Spotlight on Health Promotion Research in North America:
The Health Impact of Incarceration on HIV Positive African Americans
MA (Criminal Justice, John Jay College of Criminal Justice at the City University of New York), MS (Community Research and Action, Vanderbilt University), PhD (Community Research and Action, Third Year, Vanderbilt University). Interview and editing by Emily Fisher
The aims of my PhD project are:
- To understand how incarceration impacts the health of HIV positive African Americans after release and over time
- To investigate how substance use and addiction affect the health of HIV positive African Americans who have been formerly incarcerated
- To assess how social conditions affected by incarceration impact the health of HIV positive African Americans after release and over time
I used ethnographic research methods to illuminate the intersection of substance use, incarceration, and HIV by conducting four sets of interviews and observations over a 12 month period with 12 HIV positive African Americans in the US. These methods facilitate opportunities for uncovering important nuances in the participants’ lives (Hesse-Biber, 2010). These subtle distinctions, which remain undetected by conventional research approaches, may have the potential to significantly contribute to society’s understanding of the intersection of HIV and incarceration in especially vulnerable populations. The results will be used to inform programs and policies that affect African American HIV positive incarcerated populations (pre- and post-release) and catalyze future research that examines the impact of incarceration on HIV positive individuals.
The incarceration rate has risen steeply in the United States over the last several decades, with the rate from 1980 to 2010 increasing by 323% (Guerino, Harrison, & Sabol, 2011; Wacquant, 2009). In 2010, there were a total of 7.1 million people in the criminal justice system, including 2.3 million in jails or prisons and 4.8 million on probation or parole (Glaze, 2011). Drucker (2011) suggested that if this population of incarcerated individuals were likened to a city, this city would be the second largest in the United States.
The causes of this extreme increase in the incarceration rate have been explored extensively. Importantly, the social context of incarceration, both at the macro policy level and at the individual level, has been widely cited as contributing to the surge in the incarcerated population. Research has shown that substance use policies in the 1980s, which were stimulated by the move toward determinant sentencing in the 1970s (such as the Rockefeller Drug Laws), led directly to an increase in drug-related arrests and the creation of harsher, more punitive laws regarding drug use, such as mandatory and fixed sentencing (Boutwell & Rich, 2004; Drucker, 2011; Lurigio & Swartz, 2001). Research has demonstrated that 88% of the increase in the incarceration population between 1980 and 1996 was due to stricter and more mandatory and determinant sentencing for drug crimes rather than an actual increase in crime (Blumstein & Beck, 1999).
The experiences and effects of incarceration are varied, but the greatest negative impact is borne by African Americans who are incarcerated at a much higher rate than other ethnic groups. In 2009, the imprisonment rate for African Americans was 4,479 per 100,000 persons compared to 708 per 100,000 for Whites (West, 2010). Additionally, one in every three African American males is likely to go to jail or prison in his lifetime (Bonzar, 2003). Strikingly, African Americans and Whites have nearly the same rate of drug use (9.6% for African Americans and 8.8% for Whites), but African Americans averaged a drug arrest rate of 1,165 per 100,000 persons while their White counterparts averaged only 375 per 100,000 persons (Federal Bureau of Investigation, 2010; Substance Abuse and Mental Health Administration, 2010).
Those most at risk of becoming incarcerated, such as substance users and African Americans, are similarly at increased risk of becoming HIV positive. The rate of HIV among those who are incarcerated is estimated to be 4 to 6 times higher than the rate of prevalence in the general population of the U.S. (Maruschak, 2006). In 2008, 1.5% of inmates were HIV positive, and 24% of these individuals also had AIDS, which represents a rate that is nearly 3 times the rate of that found in the U.S. general population (Maruschak, 2009). Additionally, incarcerated individuals often experience concurrent disorders that also negatively affect their health. Research has shown that mental illness, substance use, other sexually transmitted diseases, and other socially marginalizing conditions such as homelessness, victimization, and poverty are prevalent in incarcerated populations (Altice, Kamarulzaman, Soriano, Schecter, & Friedland, 2010; Millay, Satyanarayana, O’Leary, Crecelius & Cottler, 2009; Rich et al., 2011; Sabol, Minton, & Harrison, 2007).
