U.S. Department of Justice Office of Justice Programs Bureau of Justice Statistics ------------------------------------------------------ This file is text only without graphics and many of the tables. A Zip archive of the tables in this report in spreadsheet format (.csv) and the full report including tables and graphics in .pdf format are available on BJS website at: http://www.bjs.gov/index.cfm?ty=pbdetail&iid=5219 ------------------------------------------------------ ******************* Special Report ******************* Medical Problems of State and Federal Prisoners and Jail Inmates, 2011–12 Laura M. Maruschak, BJS Statistician Marcus Berzofsky, Dr. P.H., and Jennifer Unangst, RTI International In 2011–12, half of state and federal prisoners and local jail inmates reported ever having a chronic condition (figure 1). Chronic conditions include cancer, high blood pressure, stroke- related problems, diabetes, heart-related problems, kidney- related problems, arthritis, asthma, and cirrhosis of the liver. Twenty-one percent of prisoners and 14% of jail inmates reported ever having an infectious disease, including tuberculosis, hepatitis B and C, and other sexually transmitted diseases (STDs). About 1% of prisoners and jail inmates who had been tested for HIV reported being HIV positive. This report uses data from the 2011–12 National Inmate Survey (NIS-3) to describe the health status and the health services and treatment received by state and federal prisoners and local jail inmates. Data from the 2009–2012 National Survey on Drug Use and Health (NSDUH) were used to compare the incarcerated populations to the general population. The general population was standardized twice, once to match the prison population and once to match the jail population by sex, age, race, and Hispanic origin. Standardizing the general population to the inmate population controls for differences in the distributions of sex, age, and race, and Hispanic origin, which are important risk factors for medical problems. Standardization removes the effect of sex, age, race, and Hispanic origin when comparing the prevalence of medical conditions between the incarcerated populations and the general population. However, it does not remove the effect of other factors associated with both incarceration status and outcome. The report details the prevalence of specific chronic conditions and infectious diseases and highlights important differences in the rates of each by demographic characteristics. It examines treatment received by inmates with health problems and describes inmate satisfaction with health services received while incarcerated. *************************************************************** **************** Highlights **************** * In 2011–12, half (51%) of prisoners and jail inmates (50%) reported ever having a chronic condition. *Twenty-one percent of prisoners and 14% of jail inmates reported ever having tuberculosis, hepatitis B or C, or other STDs (excluding HIV or AIDS). * Both prisoners and jail inmates were more likely than the general population to report ever having a chronic condition or infectious disease. The same finding held true for each specific condition or infectious disease. * Among prisoners and jail inmates, females were more likely than males to report ever having a chronic condition. High blood pressure was the most common chronic condition reported by prisoners (30%) and jail inmates (26%). * The majority of prisoners (74%) and jail inmates (62%) were overweight, obese, or morbidly obese. * While female prisoners and jail inmates were less likely than males to be overweight, they were more likely to be obese or morbidly obese. * About 66% of prisoners and 40% of jail inmates with a chronic condition at the time of interview reported taking prescription medication. * The majority of prisoners reported having been tested for HIV (71%) and for tuberculosis (94%) since admission. Among jail inmates, 11% had been tested for HIV and 54% for tuberculosis. * Seventeen jurisdictions reported testing all inmates for HIV during the intake process, 11 reported opt-out testing, and 10 reported opt-in testing. * More than half of prisoners (56%) and jail inmates (51%) said that they were either very satisfied or somewhat satisfied with the health care services received since admission. *************************************************************** *************************************** Prisoners and jail inmates were more likely than the general population to report ever having a chronic condition or an infectious disease *************************************** When compared to the general population, both prisoners and jail inmates were more likely to report ever having a chronic condition, and they were more likely to report each of the specific chronic conditions measured. When compared to the general population, the measure of ever having a chronic condition excludes cancer, kidney-related problems, and arthritis or rheumatism because data were not collected on these chronic conditions in the NSDUH. Forty-four percent of prisoners reported ever having a chronic condition, compared to 31% of persons in the general population (table 1). Prisoners were about 1.5 times more likely than persons in the standardized general population to report ever having high blood pressure, diabetes, or asthma. About 45% of jail inmates reported ever having a chronic condition, compared to 27% of the standardized general population (table 2). Jail inmates were nearly two times more likely than persons in the general population to report ever having high blood pressure, diabetes, or asthma. An estimated 21% of prisoners and 14% of jail inmates reported ever having tuberculosis, hepatitis, or other STDs excluding HIV or AIDS, compared to 5% of the general population.