death during periods of incarceration in jails. Traditional quantitative methods analyzing the factors associated with overdose following incarceration may fail to capture structural and environmental factors present in specific communities. People with lived experiences in the criminal legal system and with substance use disorder hold unique perspectives and must be involved in the research process. OBJECTIVE: To identify perceived factors that impact overdose following release from incarceration among people with direct criminal legal involvement and experience with substance use. METHODS: Within a community-engaged approach to research, we used concept mapping to center the perspectives of people with personal experience with the carceral system. The following prompt guided our study: "What do you think are some of the main things that make people who have been in jail or prison more and less likely to overdose?" Individuals participated in three rounds of focus groups, which included brainstorming, sorting and rating, and community interpretation. We used the Concept Systems Inc. platform groupwisdom for our analyses and constructed cluster maps. RESULTS: Eight individuals (ages 33 to 53) from four states participated. The brainstorming process resulted in 83 unique factors that impact overdose. The concept mapping process resulted in five clusters: (1) Community-Based Prevention, (2) Drug Use and Incarceration, (3) Resources for Treatment for Substance Use, (4) Carceral Factors, and (5) Stigma and Structural Barriers. CONCLUSIONS: Our study provides critical insight into community-identified factors associated with overdose following incarceration. These factors should be accounted for during resource planning and decision-making.

Longitudinal pathways between maternal depression, parenting behaviors, and early childhood development: a mediation analysis.

Maternal depression is a global public health concern with far-reaching impacts on child development, yet our understanding of mechanisms remains incomplete. This study examined whether parenting mediates the association between maternal depression and child outcomes. Participants included 841 rural Pakistani mother-child dyads (50% female). Maternal depression was measured at 12 months postpartum, parenting behaviors (warmth, stimulation, and harsh parenting) were measured at 24 months, and child outcomes (mental health, socioemotional development, and cognitive skills) were measured at 36 months. Maternal depression predicted increased harsh parenting, child mental health difficulties, and child socioemotional concerns; however, there was little evidence for parenting as a mediator between maternal depression and child outcomes. Sex-stratified results are discussed, and findings are situated in context.

Mass Probation: Effects of Sentencing Severity on Mental Health for Black and White Individuals.

BACKGROUND: Incarceration is associated with negative impacts on mental health. Probation, a form of community supervision, has been lauded as an alternative. However, the effect of probation versus incarceration on mental health is unclear. Our objective was to estimate the impact on mental health of reducing sentencing severity at individuals' first adult criminal-legal encounter. METHODS: We used the US National Longitudinal Survey on Youth 1997, a nationally representative dataset of youth followed into their mid-thirties. Restricting to those with an adult encounter (arrest, charge alone or no sentence, probation, incarceration), we used parametric g-computation to estimate the difference in mental health at age 30 (Mental Health Inventory-5) if (1) everyone who received incarceration for their first encounter had received probation and (2) everyone who received probation had received no sentence. RESULTS: Among 1835 individuals with adult encounters, 19% were non-Hispanic Black and 65% were non-Hispanic White. Median age at first encounter was 20. Under hypothetical interventions to reduce sentencing, we did not see better mental health overall (Intervention 1, incarceration to probation: RD = -0.01; CI = -0.02, 0.01; Intervention 2, probation to no sentence: RD = 0.00; CI = -0.01, 0.01) or when stratified by race. CONCLUSION: Among those with criminal-legal encounters, hypothetical interventions to reduce sentencing, including incremental sentencing reductions, were not associated with improved mental health. Future work should consider the effects of preventing individuals' first criminal-legal encounter.

Documenting Competing Needs to Well-Being Among Those on Community Supervision in the South.

Although the harms of incarceration on health are well known, little is known about individuals' competing priorities to maintaining their health while on probation and parole after release from incarceration. We explored individuals' competing needs on probation and parole (lack of health insurance/access, hazardous alcohol use, substance use, food insecurity, un/underemployment, housing insecurity, lack of social support, length of recent incarceration, prohibitive monthly fees, criminal legal discrimination) to achieving well-being. We explored overlap between competing needs and overall well-being. This descriptive, cross-sectional analysis assesses the relationship between competing needs and current well-being of participants in The Southern Pre-Exposure Prophylaxis Study. Of 364 enrolled participants, 48% were thriving. The most common competing need was substance use (73%). Of the 10 competing needs, participants experienced a median 4 (interquartile range [IQR] 3-6). Those considered to be thriving experienced a median 4 (IQR 3-5) competing needs while those not thriving experienced a median 5 (IQR 4-6; p < .001). People on probation and parole experience competing needs to achieving health and well-being. To improve well-being among this population, programs and policies must focus on not only the health of those exiting incarceration but also the multiple competing needs that they face.

