'Owned by Nobody' : health status and its determinants among New South Wales prisoners

Abstract

OBJECTIVES The overall aim of the project were to conduct a survey of the physical and mental health status of prisoners in New South Wales (NSW). A more specific aim, which is addressed in this PhD, was to analyse in detail a number of key health areas which have particular relevance to prisoner populations namely: tuberculosis, viral hepatitis, herpes simplex type 2 virus, childhood sexual abuse (CSA), and drug and alcohol use.

METHODS A cross-sectional, random sample of prisoners, stratified by sex, age and Aboriginality was chosen from 27 correctional centres (24 male and 3 female) in NSW in 1996. Screening was conducted by nurses from within the correctional health system.

A detailed face-to-face interview was used to collect self-reported information on a range of physical and mental health characteristics, and behavioural issues. The physical health component covered chronic illness, recent symptoms, health services utilisation, medications, and self assessed health status. Mental health issues which were covered included: suicide attempts, self-harm, prior mental illness and psychiatric medication. Standardised screening instruments were used to test for depression, hopelessness and suicidal intent. Behavioural factors sought were drug and alcohol use, gambling, and sexual abuse.

Blood samples were taken to screen for a range of infectious diseases and health indicators. These included HIV, syphilis, herpes simplex type-2 virus, rubella, chlamydia, and hepatitis (B, C, and G). A Mantoux skin test was performed to screen for tuberculosis infection. Hearing was assessed using otoacoustic emissions.

RESULTS A total of 789 inmates (657 males and 132 females), including 235 Aboriginal people were screened, representing approximately 11% of males and 40% of females in full-time incarceration. For the key areas examined in the chapters we found: Overall health status ¡¤ Overall health status was poor compared with the NSW general population in regard to self-reported chronic illness, recent health complaints, and well-being. Hospitalisation was less frequent in male prisoners than general community males but higher in female prisoners for mental health problems compared with community females. Tuberculosis ¡¤ No previously undetected cases of tuberculosis were found; however, Mantoux positivity was higher in Aboriginal and overseas born prisoners. Viral hepatitis ¡¤ Markers for hepatitis B, hepatitis C, and hepatitis G were significantly more common in the NSW prisoner population than in the general community. Significant disparities were found between prisoners¡¯ self-report of past exposure to hepatitis (B and C) and their serostatus. Thirty five percent of inmates who were hepatitis C antibody positive believed that they were negative, and for hepatitis B, 72% of positives reported they were negative. Multivariate analysis identified Aboriginality, long-term injecting, and injecting while in prison as risk factors for HBV. Risk factors for exposure to HCV were female sex, non-Aboriginality, history of childhood institutionalisation, and injecting-related behaviours. For HGV, female sex, and previous imprisonment were significant risk factors but injecting was not; being aged 25-39 years was associated with a decreased risk for HGV as compared to younger and older inmates.

Herpes simplex virus type 2 ¡¤ The prevalence of HSV-2 antibodies in this prisoner population was similar to that observed in NSW STD clinic attendees, and was higher in females than males. Exposure was related to: increasing age and Aboriginality for men, and higher reported number of lifetime sexual partners and the presence of hepatitis C antibodies for women. Few prisoners (1%) reported a previous diagnosis of genital herpes. Childhood sexual abuse ¡¤ The prevalence of self-reported childhood sexual abuse was higher in females than males, and similar to that observed in clinical populations. There was an association between CSA and mental health outcomes, including a history of psychiatric treatment and suicide attempts. Male survivors of CSA were more likely to report self-harm, depression, and involvement in violent relationships. Both men and women with a history of CSA were more likely to report having a sexually transmissible disease (STD). Females exposed to CSA were more likely to report subsequent abusive adult relationships involving physical assault, sexual assault, and verbal abuse. Drug use ¡¤ Overall, 64% of prisoners had used illicit drugs at some time in the past with cannabis (males 56%, females 63%) and heroin (males 29%, females 49%) being the most common. Forty four percent of prisoners had a history of injecting drug use, with injecting prevalence significantly higher in females than males (64% vs. 40%). Half of male and female injectors had done so while in prison. Harmful or hazardous use of alcohol was associated with imprisonment for violent crimes, whereas opiate and methadone use were associated with non-violent crimes. Sixty two percent of property offenders had an injecting history. Alcohol intoxication at the time of offending was associated with imprisonment for homicides and assaults. Males were more likely than females to seek treatment in prison for drug problems. IMPLICATIONS Prisoners in NSW have a number of special health needs which are evidenced in the high levels of infectious diseases (hepatitis B, hepatitis C, hepatitis G, and herpes simplex virus type 2) and exposure to factors (childhood sexual abuse and alcohol and drug use) with a clear relationship to adverse health outcomes. Prisons represent an opportunity for public health interventions to address some of the health problems identified in this study. Potentially valuable programmes include education to prevent the spread of blood borne communicable diseases and STDs, immunisation for vaccine preventable diseases such as hepatitis B, and treatment to alleviate the effects of drug use and childhood sexual abuse. In the case of prison drug use the prison environment itself presents a threat to health in that sterile injecting equipment is not available to prisoners despite evidence that injecting in prison is widespread. The challenge for prison health planners is twofold: to make maximum use of the window of opportunity to improve the health status of this group, and to provide a continuum of care between the community and prison.