***FOOTNOTE 1: In the NSDUH, hepatitis includes all types. In the NIS-3, hepatitis includes hepatitis B and hepatitis C.*** For each type of infectious disease, prisoners and jail inmates were more likely than those in the general population to report ever having that infectious disease. *************************************************************** ********************************** Difference between ever having and currently having chronic medical conditions ********************************** Estimates of chronic medical conditions among state and federal prisoners and jail inmates are based on self-reported information in the National Inmate Survey (NIS-3). Inmates were asked whether a doctor, nurse, or other health care provider ever told them they had select noninfectious medical conditions which were categorized as chronic conditions. Chronic medical conditions involve persistent health problems that have long-lasting effects, and include but are not limited to the select conditions that were asked about in the NIS-3. This measure indicated a diagnosis of having the condition at least once in their lifetime, but does not mean that the inmate currently has the medical condition. As a measure of current medical conditions in the NIS-3, inmates were also asked at the time of the interview whether a doctor, nurse, or other health care provider had told them they currently had select noninfectious medical conditions. The data show that an estimated 50% of prisoners and jail inmates reported ever having a chronic condition compared to 40% currently having a chronic condition. The percentage of inmates who reported currently having a chronic condition was lower than those who reported ever having a chronic condition because over time, a past condition may have been resolved, gone into remission, or no longer required treatment. The measure of ever having a chronic medical condition indicates the percentage of inmates who are potentially at risk for future medical problems while the measure of current condition indicates the percentage of inmates who may have needed health care services at the time of interview. *************************************************************** ****************************************** High blood pressure was the most commonly reported chronic condition among prisoners and jail inmates ****************************************** Similar to the standardized general population, the most commonly reported chronic condition reported by both prisoners and jail inmates was high blood pressure. Nearly a third (30%) of prisoners and more than a quarter (26%) of jail inmates reported high blood pressure. Asthma (15% for prisoners and 20% for jail inmates) and arthritis (15% for prisoners and 13% for jail inmates) were the second and third most common chronic conditions. Among prisoners, hepatitis C was the most commonly reported infectious disease (10%), followed by tuberculosis and STDs (6% each). Among jail inmates, nearly 6% reported ever having hepatitis C, 6% ever had some other STD, and 2% ever had tuberculosis. About 1% of both prisoners and jail inmates who were tested reported having HIV or AIDS. ****************************************** Chronic conditions were more commonly reported by female inmates both in prisons and jails ****************************************** Female prisoners and jail inmates were more likely than males to report ever having a chronic condition (table 3). About two- thirds of females in both prisons (63%) and jails (67%) reported ever having a chronic condition, compared to half of males in prisons (50%) and jails (48%). In prisons, 25% of females and 21% of males reported ever having an infectious disease. In jails, 20% of females reported ever having an infectious disease, compared to 13% of males. Hispanic prisoners and jail inmates were less likely than white and black prisoners and jail inmates to report ever having an infectious disease. About 57% of white, 52% of black, and 41% of Hispanic prisoners reported ever having a chronic condition. Similarly, 54% of white, 50% of black, and 37% of Hispanic jail inmates reported ever having a chronic condition. White prisoners were almost 1.5 times more likely than black prisoners to report ever having an infectious disease. About 15% of both white and black jail inmates reported ever having an infectious disease, compared to 10% of Hispanic inmates. ****************************************** Older prisoners were about 3 times more likely than younger persons to report ever having a chronic condition or infectious disease ****************************************** Older prisoners and jail inmates were more likely than younger persons to report ever having a chronic condition or infectious disease. Prisoners age 50 or older were about 2.5 times more likely than those ages 18 to 24 to report ever having a chronic condition. Similarly, jail inmates age 50 or older were about 2 