The purpose of this study was to test whether variations in substance abuse, mental health diagnoses, individual experiences of violence, community experiences of violence, and incarceration history may be reduced to a single underlying syndemic factor for a sample of women incarcerated in three Midwestern U.S. jails.
Design and Sample
Secondary data analysis of a cross-sectional study of a medical utilization survey; initial confirmatory factor analysis tested fit of model; modification indexes provided confirmatory fit. 290 women incarcerated in three urban Midwestern U.S. jails.
Demographics and variables associated with women's criminal justice experience and sexual health risk were assessed. The analysis included women's mental health, drug dependence, childhood sexual and physical abuse, and partner violence.
The final model had four variables with significant pathways: childhood sexual abuse, childhood physical abuse, domestic violence, and mental health diagnoses. The fit of this model was very good (χ2 (1) = 0.6; CFI = 1.00; standardized RMR = 0.0147), strongly suggesting the intertwined nature of the variables.
Clarification of the specific components in a syndemic model for this population will allow for the implementation of interventions with the appropriate inclusion of content. In interventions and clinical practice, public health nurses should consider these interrelationships.
The number of women in the criminal justice system has dramatically increased over the past 30 years, with the incarceration of women increasing at nearly twice the rate of men (Bloom, Owen & Covington, 2005; Pew Center on the States, 2008). This increase is the result of changes in arrest and sentencing policies in states and localities across the country. The policies of the ‘war on drugs’, in particular, have led to a 600% increase in the number of women who have passed through the justice system over the last 25 years.
These policy changes have also resulted in the disproportionate criminalization of women of color (Mauer, 2006). Black women makeup half the population of women in U.S. prisons and jails and are seven times as likely to have been incarcerated than White women (West & Sabol, 2009). The overwhelming majority of incarcerations, 85%, are for nonviolent offenses. The arrests and incarcerations of women disrupt the lives of families and communities, with 70% of incarcerated women leaving behind children under the age of 18; 30% have children under age five living with them (Glaze & Maruschak, 2010).
Much data from the criminal justice system combine statistics on women in prisons and local jails. The former are in state and federal facilities that are often far from their homes; their sentences may be as short as 1 year in length, but may extend to life. Jails, on the other hand, house women who are pending sentencing, who have short sentences (generally less than 1 year) and/or who are arrested for relatively minor offenses. Jail populations have particular relevance for public health nurses because women from local jails generally live in and return to the larger community in which they were arrested. They are a population that is generally difficult to access through traditional community programs. Jail offers an opportunistic venue for intervention with these vulnerable women.
The backgrounds of the women in the criminal justice system are distressingly similar. More than 35% report histories of childhood physical, emotional or sexual abuse (Raj et al., 2008). Worldwide, up to 30–60% have histories of substance abuse, with smaller studies showing rates up to 80% (Fazel & Baillargeon, 2011; Kelly, Peralez-Dieckmann, Cheng & Collins, 2010). Over half of incarcerated women have mental health diagnoses ranging from anxiety and depression to personality disorders and schizophrenia (Magaletta, Diamond, Dietz & Jahnke, 2006). Over half have been victims of domestic violence (Kelly et al., 2010), with a similar percentage with histories of sexually transmitted infections (Hale et al., 2009); 30% have traded sex for drugs or life necessities (Ramaswamy et al., 2011).
These events of past history and current life of the women in this population make up what is referred to as a “cycle of violence”. Health care and social service providers working to address specific parts of this cycle easily experience frustration at the seeming intransience of the individual components. The cycle is compounded by the reality that almost all incarcerated women live in marginal economic conditions and communities with minimal amenities (Heimer, 2000). Gender and wage inequalities make their housing and financial resources even more limited than those of incarcerated men. The responsibilities of children added to these economic and mental health issues strongly suggest the need for gender-specific programming and understanding of the unique challenges that they face.
