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Studies from Europe, Australia, the United States and Taiwan have shown that the rate of mortality in ex-prisoners is elevated in the weeks immediately following release, compared with subsequent weeks. These studies have also shown that mortality rates in ex-prisoners remain elevated, compared with the non-institutionalized population, for many years post-release. Several mechanisms have been hypothesized to explain the elevated risk and a key debate relates to the relative contribution of incarceration itself and the high level of underlying risk among former inmates. Preventive efforts need further development and evaluation, and methodological limitations hinder synthesis of the literature.
Correctional services have a duty of care to prisoners in their charge, and in most jurisdictions, deaths in custody are closely monitored (Curnow and Larsen 2009; Noonan 2010). In Australia for example, deaths in police custody and in prison are routinely monitored and reported annually through the National Deaths in Custody Program (NDICP). Similarly in the United States, deaths in custody are reported to the Bureau of Justice Statistics through the Deaths in Custody Reporting Program. Almost all prisoners return to the community eventually, most after a relatively short period of time in custody; however, it has only been relatively recently that researchers have turned their attention to deaths after release from custody. One of the first such studies examined mortality outcomes among persons released from a 300-bed prison in Geneva, Switzerland, from 1982 to 1986; the researchers identified 102 unnatural deaths in the cohort with a disproportionate number occurring in the first year following release, often due to opiate poisoning (Harding-Pink and Frye 1988). In a subsequent study, Seaman and colleagues used record linkage to examine mortality outcomes for a cohort of 238 HIV-infected injecting drug users after release from prison in Edinburgh, Scotland. The researchers found that the risk of death (the “crude mortality rate,” or CMR) from overdose was 7.7 times higher in the 2 weeks after release, than in the subsequent 10 weeks, highlighting an acute period of vulnerability after release from prison (Seaman et al. 1998). Subsequent studies in Europe, North America, and Australia confirmed that this phenomenon was widespread, with a meta-analysis finding that the risk of drug-related death was between 3 and 8 times higher in the first 2 weeks following release from custody, than in the subsequent 10 weeks (Merrall et al. 2010). Some studies have also shown that the risk of death in recently released prisoners is higher than that of current prisoners (Binswanger et al. 2007; Kariminia et al. 2007; Kinner et al. 2011), and higher than that of age-and sex-matched members of the general community (the “standardized mortality ratio,” or SMR) (Binswanger et al. 2007; Kariminia et al. 2007; Rosen et al. 2008; Stewart et al. 2004).
Although drug-related causes account for a large proportion of deaths in former prisoners, most studies report that the majority of deaths are not drug related. Another key cause of preventable death in this population is suicide, which may reflect the very high rates of mental illness in prisoners, particularly among women (Fazel and Danesh 2002). For example, in a study of almost 250,000 ex-prisoners in England and Wales, Pratt and colleagues found that the rate of suicide in the first year after release from prison was 8.3 times higher for males and 35.8 times higher for females, than for age-and sexmatched members of the community. Reflecting the concentration of risk in the immediate post release period, 21 % of these deaths happened in the first 28 days post-release (Pratt et al. 2006). Similarly, in a cohort of male ex-prisoners in New South Wales, Australia, Kariminia and colleagues found that the rate of suicide was 3.9 times higher in the first 2 weeks post-release, than after 6 months post-release (Karaminia et al. 2007). Although the risk of suicide is greatest in the immediate post-release period, there is some evidence that it remains elevated for much longer. In a study of 168,001 exprisoners in North Carolina followed for a median of 10.3 years, Rosen and colleagues found that the rate of death from suicide was significantly elevated for white ex-prisoners (compared with ageand sex-matched white people in the community), although not for black exprisoners (compared with ageand sex-matched black people in the community) (Rosen et al. 2008).
Drug overdose and suicide are the leading causes of death in ex-prisoners; however, other key causes of unnatural death in this population include motor vehicle accidents (MVAs) and drowning and, in some countries, homicide. One study of 9,381 ex-prisoners in Western Australia found that of 326 observed deaths, 29 % were drug related, 20 % were due to suicide, and 12 % due to motor vehicle accidents (Stewart et al. 2004). Similarly, in the Australian study by Kariminia and colleagues, 33 % of deaths were drug related, 16 % were suicides, 8 % were transport related, and 4 % were due to homicide (Kariminia et al. 2007). By contrast, in the Rosen study in North Carolina, only 12 % of deaths were drug related, 5 % were due to suicide, 11 % due to homicide, and 9 % due to motor vehicle accidents (Rosen et al. 2008). Understanding patterns in mortality in ex-prisoners is complicated by the fact that most deaths have multiple contributing causes, and coronial processes may differ between jurisdictions and over time. For example, suicides involving drugs may be classified as a suicide or a drug-related death; accidental deaths such as MVAs may be related to intoxication from alcohol or other drugs; homicides may be related to substance use, involvement in the drug trade, and criminal subculture or, particularly for women, the return to violent relationships.