times more likely than those ages 18 to 24 to report ever having a chronic condition. About 1 in 10 prisoners and jail inmates ages 18 to 24 reported ever having an infectious disease. Prisoners (35%) and jail inmates (30%) age 50 or older were about 3 times more likely to report having an infectious disease than those ages 18 to 24. *************************************************************** ****************************************** Rates of high blood pressure and diabetes increased among prisoners and jail inmates ****************************************** In the Bureau of Justice Statistics’ (BJS) 2002 Survey of Inmates in Local Jails and 2004 Survey of Inmates in State and Federal Correctional Facilities, inmates were asked a series of questions to determine if they ever had or at the time of interview had a chronic condition. Inmates were also asked about specific chronic conditions. The 2011–12 National Inmate Survey (NIS-3) included a more restricted measure of ever had or currently having a chronic condition. In the NIS-3, inmates were asked if a doctor, nurse, or other health care provider ever told them that they had a certain chronic condition and, if a doctor, nurse, or health care provider told them that they currently had the chronic condition. Although the NIS-3 collected a more conservative measure, prevalence estimates of some common chronic conditions were higher in 2011–12 than 2002 and 2004, indicating true increases have occurred over time. Between 2004 and 2011–12, rates of high blood pressure and diabetes rose among prisoners (figure 2). The rate of diabetes in 2011–12 (899 per 10,000 prisoners) was almost twice the rate in 2004 (483 per 10,000). The rate of high blood pressure (3,020 per 10,000 prisoners) was almost 1.5 times the rate in 2004 (2,093 per 10,000). Similar rates were observed for asthma, arthritis, and heart-related problems. Although data suggest stability in these rates, caution should be taken when interpreting data, as the methodology was updated for 2011–12. Similar trends were observed among jail inmates (figure 3). The 2011–12 rate of jail inmates who reported ever having diabetes (723 per 10,000 jail inmates) was twice the 2002 rate (361 per 10,000), and the rate of high blood pressure in 2011–12 was almost 1.5 times higher than the rate in 2002. The rate of asthma also rose between 2002 and 2011–12, from 1,502 per 10,000 jail inmates to 2,012 per 10,000. Although data suggest that the rates of arthritis and heart-related problems among jail inmates were relatively stable, caution should be taken when interpreting data, as the methodology was updated for 2011–12. *************************************************************** *************************************************************** ********************************** Rate of HIV or AIDS in state and federal prisons continued to decline ********************************** Based on data from administrative records reported through BJS’s National Prisoner Statistics (NPS-1) data collection, 18,945 state and federal prisoners were infected with HIV or had confirmed AIDS in 2012—down from 19,536 in 2011 (appendix table 1). Between 2011 and 2012, the estimated rate of HIV or AIDS declined from 145 per 10,000 prisoners to 143 per 10,000. This decline is consistent with declines observed over the previous decades (figure 4). ************************************************************* ********************************** 24% of prisoners and jail inmates reported at least two chronic conditions ********************************** In 2012, nearly a quarter (24%) of both prisoners and jail inmates reported ever having multiple chronic conditions (table 4). About 7% of prisoners and 4% of jail inmates reported high blood pressure and diabetes—two chronic conditions that are risk factors for cardiovascular disease. About 12% of prisoners and 9% of jail inmates reported ever having a chronic condition and an infectious disease. Among prisoners and jail inmates who reported ever having hepatitis B, about 15% reported ever having cirrhosis of the liver. About 11% of those in both populations who ever had hepatitis C reported that they had cirrhosis of the liver. **************************************************************** ********************************************* Majority of prisoners and jail inmates were either overweight, obese, or morbidly obese***FOOTNOTE 2: This finding is consistent with the general population of adults age 20 or older (Health, United States, 2013, Centers for Disease Control and Prevention).*** ******************************************** In 2011–12, nearly three-quarters of prisoners were either overweight (46%), obese (26%), or morbidly obese (2%), with about a quarter of prisoners being either normal weight (26%) or underweight (1%) (table 5). Measures of overweight, obese, and morbidly obese were calculated using the body mass index (see Methodology). Female prisoners (35%) were less likely than males (47%) to be overweight. However, female (43%) prisoners were more likely than males (27%) to be either obese or morbidly obese (appendix table 2). Prisoners ages 18 to 24 were less likely than all other age groups to be obese. About 14% of prisoners ages 18 to 24 were obese, compared to 20% of those ages 25 to 34, 33% of those ages 35 to 49, and 25% of those age 50 or older. Black prisoners (29%) were more likely than white prisoners (23%) to be obese. In 2011–12, more than 6 in 10 jail inmates were either overweight (39%), obese (20%), or morbidly obese (2%), while about 4 in 10 jail inmates were either normal weight (37%) or underweight (1%). Female (32%) jail inmates were less likely than males (40%) to be overweight. However, female (37%) jail inmates were more likely than males (20%) to be either obese or morbidly obese (appendix table 3). Similar to prisoners, jail inmates ages 18 to 24 were less likely than all other age groups to be obese. About 13% of jail inmates ages 18 to 24 were obese, compared to 19% of those ages 25 to 34, 27% of those ages 35 to 49, and 22% of those age 50 or older. About 44% of Hispanic jail inmates reported being overweight—the highest percentage among all racial or ethnic categories. About 1 in 5 jail inmates in each racial category was obese. Black jail inmates (3%) were more likely than white jail inmates (1%) to be morbidly obese. *************************************************************** ************************************** Most prisoners and jail inmates received medical assessments or exams since admission ************************************** Prisoners were more likely than jail inmates to report being assessed and questioned about medical issues at time of admission; to have seen a doctor, nurse, or health care professional for any medical reason; or to have been tested for infectious diseases (table 6). An estimated 85% of prisoners were questioned by staff about their health or medical history, compared to 82% of jail inmates. About two-thirds of prisoners (64%) and half (50%) of jail inmates reported being assessed by staff to see if they were sick, injured, or intoxicated. An estimated 80% of prisoners and 47% of jail inmates reported seeing a health care professional for a medical reason since admission. Prisoners (71%) were about 6.5 times more likely than jail inmates (11%) to be tested for HIV. Among prisoners, 57% were tested for hepatitis B and 54% were tested for hepatitis C, compared to 6% for both among jail inmates. Almost all prisoners (94%) reported being tested for tuberculosis since admission, compared to about half (54%) of jail inmates. *************************************************************** *************************************** About a third of jurisdictions reported testing all inmates on entry *************************************** In 2012, as part of the prison intake process, 17 jurisdictions reported that they test all inmates for HIV, 11 reported that they offer opt-out HIV testing (i.e., all inmates are offered the test, and the test is given unless the inmate declines the test), and 10 reported opt-in HIV testing (i.e., all inmates are offered the test, and the test is given if the inmate wants to be tested). The remaining jurisdictions either had some other practice for testing, did not test, or did not report the testing practice in their jurisdiction (appendix table 4). Thirty-two percent of prisoners were held in the jurisdictions that reported testing all inmates for HIV, 26% were held in the jurisdictions reporting opt-out testing, and 15% were held in the jurisdictions that reported opt-in testing. The remaining quarter of prisoners were held in jurisdictions that either reported other testing circumstances or did not report their testing practices. Among the 10 jurisdictions offering opt-in testing, consent specifically for HIV testing was obtained in 9 jurisdictions, and general consent for medical services was obtained in 1 jurisdiction. For jurisdictions with opt-out testing, type of consent for testing was not consistent. Three jurisdictions obtained consent specifically for HIV testing, six jurisdictions obtained consent for medical services, one jurisdiction did not obtain any consent, and one jurisdiction did not report type of consent. In 2012, the majority of jurisdictions reported testing inmates in custody who requested an HIV test (42), if there was clinical indication (39), who were involved in an incident (34), and who were under court order (32) (appendix table 5). Twenty jurisdictions reported offering HIV testing during routine medical exams, and 19 offered testing to high-risk inmates. On discharge, most jurisdictions (24) provided inmates with an HIV test, if requested (appendix table 6). Seven jurisdictions offered an HIV test to all inmates being released, three offered an HIV test to some inmates, and six reported that they did not provide HIV testing on discharge. **************************************************************** *************************************** Among prisoners and jail inmates who reported ever having a chronic condition, about three-quarters reported having a chronic condition at admission *************************************** Among those who reported ever having a chronic condition, 73% of prisoners and 77% of jail inmates reported that they had a condition at admission (figure 5). Both prisoners and jail inmates were more likely to report a chronic condition at admission than since admission. Among those who reported ever having a chronic condition, about a quarter (27%) of prisoners and a tenth (8%) of jail inmates did not report a chronic condition at admission, but were told that they had the condition since admission. Prisoners and jail inmates who had