A framework that brings these interconnected health issues together is a syndemic model. A syndemic exists when multiple health and social issues interact to result in disproportionate rates of disease in vulnerable populations, and as such, offers an excellent understanding of the critical factors that contribute to health disparities (Singer, 2009). The model considers the “concentration and deleterious interaction of two or more diseases or other health conditions in a population, especially as a consequence of social inequity and the unjust exercise of power” (Singer, 2009, p. XV). Health problems are not considered from the biomedical approach to disease that has dominated the second half of the 20th and now the 21st century, in which each disease and problem is treated as if it were a distinct entity. For example, it has been clear for many years that high rates of HIV infection, substance abuse, and tuberculosis in many communities cannot be effectively addressed unless the contributions of poverty, poor schools. and joblessness are also addressed (Farmer, 2001). While cholera may be treated medically with IV fluids and antibiotics, it is only when the etiologic problem of unsafe water supplies, generally the result of extreme poverty and lack of societal infrastructure, is addressed that the disease can be effectively minimized or eliminated (Gulland, 2012). The syndemic of the clustering health conditions of substance abuse, intimate partner violence, HIV infection, and mental health among Hispanics was explored by Gonzalez-Guarda, Florom-Smith and Thomas (2011) in this journal. Documentation of a syndemic through both a biological and a statistical pathway provides a strong counter to the dominant biomedical discourse and a way for public health nurses to consider the interconnected social and medical factors that work together to create health disparities.
The classic literature on pathways to crime is male-centered, with little acknowledgment of gender dynamics, power, and inequality for women (Cloward & Ohlin, 1966; Matza, 1990). Public health and public policy literature has extensively examined at the individual associations between incarceration and childhood sexual abuse, childhood physical abuse, mental health, and substance abuse (Mauer, Potler & Wolf, 1999; Raj et al., 2008; Wingood & DiClemente, 1997). However, an analytic approach to the “cycle of violence” as provided by syndemic theory is rare. Such an analytic approach has important implications for intervention and would provide a research basis for a multifactorial approach to working with women in the criminal justice system.
The purpose of this study was to test whether variations in substance abuse, mental health diagnoses, individual experiences of violence, community experiences of violence, and incarceration history may be reduced to a single underlying syndemic factor for a sample of incarcerated women in the United States. The goal of our analysis was to answer the research question, “How can the application of a syndemic model fit the experiences of women in the criminal justice system of local community jails?”
Design and sample
We conducted this cross-sectional survey of health needs and service use with a convenience sample of 290 women in three urban jails in the greater Kansas City metropolitan area (with one facility on the Missouri side of the state line and two on the Kansas side) over a 6-month study period in 2010 (Ramaswamy et al., 2011; Kelly & Ramaswamy, 2012). Recruitment of the convenience sample occurred on an ongoing basis over the 6-month data collection period and depended on the number of willing and available participants (for example, those not making court appearances). On any given day, about 150 women, total, were housed in the three jails. We estimate that we interviewed approximately half of the women housed in the jails, given the study period, average daily population, and turnover at the jails. Participants were similar to the rest of the women at the three jails on the basis of average age, race, and ethnic characteristics, according to records from each facility and discussions with administrative staff about the inmates' characteristics. Permission to conduct the study was provided by the Institutional Review Boards at the two universities where investigators had faculty appointments.
Participants were recruited with flyers posted at the three jails and through word of mouth in each housing unit by the special programs coordinators. All women in the facilities were eligible and invited to participate, although only those who volunteered were included as potential participants. The reasons for the women not wanting to participate are unknown. Interviewers read a standardized recruitment script and consent form to each potential participant in English. After the women signed the informed consent document and agreed to participate in the study, we conducted a face-to-face survey administered by the interviewer in English. All interviews were conducted in semi-private spaces at the jail, with interviewer and participant on either side of a table. A correctional officer or the special programs coordinator stood about 20 feet away during the interviews. Each participant was given a $5 credit to her commissary account or gift basket with snacks and hygiene products of equivalent value as compensation for participation.
Standard measures of demographics were collected. Age was assessed by asking participants the year in which they were born. Race/ethnicity was measured by asking participants to identify their race and whether or not they identified as Hispanic. Education was assessed by asking participants whether they had completed high school or a GED exam. We also included several variables—sociodemographic, behavioral, and personal background variables known to be associated with both women's criminal justice experience (Kelly et al., 2010; Kim et al., 2002) and their sexual health risk (McClelland, Teplin, Abram & Jacobs, 2002; Wingood & DiClemente, 1997) as possible covariates in our analysis. Women's criminal justice history was assessed with three items asking how many times they had been arrested, how many months total they had spent in prison or jail in their lifetime, and how many days they were incarcerated in the past year. Neighborhood violence in the 6 months prior to incarceration was assessed by asking if participants had heard about a fight in which a weapon was used, a violent argument between neighbors or friends, a gang fight, a robbery or mugging, or a murder, with possible yes/no responses for each item (Adult Violence Score, Wright et al., 2004—originally adapted from Perceived Neighborhood Violence Scale, Sampson, Raudenbush & Earls, 1997). We computed a summary score of all types of violence, with higher scores indicating a greater level of neighborhood violence.
