Individuals with a history of incarceration have higher rates of cardiovascular disease (CVD) morbidity and mortality compared to the general population, especially in the weeks following release from correctional facilities, but factors driving observed higher rates of CVD morbidity are unknown. Given the disproportionate incarceration of poor and racial/ethnic minorities, there is an urgent need to understand the epidemiology of CVD among individuals with a history of incarceration. Until these mechanisms are defined, we will not be able to identify effective and durable interventions to mitigate CVD morbidity and mortality in this substantial population of young adults. The long-term goal of this application is to reduce morbidity and mortality among individuals with a history of incarceration and CVD risk factors. The overall objective, which is the next step toward achieving this long-term goal, is to design the first longitudinal observational study of individuals who are released from a correctional facility, so as to understand the epidemiology of CVD risk factors and modifiable mediators of CVD risk factor control. The central hypothesis of JUSTice Involved Individuals Study of Cardiovascular Disease Epidemiology (JUSTICE) is that there are population-specific risk factors that affect poor control of traditional CVD risk factors, which in turn contribute to increased CVD morbidity and mortality upon release. Preliminary data indicate that exposure to stricter incarceration policies results in higher levels of chronic perceived stress and lower levels of self-efficacy, which in turn contributes to higher CVD risk. To test the central hypothesis, the proposal tackles three aims: (1) Examine the association between population- specific risk factors and clinical evidence of CVD risk factor control (hypertension, hyperlipidemia, diabetes, and obesity), (2) Assess how changes in population-specific risk factors over time impact CVD risk factor control, and (3) Estimate the impact of population-specific risk factors on long-term CVD morbidity and mortality. Because there are no ongoing or past epidemiologic studies that enable us to test this hypothesis, 500 individuals just released from a Connecticut correctional facility will be recruited in a year-long, prospective cohort study to explore the associations between psychosocial stress, self-efficacy, and exposure to incarceration-related policies and CVD risk factor control, and then followed for an additional three years using electronic health records. These data will be incorporated into the Cardiovascular Disease Policy Model, a CVD risk prediction model, which will generate estimates of the impact of these factors on 10-year CVD morbidity and mortality. JUSTICE represents a new and substantial departure from the status quo by shifting focus to primary data collection to assess CVD risk factor control among a population recently released from correctional facilities. It will be the first study to examine the temporal relationship between incarceration and CVD risk factor control and to simulate the impact of incarceration on CVD morbidity and mortality.
The proposed work is relevant to public health given the high rates of incarceration among African-American and Latino men and that 95% of incarcerated persons will return to mainstream healthcare systems upon release. The project is relevant to NHLBI's mission-driven strategic goals to investigate factors that account for differences in health among populations and to optimize clinical and implementation research to improve health and reduce disease. Including the criminal justice system as a part of the public health infrastructure and thus a target for clinical and implementation science research will be important to eliminating disparities in cardiovascular disease.