a chronic condition at admission were equally likely to report taking prescription medication or receiving some other type of treatment in the 30 days prior to admission (table 7). In both populations, about 6 in 10 reported taking prescription medication and more than 3 in 10 reported receiving some other type of treatment. ************************************ 66% of prisoners and 40% of jail inmates with a current chronic condition reported taking prescription medication ************************************ In 2011–12, about 4 in 10 prisoners (41%) and jail inmates (40%) reported having a chronic condition at the time of interview (appendix table 7). Among prisoners with a chronic condition at time of interview, 66% reported that they were taking prescription medication, and 20% said they were receiving some other type of medical treatment. Although inmates could report multiple reasons for not taking prescription medication, prisoners most commonly cited reasons related to lack of health services or doctor’s provision of a prescription. More than a third (36%) of prisoners who were not taking prescription medication said that the doctor did not think medication was necessary or that the facility would not provide the medication, while about 20% reported that they had not seen a doctor. About 19% of prisoners reported that they did not think the medication was necessary, and about 11% reported that they did not like taking the medication. Among prisoners who were HIV positive, 84% reported taking prescription medication. Jail inmates who reported having a chronic condition at the time of interview were less likely than prisoners to report taking prescription medication or receiving some other type of medical treatment. About 40% of jail inmates with a chronic condition at the time of interview reported that they were receiving prescription medication, and 14% reported receiving some other type of medical treatment. Similar to prisoners, jail inmates most commonly reported reasons for not taking prescription medication that were related to lack of health services or doctor’s provision of a prescription. More than a third (39%) of jail inmates who were not taking prescription medication reported that they had not seen a doctor and 36% said the doctor did not think medication was necessary or the facility would not provide the medication. Nearly a third (31%) of jail inmates said that they did not think the medication was necessary, and 16% reported that they did not like taking the medication. Among jail inmates who were HIV positive, 66% reported taking prescription medication. **************************************** More than half of prisoners and jail inmates reported being somewhat or very satisfied with health care services received since admission **************************************** In 2011–12, 13% of prisoners were very satisfied with the health services received since admission and 44% were somewhat satisfied (table 8). Among jail inmates, 14% were very satisfied with the health services received since admission and 37% were somewhat satisfied. Jail inmates (49%) were more likely than prisoners (44%) to report not being satisfied with the health care services received since admission. Nearly half (48%) of prisoners and 43% of jail inmates reported that the health care received while incarcerated was better than or about the same as the care they received in the 12 months prior to admission. ************** Methodology ************** National Inmate Survey ************************ The 2011–12 National Inmate Survey (NIS-3) was conducted in 233 state and federal prisons, 358 local jails, and 15 special facilities (i.e., military facilities, Indian country jails, and Immigration and Customs Enforcement (ICE) facilities) between February 2011 and May 2012. Data were collected by RTI International under a cooperative agreement with the Bureau of Justice Statistics (BJS). The NIS-3 administered two questionnaires to inmates—a survey about sexual victimization and a survey about mental and physical health, past drug and alcohol use, and treatment for substance abuse. Inmates were randomly assigned to receive one of two questionnaires to ensure that the content of the survey remained unknown to facility staff and the interviewers at the time of the interview. A total of 106,532 inmates participated in the NIS-3, receiving either the sexual victimization survey or the randomly assigned companion survey. Combined, the surveys were administered to 43,721 inmates in state and federal prisons, 61,351 inmates in jails, 605 inmates in military facilities, 192 inmates in Indian country jails, and 663 inmates in ICE facilities. The interviews, which averaged 35 minutes in length, used computer-assisted personal interviewing (CAPI) and audio computer-assisted self-interviewing (ACASI) data collection methods. For approximately the first 2 minutes, interviewers conducted a personal interview using CAPI to obtain background information and date of admission to the facility. For the remainder of the interview, inmates interacted with a computer- administered questionnaire using a touchscreen and synchronized audio instructions delivered via headphones. Respondents completed the ACASI portion of the interview in private, with the interviewer either leaving the room or moving away from the computer. A shorter paper questionnaire