Additionally, infrastructure in correctional facilities can create barriers that limit access to medical care, which may deleteriously affect the health of HIV positive individuals (Magee, Hult, Turalba, & McMillan, 2005). Hatton, Kleffel, and Fisher (2007) investigated the specific issues related to health-care access while incarcerated and found that administrative errors, hygiene issues, mandatory requirement of co-payment, delay in obtaining needed medications, side effects from medications, administration of wrong medications, medications stopped by mistake, and allergic reactions to medications were common and often negatively affected the health of inmates. Research has also explored the risky behavior (e.g., substance use) of individuals who are prone to experience incarceration and has shown that it profoundly affects both their risk of re-incarceration and their health status (Azar, Springer, Meyer, & Altice, 2010; Wilson, Draine, Hadley, Metraux, & Evans, 2011).
Further complicating this issue, research has also demonstrated that incarceration affects the social conditions post-release. During this transition period, incarceration has been shown to affect the ability to find a job or job training, access to medications (for those who are already ill), finding housing and shelter, provision of social or medical services, and social and familial support (Breese, Ra’el, & Grant, 2000; Pager, 2003; Raphael, 2011; Sowell et al., 2001; Western, 2006). Additionally, these worsened social conditions have also been shown to have a negative impact on self-rated health and health-care service utilization (Fasoli, Glickman, & Eisen, 2012; Klein, Vonneilich, Baumeister, Kohlman, & von dem Knesebeck, 2012).
2. During the time that you began your project until now, how have your views of the issue and the project changed?
When I conceptualized this project, I was narrowly interested in substance abuse and incarceration and the subsequent impact on the health of African Americans who were HIV positive. However, soon after I started the fieldwork I realized how complex the lived realities of the participants actually were. These individuals were dealing with an unbelievable number of issues that ranged from intermittent homelessness to the co-occurrence of multiple medical issues and often had little support from their family, friends, or a social safety net. The effects of incarceration on the ability of individuals to reintegrate into the community after their release are also startling. Many had limited or no employment opportunities, trouble accessing housing, and experienced barriers to re-linking to HIV relevant medical and social services.
3. What major challenges throughout the project did you face?
One of my earlier challenges was related to Vanderbilt University’s Institutional Review Board. I originally wanted to give the participants monetary incentives, but was unable to make it through the review process without changing this to instead give participants gift cards. It was the opinion of the Institutional Review Board that cash incentives would be coercive.
Another challenge was how to emotionally and professionally experience the dualism that is present when you simultaneously exist in two very different and distinct social realms. At times I found it very difficult to be with a participant and to understand their world through their experiences, their perceptions and their words and then spend the rest of my time at Vanderbilt which is a location abundant with resources and support.
4. Can you discuss some of your major discoveries?
One of my early major discoveries was related to strategies to “gain access” to the study population. Several methodological reports and papers have postulated that formerly incarcerated populations are hard to enrol in longitudinal studies and that those studies that have endeavoured to study these individuals long term experience serious levels of participant attrition. However, I had the completely opposite experience. I did not experience ANY attrition and was able to retain all of the participants over the 12-month study period. At the last interview session I asked all of the participants why they stayed in the study. Their answers included: the amount and type of incentive they received, the commitment acts (engaging in day to day activities with the participant, answering their phone calls or texts “afterhours”) demonstrated by the researcher, and because they felt they could talk openly and freely with feeling stigmatized.
The persistent, long-term and multiplicative nature of the impact of incarceration on the lives and health of HIV positive African Americans was also very apparent. Even after a year of being released, many still struggled to find employment and stable housing. Institutional discrimination (including policies that disproportionately affect those who have a history of incarceration) played a major role in their inability to successfully reintegrate back into society and engage in routine medical care and self-maintenance.
5. How do you see your research impacting the lives of those impacted by these issues?
I plan to utilize the findings of this project to inform a quantitative project that measures the specific effects of incarceration on health. The findings from this study, in concert with the quantitative project, will inform the development of an intervention aimed at mediating the effect of incarceration on health.
Participants from this study are also integrally involved in developing the survey that will be used in the quantitative project. Additionally, those participants who are interested will help with the administration and collaborative interpretation of the quantitative data analysis.
6. How do you see your research impacting the field of health promotion?
This work furthers the field of incarceration and health research in that the specific mechanisms via which incarceration affects health will be illuminated. Hopefully, this can inform practices, programs, and prevention and intervention efforts that seek to understand and address the effect of incarceration on vulnerable populations.
7. What are your future research plans?
My long term plan is to continue researching the intersection of health and incarceration. I hope to conduct a quantitative counterpart to this study to inform the development of an intervention aimed at mediating the effect of incarceration on the health of HIV positive individuals. After I graduate from Vanderbilt, I hope to obtain an assistant professor position at a research-oriented University.
If you are interested in contacting Lauren, you can reach her by email at: Lauren.Brinkley@gmail.com
Published: November 2012, Health Promotion Connection