Although the majority of deaths in exprisoners are due to unnatural causes, exprisoners are also at increased risk of death from natural causes such as cancer; liver, cardiovascular, and respiratory disease; and infectious diseases such as HIV and hepatitis C (Kariminia et al. 2007; Rosen et al. 2008), reflecting the high prevalence of health risk behaviors such as injecting drug use, unprotected sex, and tobacco use in this population (Binswanger et al. 2007; WHO 2007). Furthermore, although the risk of death is greatest in the period immediately following release from custody, this risk remains elevated relative to the sexand age-adjusted non-institutionalized population for at least a decade (Karaminia et al. 2007; Rosen et al. 2008). To date, no studies have examined whether the key causes of death or risk factors for death in ex-prisoners vary over this time.
Not all ex-prisoners are at equal risk of death following release from custody. Using survival analysis, some studies have charted the probability of “surviving” (i.e., remaining alive) over time, from the point of release from prison, for different subgroups. These studies provide a graphic illustration of the precipitous drop in survival in the immediate post-release period, and show that different subgroups of ex-prisoners (for example, defined by sex, age and race) have a different probability of “survival” after release from prison. Record linkage studies have also been used to identify risk factors for death in ex-prisoners. Although findings have not always have been consistent, most studies find that each additional episode of imprisonment (and subsequent release) increases the risk of death; not surprisingly, a history of substance abuse and mental illness is also associated with increased risk of death (Singleton et al. 2003; WHO 2010). Findings regarding age have been mixed, with some studies finding that younger people are at greater risk of death, while others find the converse (Binswanger et al. 2007; Chen et al. 2010; Larney 2010). One study of drug-using exprisoners in Taiwan found that HIV infection was associated with increased risk of death while retention in methadone maintenance treatment (MMT) post-release was protective (Chen et al. 2010). In another study of drug-related death among ex-prisoners in the United Kingdom, a history of relationship breakdown and limited social support post-release were associated with death (Singleton et al. 2003), highlighting the importance of post-release support mechanisms. Many studies find that ethnic and racial minority groups are at greater absolute risk of death (Stewart et al. 2004), although when compared with race-matched peers in the community, this difference is usually attenuated (Rosen et al. 2008; Stewart et al. 2004). Conversely, although most studies find that the absolute risk of death is lower for women than men, the elevation in risk of death for women, compared with ageand sex-matched peers in the community, is consistently greater for women than for men (Larney 2010; Stewart et al. 2004). This apparent paradox is explained by the fact that women in the community have a lower ageadjusted rate of death than men, but this difference is smaller among ex-prisoners. This may be due to the greater underlying risk among women who get incarcerated than men (differential selection).
Several mechanisms have been proposed to explain the elevated risk of death among former inmates, depending on the cause of death and the time since release. Early studies focused on an acute elevation in risk of drug-related death (Seaman et al. 1998). The presumed mechanism was diminished physiologic tolerance, with opioid (usually heroin) dependent individuals ceasing or reducing their drug use while incarcerated, and upon release relapsing to substance use and experiencing an accidental poisoning (overdose). Accordingly, the main response to prevent such deaths was to educate soon-to-be-released prisoners about drug tolerance, and counsel them to avoid drug use or at least consume smaller quantities. This approach remains central to many correctional authorities’ response to mortality prevention in ex-prisoners. In some jurisdictions, opioid tolerance is maintained throughout the period of incarceration via opioid substitution therapy, such as methadone or buprenorphine. Although it is clear that a substantial proportion of preventable deaths in ex-prisoners is due to drug-related causes, it remains unclear what proportion of these deaths is attributable to reduced drug tolerance. Furthermore, while former inmates may have knowledge gaps about tolerance to drugs and its potential ramifications (Adams et al. 2011), it is not clear whether education alone is sufficient to reduce drug-related mortality.