was made available for inmates who were unable to come to the private interviewing room or interact with the computer. The paper form was completed by 751 state and federal prisoners (1.9% of all prisoner interviews) and 264 jail inmates (0.5% of all jail inmate interviews). Inmates who completed the paper form were not asked about their physical health, mental health, past drug and alcohol use, or treatment for substance abuse. Additional information on the methodology for sample selection of facilities and inmates can be found in the report, Sexual Victimization in Prisons and Jails Reported by Inmates, 2011–12 (NCJ 241399, BJS web, May 2013). In this report, the analysis of the physical health module was restricted to adult inmates in prisons or jails. Therefore, this report excludes juvenile inmates ages 16 or 17 and inmates in military facilities, Indian country jails, or ICE facilities. Administration of the physical health module ******************************** The physical health module was administered to participating inmates in the NIS-3 for one of two reasons-- 1. to ensure the sexual victimization survey length was similar for all participating inmates 2. as part of the alternative survey on mental and physical health, past drug and alcohol use, and treatment for substance abuse. Among inmates who received the sexual victimization survey (90% of inmates surveyed), a brief physical health module was randomly assigned to half of the inmates who participated. Among those inmates, respondents who completed the core sexual victimization survey in 33 minutes or less received the brief physical health module. Based on the time criteria, 11,671 state and federal prisoners (67% of the prisoners who would have been randomly assigned the brief physical health module) and 17,130 jail inmates (69% of the jail inmates who would have been randomly assigned the brief physical health module) completed the brief physical health module. Among inmates who received the alternative survey on mental and physical health, past drug and alcohol use, and treatment for substance abuse (10% of inmates surveyed), the full physical health module was administered to those who completed the mental health and disabilities modules in 30 minutes or less. Of the 4,304 inmates randomized to the alternative survey, 3,833 (89%) inmates received and completed the full physical health module. Among the 6,704 jail inmates randomized to the alternative survey, 5,494 inmates (90%) received and completed the full physical health module. The module on physical health, which was administered through ACASI, relied on inmates reporting their direct experiences. The brief physical health module asked the inmate about the types of medical services received at the time of admission and about any medical conditions (i.e., chronic diseases and infectious diseases) the inmate ever had, had at the time of admission, and had developed since admission. The full physical health module asked the same questions contained in the brief physical module, plus additional items on the types of services and treatments received by inmates with a medical condition and when those services and treatments were received. The entire ACASI questionnaire (listed as the National Inmate Survey-3) is available on the BJS website. Nonresponse bias analysis to assess feasibility of using the 90% or 10% sample in the NIS-3 ************************************ To produce reliable national-level statistics, a nonresponse bias analysis was needed to assess the feasibility of using data in the physical health module from the sexual victimization survey (90% sample) and the alternative survey (10% sample). Bias arises when subjects with characteristics associated with the outcome of interest are either overrepresented or underrepresented, resulting in the estimated prevalence of an outcome being different from the actual prevalence of the outcome. Because not everybody responded to the physical health module, it might be that respondents differ from nonrespondents in significant ways. Because the time to complete earlier modules in the survey was a major factor in determining whether the respondent was administered the physical health module, those who did not receive the physical health module may be different than those who did. The time requirements may have biased the physical health estimates, making them no longer nationally representative of all inmates. To assess the potential bias in both the sexual victimization survey (90%) and alternative survey (10%) administered in the NIS-3, a nonresponse bias analysis was conducted for those who received the physical health module and those who did not. For the sexual victimization survey, differences in response status to the physical health module were assessed by whether or not an inmate had been sexually victimized, language of the interview (i.e., English or Spanish), whether or not an inmate reported a mental health problem and the interaction of victimization and mental health status. For the alternative survey, differences in response status to the physical health module were assessed by language of the interview (i.e., English or Spanish), whether an inmate reported a mental health problem, and the interaction of language of interview and mental health status. Key findings from the nonresponse bias analysis for respondents