Mental health was assessed by asking participants if a doctor or nurse had ever told them that they had depression, anxiety, schizophrenia, or bipolar disease.
Drug dependence items were based on DSM IV criteria. For example, participants were asked six questions about drug use in the year before incarceration. This included questions such as, “Did you need to use more drugs to get the same high as when you first started using?” If participants answered “yes” to three of six criteria, they were classified as “drug-dependent” (Cronbach's alpha = 0.89) (Compton, Grant, Colliver, Glanz & Stinson, 2004).
Childhood sexual abuse was measured by documenting frequency of sexual abuse before age 16 with the following question: “Did anyone ever do any of the following things when you didn't want them to: touch the private parts of your body, make you touch their private parts, threaten or try to have sex with you, or sexually force themselves on you? Did it happen 0 times, 1–2 times, 3–5, 6–10, or more than ten times?” (Walsh, MacMillan, Trocme, Jamieson & Boyle, 2008).
Childhood physical abuse was assessed by asking participants three questions about how often they had been hit, pushed or shoved, or kicked or punched before age 16 (Walsh et al., 2008). (Cronbach's alpha = 0.82 for sexual abuse and physical abuse questions). Because frequency varied across physical and sexual abuse questions, we coded abuse as having answered yes to one or more times to any of these physical and sexual abuse questions.
Intimate partner violence in the year prior to incarceration was assessed by asking participants if a sex partner had physically hurt, insulted or screamed at the participant on a regular basis or fairly often (adapted from Sherin, Sinacore, Li, Zitter & Shakil, 1998). Because we condensed all types of intimate partner violence (physical, insulting, screaming) into one question and treated this as a dichotomous variable, the psychometric properties of this question are unknown.
The primary hypothesis was tested in two stages using SPSS. Pairwise correlations between the measures were calculated using either tetrachoric or polychoric correlation, depending on the measurement level. The correlation matrix was then imported into SPSS for confirmatory factor analysis. In stage 1, confirmatory factor analysis was used to test the priori theory that childhood sexual abuse, childhood physical abuse, substance abuse, mental illness, partner abuse, neighborhood violence, and mental health problems are aspects of a single underlying phenomena (i.e., a syndemic factor). Model fit was evaluated using three fit indexed: the chi-square test, comparative fit index (CFI), and root mean square error of approximation (RMSEA). In stage 2, the initial model was revised to improve model fit based on modification indexes. The final model was based on all three model fit criteria.
The mean age of the 290 women in our study was 33.9 (SD = 9.8). Most of the women were White (43.0%) or Black (40.6%), reflecting the makeup of jails in Kansas City. Two thirds of our sample (70.1%) had graduated from high school or received a GED, 62% had a lifetime history of mental health problem diagnosis, and over half (55.2%) were drug-dependent in the year before incarceration. Many (64.5%) of our female participants reported a history of physical or sexual abuse before age 16. Nearly half (46.4%) of the women had experienced intimate partner violence in the year prior to incarceration. The overwhelming majority (230/85%) had children less than 18 years of age and 97 (36%) had children less than 5 years of age. These results are shown in Table 1.
Table 1. Characteristics of Women in Kansas City Jails, N = 290
Level of neighborhood violence in past 6 months, high summary score = greater perceived neighborhood violence.
Age, mean (SD)
Graduated from high school/GED
Children at home
Less than 18 years of age
Less than 5 years of age
Lifetime history of mental health problem diagnosis
History of physical or sexual abuse before age 16
Intimate partner violence in year before incarceration
The priori theory model with a single latent factor showed an unacceptable fit to the data: χ2 (20) = 386.7, p < .001, CFI = 0.853, RMSEA = 0.252 (Table 2). In stage 2, revisions were made to the priori theory model. First, modification indexes indicated the addition of one correlated error term between partner abuse and mental health problem. Second, three indicators were removed from the model based on small modification indexes value and model fit criteria; they are substance abuse, mental illness, and neighborhood violence. The revised model had a good fit to the data: χ2 (1) = 0.6, p = .4386, CFI = 1.000, RMSEA = 0.000 (Table 2). All indicators had significant loadings on a single latent factor, suggesting that childhood sexual abuse, childhood physical abuse, partner abuse and mental health problems may be reduced to a single latent variable, consistent with syndemic theory. The significant covariance between errors that was added suggested that another unmeasured factor, in addition to a syndemic factor, may connect partner abuse and mental health problems. The final model with unstandardized path coefficients is shown in Figure 1.