In addition to reduced drug tolerance, researchers have identified a range of other factors that may help explain the acute elevation in risk of drug-related death among recently released prisoners. Key among these is polysubstance use, and in particular the combined use of multiple central nervous system depressants such as opioids, benzodiazepines, and alcohol. Poly-substance use is a contributing factor in many drug-related deaths among former prisoners (WHO 2010); however, in order to explain the acute elevation in risk of drug-related death in the immediate post-release period, polysubstance use would need to be more common or more intense during this time. There is some indirect evidence for this, with some researchers describing an acute period of injecting risk behavior in the immediate post-release period (Seal et al. 2001). Another potential risk factor is single-room occupancy: Many recently released prisoners experience difficulty finding accommodation and may resort to living alone in single-room dwellings; drug overdoses in such settings are more likely to be fatal because the victim is unlikely to receive assistance from other users or passersby. Another potential contributing factor relates to the transition from the predictability of the prison environment to an ever-changing and unfamiliar outside world. Due to the process of classical conditioning, it appears that drug effects are attenuated in familiar environments and potentiated in novel environments, such that drug use in a novel environment may produce greater intoxication (Siegel 2001). Finally, some authors have argued that risk of fatal overdose may be increased by systemic disease, in particular lung and hepatic dysfunction (Warner-Smith et al. 2001). Consistent with this, the prevalence of both tobacco smoking and hepatitis C infection is very high among prisoners (WHO 2007).
Although the majority of deaths in former prisoners are not drug related, there has been less consideration of the mechanisms underpinning other causes of death in this population. One contributing factor in suicide deaths is likely to be mental illness, which is highly prevalent in prisoners (Fazel and Danesh 2002). Given that many prisoners experience mental illness and only a small minority commit suicide post-release, mental illness may be better conceived of as a predisposing factor than a direct cause. Given the concentration of suicide deaths in the immediate post-release period, at least part of the explanation for these deaths must be related to the transition from prison to community. For vulnerable prisoners, particularly those with a mental illness, the transition to the community is likely to be a highly stressful time characterized by uncertainty, frustration, and disappointment (Binswanger et al. 2011b). Many exprisoners experience homelessness, poverty, and discrimination, and may have difficulty reestablishing relationships with family and friends. These challenges may be compounded by a sudden reduction in access to healthcare and other support services, which are more readily accessible in prison environments (Adams et al. 2011; Levy 2005). For those experiencing mental illness, one consequence of this may be reduced access to and adherence to medication, and a subsequent relapse to decompensated mental illness. In this context, intentional overdose and suicide have been perceived by some former inmates as a “way out” for intolerable conditions in the community (Binswanger et al. 2011b).
Poor access to health care may also be an important factor in other causes of death in exprisoners, particularly given the high prevalence of chronic and infectious disease in this population. For example, there is evidence that among HIV-infected injecting drug users, release from prison is associated with reduced adherence to antiretroviral medications and subsequent increase in viral load (Palepu et al. 2004). Even if appropriate health services are available in the community, unless recently released prisoners are connected with these services before release, they may “fall through the cracks” after release, failing to access appropriate health care until an acute health issue arises. Increased support during the transition from prison to community, and improved access to healthcare for recently released prisoners, may reduce the risk of death from both unnatural and natural causes; however, the links between transitional health services and mortality outcomes are poorly understood (Kinner 2010).
Prison As A Cause Or Marker Of Underlying Risk
Although there is clearly a strong association between release from prison and death, this does not necessarily imply that the release “caused” the death. As discussed above, the reasons for death after release from prison are likely to be complex and variable over time. One view is that prison is a “marker” for underlying risk and that death may even be delayed by imprisonment. That is, populations who move through prison systems are already at increased risk of death, because the factors predisposing to death, such as substance abuse, mental illness, impulsivity, and poverty, also predispose to crime and incarceration. Epidemiological studies consistently reveal a high prevalence of disadvantage, poor health, and health risk behaviors such as injecting drug use among prison samples (Fazel and Danesh 2002; WHO 2007). Also consistent with the view that imprisonment is a “marker” for mortality risk is evidence that ex-prisoners remain at elevated risk of death for many years after release from custody (Kariminia et al. 2007; Rosen et al. 2008). Although it is possible that the experience of imprisonment and release has a long-term impact on mortality risk (for example, through promoting marginalization and disadvantage, initiation into risky behaviors such as injecting drug use, and/or exposure to chronic infections such as hepatitis C or HIV), it is clear that many people entering prisons for the first time are already characterized by a number of risk factors for mortality.