to the sexual victimization survey include-- * For both prisons and jails, inmates who reported a sexual victimization were significantly less likely than inmates who did not report a sexual victimization to receive and complete the brief physical health module (p-value less than 0.0001 for prisoners and jail inmates). * For both prisons and jails, inmates who responded to the survey in Spanish were significantly less likely than those who responded in English to receive and complete the brief physical health module (p-value less than 0.0001 for prisoners and jail inmates). * For both prisons and jails, inmates who reported a mental health condition were significantly less likely than those who did not report a mental health condition to receive and complete the brief physical health module (p-value less than 0.0001 for prisoners and jail inmates). * Among prisoners and jail inmates who reported a sexual victimization, inmates who reported a mental health condition were significantly less likely than inmates who did not report a mental health condition to receive and complete the brief physical health module (p-value less than 0.0001 for prisoners and jail inmates). * Among prisoners, 1.5% (177 of 11,671 respondents) reported a sexual victimization, reported a mental health condition, and received and completed the brief physical health module. Among jail inmates, 1.1% (190 of 17,130 respondents) reported a sexual victimization, reported a mental health condition, and received and completed the brief physical health module. Key findings from the nonresponse bias analysis for respondents to the alternative survey include-- * For both prisons and jails, inmates who reported a mental health condition were significantly less likely than inmates who did not report a mental health condition to receive and complete the full physical health module (p-value less than 0.0001 for prisoners and jail inmates). However, among those with a mental health condition, 92.0% of prisoners and 86.5% of jail inmates received and completed the physical health module. * In prisons, 225 inmates (5.2% of respondents) responded to the alternative survey in Spanish. * In jails, 321 inmates (5.3% of respondents) responded to the alternative survey in Spanish. * Among prisoners and jail inmates who responded in Spanish, inmates who reported a mental health condition were not significantly less likely than inmates who did not report a mental health condition to receive and complete the full physical health module (p-values of 0.3989 and 0.0678 for prisoners and jail inmates). For the alternative survey, based on the results of the nonresponse bias analyses, it was determined that a weight adjustment could properly correct for potential bias among respondents to the full physical health module. However, based on the results of the nonresponse bias analyses for the sexual victimization survey, it was determined that a weight adjustment might not fully compensate for the potential bias among those who responded to the brief physical health module. Therefore, the analyses of the physical health data were restricted to inmates who completed the alternative survey. Weighting and nonresponse adjustments **************************************** Responses from interviewed inmates were weighted to produce national-level estimates. Each interviewed inmate was assigned an initial weight corresponding to the inverse of the probability of selection within each sampled facility. A series of adjustment factors was applied to the initial weight to minimize potential bias due to nonresponse and to provide national estimates. For the analysis of the physical health module, these adjustments were one of two types: 1. adjustments to account for survey nonresponse 2. adjustments to account for module nonresponse due to time constraints. Methods to adjust for survey nonresponse are detailed in the report, Sexual Victimization in Prisons and Jails Reported by Inmates, 2011–12 (NCJ 241399, BJS web, May 2013). Once adjusted weights were developed to account for survey nonresponse, an additional weighting adjustment was conducted to account for the potential bias induced by nonresponse due to time constraints. Bias could result if the module nonrespondents were different from the module respondents. The adjustment for module nonresponse included a calibration of the weights to ensure that the weight from a nonresponding inmate was assigned to a responding inmate with similar characteristics. Because both respondents and nonrespondents to the physical health module completed part of the alternative survey, the adjustment used data from modules that both groups completed. These data included demographic, criminal history, mental health, and interview debriefing characteristics. This adjustment ensured that the estimates accurately reflected the full sample, rather than only the inmates who responded to the physical health module. For each inmate, these adjustments were based on a generalized exponential model, developed by Folsom and Singh (2002), and applied to the sexual victimization survey respondents.***FOOTNOTE 3 Folsom, Jr., R.E. & Singh, A.C. (2000). The Generalized Exponential Model for Sampling Weight Calibration for Extreme Values, Nonresponse, and Poststratification. Proceedings of the American Statistical Association, Survey Research Methods Section, pp. 598–603.