Maternal adverse childhood experiences on child growth and development in rural Pakistan: An observational cohort study.

Maternal adverse childhood experiences (ACEs) have significant impacts on the next generation with links to negative birth outcomes, impaired cognitive development, and increased socioemotional problems in children. However, not all types or levels of adversity are similarly deleterious and research from diverse contexts is needed to better understand why and how intergenerational transmission of adversity occurs. We examined the role of maternal ACEs on children's growth, cognitive, and socioemotional development at 36 months postpartum in rural Pakistan. We used data from 877 mother-child dyads in the Bachpan Cohort, a birth cohort study. Maternal ACEs were captured using an adapted version of the ACE-International Questionnaire. Outcomes at 36 months of age included child growth using the WHO growth z-scores, fine motor and receptive language development assessed with the Bayley Scales of Infant and Toddler Development, and socioemotional and behavioral development measured with the Ages and Stages Questionnaire: Socioemotional and Strengths and Difficulties Questionnaire. To estimate the associations between maternal ACEs and child outcomes, we used multivariable generalized linear models with inverse probability weights to account for sampling and loss to follow-up. Over half of mothers in our sample (58%) experienced at least one ACE. Emotional abuse, physical abuse, and emotional neglect were the most commonly reported ACEs. We found null relationships between the number of maternal ACEs and child growth. Maternal ACEs were associated with higher fine motor and receptive language development and worse socioemotional and behavioral outcomes. Maternal ACE domains had similarly varying relationships with child outcomes. Our findings highlight the complexity of intergenerational associations between maternal ACEs and children's growth and development. Further work is necessary to examine these relationships across cultural contexts and identify moderating factors to mitigate potential negative intergenerational effects.

Challenging Health Inequities in Incarceration: a Call for Equitable Care for Kidney Disease and Hypertension.

PURPOSE OF REVIEW: To review the current literature on care of hypertension and chronic kidney disease for people who are currently and formerly incarcerated, and to make recommendations for improving outcomes. RECENT FINDINGS: There is a growing body of literature describing care for kidney disease and hypertension for incarcerated and formerly incarcerated individuals that documents the provision of care itself, notably that many jails contract with private companies; the system is not designed to provide sustained, chronic disease care; and the transition from incarceration to community is fraught with gaps in care. However, deficiencies in data collection and regulation still limit our understanding of the quality of care provided in jails and prisons. Furthermore, more data is needed to understand the impact of structural racism in the criminal legal system on overall disparities in care for hypertension and kidney disease. Insurance coverage rates for people who were formerly incarcerated continue to be lower than the general population despite Medicaid expansion in many states. There is little recent data regarding kidney replacement therapy for this population despite known variation in dialysis modalities and transplant programs by state. Transitions clinics, which connect people who were formerly incarcerated with care in the community upon release, are growing and are important avenues by which to deliver care. People who are incarcerated are disproportionately affected by hypertension and kidney disease, yet data regarding the extent of these inequities and availability of quality care is lacking. More work is needed to understand the care of individuals with kidney disease and hypertension in prisons and to improve outcomes for these common chronic conditions. Both providing effective treatment of kidney disease and hypertension in prisons and jails and providing coordinated, quality transition to community care upon release represents an important opportunity for reform in care for a marginalized population.

Suicides in state prisons in the United States: Highlighting gaps in data.

OBJECTIVES: Our objectives were to document data availability and reporting on suicide mortality in state prison systems. The United States leads the world in mass incarceration, a structural determinant of health, but lacks real-time reporting of prison health statistics. This absence is particularly notable in suicides, a leading cause of death that carceral policies play a key role in mitigating. METHODS: Suicide data for each state prison system from 2017-2021 were gathered through statistical reports, press releases, and Freedom of Information Act requests. We graded states based on data availability. RESULTS: Only sixteen states provide updated, frequent, granular, freely provided suicide data. An additional thirteen states provided frequently updated data but that had little granularity, was incomplete, or was not freely provided. Eight states provided sparse, infrequent, or outdated data, and thirteen provided no data at all. CONCLUSIONS: The 2000 Death in Custody Reporting Act requires that states provide these data freely, yet the majority of states do not. There is a need for reliable, real-time data on suicides, suicide attempts, and conditions of confinement to better understand the harms of the carceral system and to advocate for change.