Despite this some authors, pointing to the acute elevation in risk of death immediately after release from custody, have implicated correctional authorities, implying a causal relationship between incarceration and death. In this view, correctional authorities are responsible for the deaths of recently released prisoners. Not surprisingly, most correctional authorities reject this view, arguing that deaths occurring in the community are, by definition, a community responsibility. While this may be true in some cases, the situation is less clear for those exprisoners subject to some sort of post-release supervision. At least one study has examined mortality outcomes according to post-release supervision and found no relationship, suggesting that involvement with correctional services after release may not be protective against mortality (Binswanger 2011a). Whether or not correctional authorities are in any way “responsible” for the deaths of recently released prisoners, the well-established association between release from prison and death suggests some sort of causal relationship between release from custody and death.
Given the acute elevation in risk of death in the first few weeks after release from custody, and evidence of ongoing elevation in risk of death for years after release, prison may be both a risk marker and a cause of mortality in exprisoners. That is, release from prison precipitates a period of particularly elevated risk of death, but given the preexisting risk factors that characterize many ex-prisoners, this risk never returns to that of non-incarcerated community peers. From a public health perspective, assigning blame for the deaths of ex-prisoners is less important than preventing these deaths. Although the majority of deaths in ex-prisoners do not occur in the weeks immediately following release, a disproportionate number of deaths do occur in this period and in the context of limited resources, it is probably prudent to target preventive interventions in the immediate post-release period.
A growing body of literature has described patterns of mortality in ex-prisoners, but to date, there have been few attempts to evaluate interventions designed to prevent these deaths. Based on a review of largely descriptive evidence, the World Health Organization (WHO) proposed strategies to prevent drug-related death in recently released prisoners at the policy and program level (WHO 2010). Although oriented to the prevention of acute drug-related deaths, many of these recommendations are also relevant to the prevention of death due to other causes. Among the key policy responses recommended by WHO is the adoption of an evidence-based drug treatment framework that diverts individuals with a substance use disorder into treatment rather than prison wherever possible, and the integration of prison and community services so that gaps in service and accountability are minimized. Given persuasive evidence that the criminalization of drug use and dependence has driven rapid increases in prison populations internationally (Pettit and Western 2004), the recommendation to minimize the incarceration of drug users seems well grounded. Efforts to improve service continuity and integration for ex-prisoners, and to reduce financing silos, may also prove beneficial, although evaluation findings to date have been mixed.
At the program level, WHO advocates for evidence-based practices including opiate substitution treatment (OST) in custody and postrelease. Recent evidence suggests that in-prison OST is associated with reduced drug-related mortality in ex-prisoners (Larney 2010), although it remains unclear whether this is a direct effect due to the maintenance of opioid tolerance in prison, or an indirect effect whereby those on OST in prison are more likely to transition to OST post-release, with the latter providing the protective effect. WHO also endorses education for prisoners, prison staff and support workers to make all stakeholders aware of the increased risk of death post-release, strategies for the prevention of drug use, the risks posed by reduced drug tolerance and poly-substance use, and strategies for overdose prevention. Although there is little evidence that education alone can prevent deaths, education is appropriate as part of a broader prevention strategy, supported by pharmacotherapy in prison and post-release for high-risk individuals.
Consistent with a growing body of evidence, WHO (2010) joins a chorus of researchers specifically advocating for training the families and peers of at-risk prisoners in first aid, including the administration of naloxone, an overdose reversal drug used routinely by paramedics. There is growing evidence that with appropriate training, naloxone can be safely administered by peers and is effective in reversing overdoses, almost certainly saving lives (Lenton et al. 2009). In Scotland, naloxone kits and training are currently being provided to friends and family of soon-tobe-released prisoners, on a trial basis. If the evaluation of this initiative is favorable, it is likely that the same approach will be adopted elsewhere; however, naloxone is not a panacea. Naloxone is only effective if the overdose victim used opioids, and if the medication is administered by a bystander early and with at least basic knowledge of its use.
Given the complexity of the post-release experience, the broad range of causes of death, and the high degree of marginalization and stigma experienced by former inmates, effective prevention will likely require a combination of behavioral, environmental, service-based, and pharmacologic interventions. Financing mechanisms that support continuity and integration of care during the transition from prison to the community may also help ameliorate transitional risk, although few such initiatives have been rigorously evaluated. Similarly, diversion initiatives (e.g., drug and mental health courts) designed to reduce the imprisonment (and subsequent release) of drugdependent and mentally ill individuals, by providing appropriate community-based treatment and supervision, may reduce mortality risk. Under-investment in these programs has limited their impact and rigorous evaluations have been scarce.