Table 2. Unstandardized Loadings for Indicators of the Syndemic Factor from Confirmatory Factor Analyses
Priori theory model
Note. Variance of the latent factor is set to 1. Full model fit: χ2 (20) = 386.7, *p < .001, CFI = 0.853, RMSEA = 0.252. Final Model fit: χ2 (1) = 0.6, p = .4386, CFI = 1.000, RMSEA = 0.00.
The findings of this study suggest the presence of a layering of trauma that begins in childhood and continues into the adult life of women in many local community jails. Childhood sexual and physical abuse, domestic violence, and mental health problems converge in a syndemic for these women and make future incarceration an almost inevitable pathway without appropriate, gender-specific interventions (Bloom et al., 2005). From the community perspective, the health of women in jails is an important function of public health (Goldenson & Hennessy, 2009). These individuals return to communities in fairly short order, with most returning in the days, weeks, or months after arrest. The urban or low-income communities to which many women return have minimal resources. Interventions offered inside of correctional facilities by public health nurses such as writing or meditation programs, and general health education may be able to address overall areas of stress, rather than focusing on one specific risk factor.
An interesting omission from the syndemic model in the current analysis was the lack of inclusion of substance abuse as a statistically significant for this population. This differs from the 30–60% rate of drug abuse and dependence among women prisoners found by Fazel, Bains and Doll (2006) in their systematic review. However, these authors did not distinguish between prison and jail populations. We are not clear if the finding in our study of substance abuse not being significance is a function of our specific sample or if the population of women from local jails differs from that of women in state and federal prisons. Additional research will be important to clarify this issue.
From the perspective of a jail or prison, incarceration provides an opportunity to address the physical and mental health needs of a population that was largely medically underserved before their arrests. Interventions by jail and prison nurses can improve individual lives as well as the health of the community. However, nurses in corrections increasingly find that their employers are not the federal, state or local government entity running the correctional facility, but rather, for-profit corporations (Von Zielbauer, 2005). Limited staff and budgets make services other than those deemed urgent or emergent simply not available. Variable lengths of women's stays necessitate prioritizing health needs by the available staff. The increasing use of co-payments for any health services further restricts access to both physical and mental health care for all incarcerated women, especially those who are poor (Fisher & Hatton, 2010). This political reality suggests that nurses in such settings carefully consider their professional and ethical responsibilities to patients, especially in light of recent lawsuits against the corporations providing correctional health care and nurses working for them in which patient needs were not prioritized (see for example, http://www.ncchc.org/pubs/CC/legal_nursing.html or http://www.spokesman.com/stories/2012/mar/20/idaho-prisons-health-care-called-inhumane/ or http://www.nytimes.com/2005/02/27/nyregion/27jail.html?pagewanted=print&position=&_r=0.
Public health nurses can also apply information about the components of a syndemic of women in jail to work with this population in other settings. From a primary prevention perspective, this would include assurance of safe homes and communities for all children, with an emphasis on acknowledging and promptly addressing physical and sexual abuse for secondary prevention strategies. For tertiary prevention, first offender or community corrections programs, as well as community mental health and domestic violence programs would provide alternative venues for intervention work with women who are caught in this syndemic.
Limitations of the current analysis include the relatively small convenience sample and the use of three facilities from the same geographic area. While the sample demographics are similar to those of urban jails across the country and the descriptive and bivariate findings reflect those of other prison and jail researchers, caution should be used in generalizing beyond the Midwest. Future work might include further information about the timing and extent of childhood physical and sexual abuse, as well as amplification of intimate partner violence and inclusion of the variables of emotional and sexual abuse.
The statistically significant evidence for the existence of a syndemic of childhood sexual and physical abuse, partner abuse, and mental health issues for incarcerated women provides public health nurses with a way to consider the interconnected issues facing this vulnerable population. Treating mental health problems with medications is often an exercise in frustration without also somehow addressing the childhood issues that are strongly associated with adult mental health problems. While a safe venue from intimate partner violence is a critical initial step for women leaving jails and prisons, addressing the mental health and past abuse issues that often allowed both the abuse and the incarceration to occur must closely follow. An integrated approach to working with this population is critical, with public health nurses in a strong position to lead the interdisciplinary teams necessary to address the serious health disparities.