Understanding the Accumulation of Health-Related Inequities Over the Life Course Using the Mean Cumulative Count.

Understanding how health inequities develop over time is necessary to inform interventions, but methods for doing so are underutilized. We provide an example of the accumulation of stressful life events using the mean cumulative count (MCC), which estimates the expected number of events per person as a function of time, allowing for censoring and competing events. Data came from the National Longitudinal Survey of Youth 1997, a nationally representative data set. To compare the MCC with standard practice, we present the proportions of persons experiencing 1, 2, and ≥3 stressful events and the cumulative probability of experiencing at least 1 event by the end of follow-up. Our sample included 6,522 individuals aged 18-33 years who were followed for a median of 14 years. Using the MCC, by age 20 years the expected number of encounters was 56 events per 100 participants for Black non-Hispanic persons, 47 per 100 for White non-Hispanic persons, and 50 per 100 for Hispanic persons. By age 33 years, inequities grew to 117, 99, and 108 events per 100 persons, respectively. The MCC revealed that inequities in stressful events accumulate over the course of early adulthood, partially driven by repeat events; this information was not evident from conventional approaches. This method can be used to identify intervention points for disrupting the accumulation of repeat events to improve health equity.

Retention strategies among those on community supervision in the South: Lessons learned during the COVID-19 pandemic.

OBJECTIVES: Cohort studies must implement effective retention strategies to produce internally valid and generalizable results. Ensuring all study participants are retained, particularly those involved in the criminal legal system, ensures study findings and future interventions will be relevant to this group, who are often lost to follow-up: critical to achieving health equity. Our objective was to characterize retention strategies and describe overall retention among an 18-month longitudinal cohort study of persons on community supervision prior to and during the COVID-19 pandemic. METHODS: We implemented various retention strategy best-practices (e.g., multiple forms of locator information, training study staff on rapport building, study-branded items). During the COVID-19 pandemic, we developed and describe new retention strategies. We calculated overall retention and analyzed differences between those retained and lost to follow-up by demographic characteristics. RESULTS: Prior to the start of the COVID-19 pandemic, 227 participants enrolled across three sites (N = 46 North Carolina; N = 99 Kentucky; N = 82 Florida). Of these, 180 completed the final 18-month visit, 15 were lost to follow-up, and 32 were ineligible. This resulted in an overall retention of 92.3% (180/195). While most participant characteristics did not differ by retention status, a greater proportion of those experiencing unstable housing were lost to follow-up. CONCLUSION: Our findings highlight that when retention strategies are flexible, particularly during a pandemic, high retention is still achievable. In addition to retention best-practices (e.g., frequent requests for updated locator information) we suggest other studies consider retention strategies beyond the study participant (e.g., paying participant contacts) and incentivize on-time study visit completion (e.g., providing a bonus when completed the study visit on time).

Mass probation: Temporal and geographic correlation of county-level probation rates & mental health in North Carolina.

High community incarceration rates are associated with worse community mental health. However, it remains unknown whether higher rates of probation, a form of criminal legal community supervision, are similarly associated with worse community mental health. Our objective was to evaluate temporal and geographic correlations of county-level probation and mental health rates separately and to assess the association between county-level probation and mental health rates, measured by self-inflicted injury and suicide. We performed ecological analyses using North Carolina administrative data (2009-2019) and used repeated cross-section, multivariable spatial error models. From 2009 to 2019, probation rates trended downward while self-inflicted injury and suicide remained stable. We found positive spatial autocorrelation suggesting that there are spatial determinants of probation and self-harm, though less so for suicide. Hot spot analyses showed local variation with high self-harm and suicide rates being clustered in rural Western North Carolina and high probation rates being clustered in rural Eastern North Carolina. Probation was positively associated with self-inflicted injury and suicide. For example, in 2018, a 1 percentage point increase in probation was associated with a 0.05 percentage point increase in self-harm in 2019 (95% CI: 0.03, 0.06), meaning that in a county of 100,000 people, an increase in 1000 county residents being on probation would be associated with an increase in 50 self-harm injuries. High county-level probation rates may exert collateral damage on the mental health of those living in areas with much of the population under state control. These findings emphasize that the criminal legal system is not separate from communities and that future public health research and advocacy must consider these collateral consequences of probation on communities.