Despite the dearth of evidence regarding “what works” to improve health outcomes and reduce mortality in ex-prisoners, correctional authorities in many countries are embracing a “through-care” model, implementing policies and programs designed to facilitate a successful reentry. Although this is rarely the intention and has yet to be demonstrated empirically, such programs may also reduce mortality. Whereas deaths in prison are routinely monitored in some countries, the same cannot be said for deaths after release from prison. A recent Australian study estimated that the annual number of deaths among adult ex-prisoners in Australia, within a year of release from custody, is about ten times the number of deaths in custody over the same period (Kinner et al. 2011). Highlighting this largely forgotten group, the authors advocated for routine monitoring of ex-prisoner mortality through record linkage, which is both feasible and cost-effective in many developed countries. In the Australian context, monitoring of deaths in recently released prisoners will feature in a “national minimum dataset for prisoner health” (AIHW 2011) in the near future, allowing policy makers and researchers to examine annual trends in mortality in this group.
Many questions remain about the most effective way to prevent deaths in ex-prisoners, and there remains a need for further research (Kinner 2010; WHO 2010): First, to identify who among ex-prisoners is most at risk of death, when and why, so that preventive interventions can be appropriately targeted and tailored. And second, to rigorously evaluate both targeted and broad-based interventions designed to improve health outcomes for ex-prisoners, to reduce untimely deaths in this profoundly marginalized population.
Evidence-based prevention requires sound evidence; however, methodological limitations of existing studies have made interpretation of the evidence complex and quantitative synthesis of the evidence difficult. Methodological limitations of the existing literature can be grouped into four categories: sampling, data quality, analysis and reporting. Early studies typically included a single prison and/or selected a subgroup of prisoners thought to be at high risk: for example, HIV-infected injecting drug users (Seaman et al. 1998). Although these studies were the first to identify a period of acute risk immediately post-release, the incidence of mortality observed in these cohorts would be a poor estimate of population-wide mortality rates, and the risk factors for mortality may also differ at the (prisoner) population level. A related problem is that imprisonment may be defined differently in different countries. In the United States, jails are differentiated from prisons on the basis of several factors including conviction, sentencing status, and length of stay; it is likely that patterns of mortality will differ for those released from jails and prisons. The definition of a release can also be complex. For instance, at least one study has excluded release for extraordinary medical placement (medical parole) from the definition of release (Binswanger et al. 2007), on the premise that inclusion of persons released on the basis of imminent death will inflate the numerator. Work release, transfer to low-security facilities or to locked half-way houses all pose additional methodological challenges. Furthermore, in countries with a number of discrete, State-based correctional systems, such as the United States and Australia, it is unclear whether the findings from one State can be generalized to other States. More broadly, despite the fact that the majority of the world’s prisoners are in low-and middle-income countries, almost all studies of mortality in exprisoners have been conducted in wealthy, western countries.
Studies of mortality in ex-prisoners rely on linkage of prisoner data with death data. Limitations of the quality and scope of source data, and of the linkage process, can compromise the findings and thus the accuracy of the conclusions drawn. Studies that involve linkage to a national death register will potentially identify all deaths in the cohort, except for those who are deported or otherwise leave the country before death. However, some studies have relied on State-based registers, missing those who move interstate and die. Others have relied on coronial databases to identify deaths, thereby excluding all deaths that have not been brought to the attention or a coroner. The linkage process itself is imperfect, as it relies on probabilistic matching of prisoner and death data on the basis of identifying information such as sex, date of birth, and name, often including multiple aliases. This introduces uncertainty into the linkage process and in the United States, there is likely to be greater uncertainty for individuals of Latino ethnicity and African-Americans (Boyle and Decoufle 1990), who are more highly represented among former inmates. As a consequence, there may be selective underestimation of mortality in these groups.
Key analysis issues include numerator bias, correction for reincarceration, and selection of reference population. Examination of the association between release from prison and death is complicated by the fact that many ex-prisoners return to custody and are subsequently released again, requiring the researcher to decide which release to consider for the purposes of analysis. For example, if a prisoner is released from custody and is reimprisoned 6 months later, spends a further 3 months in custody, is released again and dies 1 month later, what is the time between release and death: 10 months or 1 month? When examining the link between release from prison and death, the latter approach biases toward releases that are followed by death, introducing “numerator bias.” Studies adopting this approach overestimate the link between release and death, and were excluded in a recent meta-analysis of this literature (Merrall et al. 2010). A related analysis issue is that in calculating crude mortality rates, some studies fail to exclude subsequent time in custody, despite the fact that the risk of death in custody is considerably lower than the risk in the community (Binswanger et al. 2007; Kariminia et al. 2007). Where this occurs, the rate of mortality may be substantially underestimated.