*** The module nonresponse adjustment maintained the benchmark totals designed to make national-level estimates for the total number of inmates age 18 or older who were held in jails at midyear 2011 or in prisons at yearend 2011. These benchmark totals represented the estimated number of inmates by sex (from BJS’s 2011 Annual Survey of Jails and 2011 National Prisoner Statistics). The national estimates for state prisons were 1,154,600 adult males and 83,400 adult females; for federal prisons, 190,600 adult males and 13,200 adult females; and for jails (with an average daily population of 6 or more inmates), 628,620 adult males and 91,551 adult females. Standard errors and tests of significance ****************************************** As with any survey, the NIS-3 estimates are subject to error arising from sampling rather than using a complete enumeration of the population of adult inmates in prisons and jails. For each physical health outcome, the estimated sampling error varies by the size of the estimate, the number of completed interviews, and the intra-cluster correlation of the outcome within facilities. A common way to express this sampling variability is to construct a 95% confidence interval around each survey estimate. Typically, multiplying the standard error by 1.96 and then adding or subtracting the result from the estimate produces the confidence interval. This interval expresses the range of values that could result among 95% of the different samples that could be drawn. Chronic conditions and infectious disease in the general population *********************************** Prevalence rates of chronic conditions and infectious diseases in the general population included in this report come from the National Survey on Drug Use and Health (NSDUH). To be most comparable to the inmate population included in the NIS-3, the survey years from 2009 to 2012 of NSDUH were used in this analysis. Statistical tests comparing the prevalence of chronic conditions and infectious diseases measured in the NIS-3 and NSDUH are presented in tables 1 and 2. NSDUH collects information on six chronic conditions (i.e., high blood pressure, stroke- related problems, diabetes, heart disease, asthma, and cirrhosis of the liver) and four infectious diseases (i.e., HIV or AIDS, tuberculosis, hepatitis, and STDs). Because the demographic makeup of the general population is different than that of the inmate population (i.e., the general population is older, more white, and more female), general population rates were standardized to the inmate population (i.e., the prison population for table 1 and the jail population for table 2) to assess the differences between comparable populations. Standardization calibrates the weights of one of the populations to the distribution of the other based on a set of specified characteristics. Standardized estimates were computed in SUDAAN using its standardization options in PROC DESCRIPT. For this analysis, the general population was standardized to inmate population based on sex, age, race, and Hispanic origin. The standardized general population estimates for disease can be interpreted as the estimate of disease among the general population, if the general population had the same sex, age, race, and Hispanic origin distribution as the prisoner and jail inmate populations. Calculation of body mass index (BMI) ************************************** BMI is a measurement of body fat, based on height and weight, that applies to both men and women ages 18 to 65. BMI can be used to determine if a person is underweight (18.5 or less), normal weight (18.5 to 24.9), overweight (25.0 to 29.9), obese (30.0 to 39.9), or morbidly obese (40 or greater). In the NIS-3, BMI was based on the following formula provided by the Centers for Disease Control and Prevention: BMI = weight (pounds) / (height (inches))2 x 703. **************************************************************** The Bureau of Justice Statistics of the U.S. Department of Justice is the principal federal agency responsible for measuring crime, criminal victimization, criminal offenders, victims of crime, correlates of crime, and the operation of criminal and civil justice systems at the federal, state, tribal, and local levels. BJS collects, analyzes, and disseminates reliable and valid statistics on crime and justice systems in the United States, supports improvements to state and local criminal justice information systems, and participates with national and international organizations to develop and recommend national standards for justice statistics. William J. Sabol is acting director. This report was written by Laura M. Maruschak, BJS Statistician, and Marcus Berzofsky, Dr.P.H., and Jennifer Unangst, RTI International. E. Ann Carson and Jennifer Bronson, Ph.D., BJS Statisticians, and Jennifer Unangst, RTI International, provided statistical verification and review. Morgan Young, Irene Cooperman, and Jill Thomas edited the report. Barbara Quinn produced the report. February 2015, NCJ 248491 ***************************************************************** ************************************************ Office of Justice Programs Innovation * Partnerships * Safer Neighborhoods www.ojp.usdoj.gov ********************************************** ************************************** 1/30/2015 JER 12:10 pm **************************************