Themed Collection: World AIDS Day 2018

There is increasing recognition that non-communicable diseases (NCDs) are an important public health issue globally. NCDs are not an issue confined to high income countries; indeed 80% of deaths from NCDs are in low and middle income countries, often affecting the poorest. The majority of people in prison are from the poorest and most marginalised sections of society and are likely be at greater risk for NCDs – this is discussed further below.

Diabetes is one of the most important NCDs and November 14th marks World Diabetes Day. Below, Sergio Bautista-Arredondo and Diego Cerecero write about their work examining diabetes in people in prison in Mexico.

The epidemiology, dynamics, and response to diabetes and other non-communicable diseases in Mexican Prisons

The global health community increasingly recognizes the health status of imprisoned populations as a public health issue. Both in high-income and in resource-scarce countries the health conditions and health care standards of prisons have received growing attention from scholars and policymakers. This is timely and welcome since universally, the most socially marginalized groups of societies are overrepresented in prisons – the economically deprived, the poorly educated, and those with substance abuse and other health-related risk behaviours.

Although prison inmates tend to be on average younger than the general population, studies have documented the presence of non-communicable chronic diseases (NCDs) in these settings. In Mexico, over the past five years, our team based at the National Institute of Public Health has conducted a series of studies to understand several aspects linked to NCDs among a large population of inmates in Mexico City's Prison System.

Mexico has recently experienced a dramatic increase in the prevalence of NCDs among the general population. Findings from the last National Health and Nutrition Survey (2012) revealed that the prevalence of self-reported medical diagnoses of hypertension and diabetes were 31.5% and 9.2% respectively (1). Also, diabetes and cardiovascular disease are among the leading causes of death in Mexico.

Between 2010 and 2011 we conducted a study in four male and two female Mexican prisons. The study consisted of two main components. The first was a general health assessment for all participants including diagnosis of HIV, Hepatitis B, Hepatitis C, syphilis, obesity, hypertension, and diabetes and dyslipidemia. The second component of the study was a self-administered questionnaire on sociodemographic backgrounds, criminology elements, health-related behaviours before and after incarceration, and psychological tests.

In the first of a series of publications, we reported measures from 17,084 inmates – 15,354 men and 1,730 women. We compared the prevalence of transmissible infections and NCDs with those documented in the general population using data from the 2006 National Health and Nutrition Survey. The prevalence of obesity was 9.5% and 33.8% among men and women, respectively; while 32.4% of men and 39.7% of women were overweight. Compared with national data on the general population, we observed a lower prevalence of obesity among male prisoners and a very similar prevalence in the case of women. We also found a higher prevalence of hypertension and diabetes among female prisoners when compared to male prisoners (hypertension 14.8 vs. 2.5%, and diabetes 4.6 vs. 1.8%, respectively) (2).

People living with NCDs who are exposed to the prison system might face changes in the availability and quality of healthcare. Prison inmates confront barriers to continuity in health care, including access to pharmaceutical treatment and suboptimal quality of health services. These barriers arise from a mixture of unfavourable physical conditions and resource constraints within the prison environment. In another study using data from our project, we analysed the prevalence of risk factors for chronic diseases and their relationship with the length of incarceration. We hypothesized that longer exposition to the prison environment is associated with changes in NCD-related outcomes: physical activity (PA), diet, smoking, and alcohol or cocaine use. We estimated PA as 579 median metabolic equivalents-min/week, the prevalence of alcohol use was 23.4%, cocaine use was 24.2%, and current smoking was 53.2%. We also observed that as the length of incarceration increased, PA as well as alcohol and cocaine use increased, whereas the quality of diet decreased (3).

We have also assessed the relationship between the length of incarceration and selected risk factors for NCDs: BMI, waist circumference (WC), systolic blood pressure, and diastolic blood pressure. We found a positive and significant trend in BMI, WC and blood pressure across quantiles of the length of incarceration (4).

The findings from our studies illuminate the need for better quality of health services for prison populations in Mexico. Our results suggest that exposure to the prison environment may contribute to the development of NCDs. Also, our studies highlight the need for effective screening services both at entry and during incarceration. Finally, our results might be useful for designing chronic disease health policy for people in prison, with the goal of consistent transition of care from community to prison and vice versa.

Diego Cerecero and Sergio Bautista-Arredondo

Diego Cerecero is a research assistant at the Health Economics and Health Systems Innovations Division at the National Institute of Public Health of Mexico. He is a Health Economist and his research interests are health status of prison population, mental health, and economic evaluation.

Sergio Bautista-Arredondo (sbautista@insp.mx) is the Director of the Health Economics and Health Systems Innovations Division at the National Institute of Public Health of Mexico. He is a Health Economist and his research focuses on the overlap between public health, microeconomic theory and methods.

References:
1. Olaiz-Fernández G, Rivera-Dommarco J, Shamah-Levy T, Rojas R, Villalpando-Hernández S, Hernández-Ávila M. Encuesta Nacional de Salud y Nutrición 2006. Cuernavaca; 2006. 
2. Bautista-Arredondo S, González A, Servan-Mori E, Beynon F, Juarez-Figueroa L, Conde-Glez C, et al. A Cross-Sectional Study of Prisoners in Mexico City Comparing Prevalence of Transmissible Infections and Chronic Diseases with That in the General Population. PLoS One. 2015;10(7). 
3. Silverman-Retana O, Servan-Mori E, Bertozzi SM, Orozco-Nuñez E, Bautista-Arredondo S, Lopez-Ridaura R. Prison environment and non-communicable chronic disease modifiable risk factors: length of incarceration trend analysis in Mexico City. J Epidemiol Community Health. 2018; 
4. Silverman-Retana O, Lopez-Ridaura R, Servan-Mori E, Bautista-Arredondo S, Bertozzi SM. Cross-sectional association between length of incarceration and selected risk factors for non-communicable chronic diseases in two male prisons of Mexico City. PLoS One. 2015; 
5. Silverman-Retana O, Servan-Mori E, Lopez-Ridaura R, Bautista-Arredondo S. Diabetes and hypertension care among male prisoners in Mexico City: exploring transition of care and the equivalence principle. Int J Public Health. 2016;

If you work with people in prison in a low or middle income country and are looking at the issue of NCDs in your population, please do contact WEPHREN WEPHREN@phe.gov.uk.