Collateral consequences of COVID-19 for people on probation and parole.

BACKGROUND: While the severe detrimental impact of COVID-19 on incarcerated people is well known, little is known about the experience of COVID-19 on those on community supervision. Our objective was to better understand the experience of the COVID-19 pandemic and its collateral consequences for those on community supervision (e.g., probation, parole). Beginning in December 2020, we conducted 185 phone surveys about COVID-19 with participants in The Southern Pre-Exposure Prophylaxis (PrEP) Study across its three sites - Florida, Kentucky, and North Carolina. We conducted rapid assessment interviews with both closed- and open-ended questions. We calculated descriptive statistics for close-ended questions and conducted a content analysis for open-ended questions. RESULTS: The COVID-19 pandemic affected those on community supervision through their experiences in the community and while incarcerated with over one-quarter of participants being reincarcerated during this time. In addition to many (128/185) experiencing COVID-19 symptoms, about half (85/185) of participants reported a diagnosis in their network with 16 of those participants losing loved ones to the pandemic. Participants experienced disruptions to their social network, healthcare, and livelihoods. Though many maintained their support systems, others felt isolated and depressed. Experiences during COVID-19 exacerbated difficulties already faced by those with criminal involvement. CONCLUSIONS: The public health community must recognize those experiencing probation and parole, not only those housed in carceral facilities, as disproportionately impacted by the COVID-19 pandemic. We must tailor programs and services to meet their needs.

Context specific HIV risk: evidence from screening into the southern pre-exposure prophylaxis study (SPECS).

While Pre-exposure prophylaxis (PrEP) is efficacious in preventing HIV, little is known about PrEP use among those on community supervision. The Southern Pre-Exposure Prophylaxis Study (SPECS) investigates barriers and facilitators for PrEP initiation and use among adults on community supervision (e.g., probation, parole). Challenges to PrEP use in this setting are abundant. SPECS uses a mixed-methods sequential design, including a multi-site, prospective cohort study in three southern states - North Carolina, Florida, and Kentucky. This analysis describes individual demographic, criminal legal, and HIV risk factor characteristics, by site and enrollment status. Pooled association analyses accounted for site via stratified statistical tests. Between June 2019-March 2020, SPECS screened 702 individuals and enrolled 276 participants (39%). Of those who were eligible, 98% agreed to enroll. Age, gender, and sexual orientation varied by enrollment and by site, while race/ethnicity varied by site but not enrollment status. Criminal legal histories varied by enrollment and HIV risk factors varied by site. SPECS provides a granular and detailed assessment of HIV risk in three diverse southern settings. It highlights how the level and type of HIV risk varies by location and by nature of criminal legal involvement and calls for the need for context-specific interventions for HIV prevention.

"Nothing but a rope to hang yourself:" The toll of mass supervision on mental well-being.

While incarceration has proven detrimental to mental well-being, it remains unknown if community supervision is better for mental well-being than incarceration. Our objective was to explore the individual- and community-level relationships between community supervision and mental well-being and to examine inequities by race. We conducted 20 in-depth interviews with individuals on community supervision (e.g., probation, parole) in North Carolina and conducted thematic analysis separately by race. For many, criminal legal involvement began at a young age, often due to substance use for White individuals or over-policing for Black participants. The themes were: (1) "It's a Thursday. Move on.": surviving over the life course in the context of the criminal legal system; (2) "Merry go round of death": the criminal legal system as a trap; (3) "I love you, but I have to love you from over here": social support as a double-edged sword while on community supervision; and (4) " [Probation] ain't nothing but a rope to hang yourself": mental health issues created and exacerbated by criminal legal involvement. Individuals' experiences on community supervision were often dehumanizing and difficult, preventing them from achieving well-being. This system must be redesigned to meet individual and community needs.

The feasibility and acceptability of a task-shifted intervention for perinatal depression among women living with HIV in Malawi: a qualitative analysis.