A final analysis issue relates to the calculation of standardized mortality ratios (SMRs), which compare the observed number of deaths in the study population with the expected number of deaths based on a reference population (usually the general population), adjusting for key demographic differences. SMRs show how much the rate of death is elevated in the study population compared with the general population: For example, in a cohort of Australian ex-prisoners followed for a median of 7.7 years, Kariminia and colleagues (2007) found that the all-cause SMR was 3.7 for men and 7.8 for women, indicating that male ex-prisoners were 3.7 times more likely to die than age-matched males in the general population, while female ex-prisoners were 7.8 times more likely to die than age-matched females in the general population. In another study, Rosen (Rosen et al. 2008) followed a cohort of male ex-prisoners in North Carolina for an average of 10.3 years and calculated an SMR of 2.08 for white ex-prisoners (vs. white males in the community, adjusted for age) and 1.03 for black ex-prisoners (vs. black males in the community, adjusted for age). Although these findings indicate that the rate of mortality was elevated to a greater degree for white than black ex-prisoners, compared with age-and racematched members of the community, they mask the fact that the mortality rate in the community is higher for blacks than for whites. Another Australian study (Stewart et al. 2004) has illustrated this in a cohort of 9,381 ex-prisoners followed for a median of 3.3 years: Among Aboriginal males, the SMR was 9.4 when the reference population was all age-matched males in the community, but fell to 2.9 when the reference population was restricted to age-matched Aboriginal males. The reason for this dramatic change is that in the Australian community, the rate of mortality among Aboriginal males is considerably higher than among non-Aboriginal males. Whether or not adjustment for race is appropriate is a matter of debate.
Interpretation and synthesis of the literature is also made challenging by heterogeneity in reporting of study findings. For example, while some studies report crude mortality rates (CMRs) and/or standardized mortality ratios (SMRs), others compare the rate of mortality across two different time periods (e.g., the first 2 weeks postrelease vs. the subsequent 10 weeks). Different studies report CMRs and SMRs across different time periods (e.g., 1 year post-release, 5 years post-release), and some do not indicate the time period, making their findings difficult to interpret. While some studies report findings disaggregated by key demographic variables (e.g., sex, race), others present whole-population findings; only a minority have reported both. A number of studies have examined only drug-related mortality, while others have considered all-cause mortality, suicide deaths, or some other grouping of death codes. This heterogeneity makes both narrative and quantitative synthesis of the literature challenging.
In order to inform evidence-based policy and practice, a more sophisticated understanding of the incidence and risk factors for mortality in ex-prisoners is required. Most studies to date have used record linkage methods which, by definition, rely exclusively on routinely collected data. Such data are usually not collected for research purposes and as such, they tend to provide only limited information about potential risk factors for death, or circumstances surrounding death (Kinner 2010). Until electronic records completely supersede paper-based correctional and coronial records, novel research designs will be required to complement the knowledge already gleaned from record linkage studies, and advance the evidence base to inform preventive efforts. Such methods may also allow examination of mortality outcomes for ex-prisoners in resource-poor settings.
Conclusions And Recommendations
Prior research has suggested an elevated risk of death among former inmates relative to incarcerated populations and non-institutionalized, general populations. Additionally, it has demonstrated significant time trends, suggesting an early peak in mortality after release from custody. We recommend the inclusion of diverse countries, including resource-poor countries, in future research efforts. In terms of surveillance, we recommend systematic monitoring of mortality in this population, particularly given increasing rates of incarceration that have been observed worldwide and in certain countries (e.g., the United States) over the past 20 years. To enhance efforts at data synthesis, we suggest improvements to the design, analysis, and reporting of research findings. Furthermore, more intervention research across a broad range of outcomes and populations is needed. Intervention efforts, which may include policy changes, should be supported by rigorous data. Collaborative efforts between public health, corrections and advocates are most likely to be successful. Policy efforts should address structural problems such as financing silos. Special attention to physiologic changes, medical comorbidity, poly-substance abuse, environmental factors and health service barriers should be routinely included in transitional interventions, as purely educational or individual behavioral interventions are unlikely to be effective in isolation, given the complexity of the physiologic, structural and policy issues.
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