BACKGROUND: Perinatal depression (PND) is prevalent and negatively impacts HIV care among women living with HIV (WLHIV), yet PND remains under-identified in Malawian WLHIV. Accordingly, this formative study explored perceptions of the feasibility and acceptability of an integrated, task-shifted approach to PND screening and treatment in maternity clinics. METHODS: We completed consecutive PND screenings of HIV+ women attending pre- or post-natal appointments at 5 clinics in Lilongwe district, Malawi. We conducted in-depth interviews with the first 4-5 women presenting with PND per site (n = 24 total) from July to August 2018. PND classification was based on a score ≥ 10 on the Edinburgh Postnatal Depression Scale (EPDS). We conducted 10 additional in-depth interviews with HIV and mental health providers at the 5 clinics. RESULTS: Most participants endorsed the feasibility of integrated PND screening, as they believed that PND had potential for significant morbidity. Among providers, identified barriers to screening were negative staff attitudes toward additional work, inadequate staffing numbers and time constraints. Suggested solutions to barriers were health worker training, supervision, and a brief screening tool. Patient-centered counselling strategies were favored over medication by WLHIV as the acceptable treatment of choice, with providers supporting the role of medication to be restricted to severe depression. Providers identified nurses as the most suitable health workers to deliver task-shifted interventions and emphasized further training as a requirement to ensure successful task shifting. CONCLUSION: Improving PND in a simple, task-shifted intervention is essential for supporting mental health among women with PND and HIV. Our results suggest that an effective PND intervention for this population should include a brief, streamlined PND screening questionnaire and individualized counselling for those who have PND, with supplemental support groups and depression medication readily available. These study results support the development of a PND intervention to address the gap in treatment of PND and HIV among WLHIV in Malawi.

Suicide Ideation within and outside the Perinatal Period: An Exploration of Interpersonal Factors from a Maternal Cohort in Rural Pakistan to Improve Intervention Targeting.

OBJECTIVE: Suicide accounts for substantial mortality in low-resourced settings and contributes to nearly 20% of maternal deaths. In Asia, interpersonal conflict is a salient factor that contributes to suicidal thoughts and actions, yet limited research has been done to explore the type and timing of such conflicts and a woman's accompanying social support. Identifying such risk factors can inform improved efforts to identify who to target for psychosocial interventions. METHODS: Using the Bachpan Cohort study of mothers in Pakistan (n = 1154), we examined the prevalence and interpersonal influences on SI within the past two weeks of pregnancy and then at 3, 6, and 24 months after birth. Using hierarchical mixed effects models, we explored the separate and combined associations of interpersonal factors [e.g., social support, interpersonal conflict, isolation, and past year intimate partner violence (IPV)] on SI at each timepoint. RESULTS: SI prevalence was highest in pregnancy (12.2%) and dropped to 5% throughout two years postpartum. The interpersonal conflict was independently associated with increased odds of SI in pregnancy and 24 months postpartum. IPV was associated with increased SI in pregnancy and 24 months postpartum. Isolation was not associated with SI at any timepoint. Perceived social support remained a robust independent factor associated with reduced SI at all timepoints. CONCLUSION: In addition to screening and deploying interventions for perinatal women with depression, targeting interventions for those who also experience interpersonal conflict, including intimate partner violence, may significantly reduce suicidal thoughts and related sequelae. Social support is a viable and potentially powerful target to reduce the burden of suicide among women.HIGHLIGHTSSuicidal ideation prevalence was higher in pregnancy compared to postpartum.Perceived social support was independently associated with reduced suicidal ideation.Interventions addressing suicide must attend to women's family and social context.

Inequities in life course criminal legal system sanctions: measuring cumulative involvement.

PURPOSE: The impact of incarceration on health is well known. Yet, most studies measure incarceration alone and miss additional exposure to the criminal legal system over time. We evaluated adult criminal legal sanctions - inclusive of arrests, charges, probation, incarceration - from ages 18-35 and inequities by juvenile sanctions and race. METHODS: Using the National Longitudinal Survey on Youth 1997, a nationally representative data set of adolescents followed into their mid-thirties (1997-2017), we calculated the mean cumulative count, or the average number of criminal legal events per person per study visit, stratified by juvenile sanctions and race. RESULTS: Of 7024 participants, 1679 experienced 3,075 encounters. There were seven arrests, 30 charges, nine probation encounters, and 13 incarceration events /100 participants by age 35. Juvenile sanctions were most common for Black individuals. Among those experiencing juvenile sanctions, Black and White individuals had similar numbers of encounters, but Black individuals had more arrests and incarceration stays. For those without juvenile encounters, Black individuals had more encounters than White individuals. CONCLUSIONS: Research on health effects of criminal legal sanctions must consider encounters beyond incarceration and focus on life course trajectories and racial inequities.