A syndemic model of women incarcerated in community jails.
ABSTRACT 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.
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 (χ(2) (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.
- Journal of Psychosocial Nursing and Mental Health Services 08/2014; 52(8):14-15. · 0.87 Impact Factor
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ABSTRACT: Notable among gaps in the achievement of the global health Millennium Development Goals (MDG) are shortcomings in addressing maternal health, an issue addressed in the fifth MDG. This shortfall is particularly acute in Sub-Saharan Africa (SSA), where over half of all maternal deaths occur each year. While there is not as yet a comprehensive understanding of the biological and social causes of maternal death in SSA, it is evident that poverty, gendered economic marginalization, social disruptions, hindered access to care, unevenness in the quality of care, illegal and clandestine abortions, and infections are all critical factors. Beyond these factors, this paper presents a review of the existing literature on maternal health in SSA to argue that syndemics constitute a significant additional source of maternal morbidity and mortality in the region. Increasing focus on the nature, prevention, and treatment of syndemics, as a result, should be part and parcel of improving maternal health in SSA.Infectious diseases of poverty. 11/2013; 2(1):26.
POPULATIONS AT RISK ACROSS THE LIFESPAN: POPULATION STUDIES
A Syndemic Model of Women
Incarcerated in Community Jails
Patricia J. Kelly, Ph.D., M.P.H.,1An-Lin Cheng, Ph.D.,1Elaine Spencer-Carver, Ph.D.,2and
Megha Ramaswamy, Ph.D.3
1School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO;2Department of Social Work, School of Liberal
Arts, University of Missouri-Kansas City, Kansas City, MO; and3University of Kansas Medical Center, Kansas City, KS
Patricia J. Kelly, PhD, Professor, University of Missouri School of Nursing and Health Studies, 2464 Charlotte Street, Kansas City, MO 64108-2718.
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. Measures: Demographics and variables associated with womens crimi-
nal justice experience and sexual health risk were assessed. The analysis included womens mental
health, drug dependence, childhood sexual and physical abuse, and partner violence. Results: 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 (v2(1) =
0.6; CFI = 1.00; standardized RMR = 0.0147), strongly suggesting the intertwined nature of the
variables. Conclusion: 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 interven-
tions and clinical practice, public health nurses should consider these interrelationships.
Objective: The purpose of this study was to test whether variations in substance
Key words: incarcerated women, syndemic, women’s health.
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 partic-
ular, 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 incarcera-
tions 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
Public Health Nursing Vol. 31 No. 2, pp. 118–125
0737-1209/© 2013 Wiley Periodicals, Inc.
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
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 gener-
ally difficult to access through traditional commu-
nity 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, emo-
tional 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 & Ba-
illargeon, 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 schizophre-
nia (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 compo-
nents. The cycle is compounded by the reality that
almost all incarcerated women live in marginal eco-
nomic conditions and communities with minimal
resources even more limited than those of incarcer-
ated 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
A framework that brings these interconnected
health issues together is a syndemic model. A syn-
demic 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
(Singer, 2009). The model considers the “concen-
tration and deleterious interaction of two or more
diseases or other health conditions in a popula-
tion, 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 domi-
nated 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
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 sup-
plies, generally the result of extreme poverty and
lack of societal infrastructure, is addressed that
the disease can be effectively minimized or elimi-
nated (Gulland, 2012). The syndemic of the clus-
tering health conditions
intimate partner violence, HIV infection, and men-
tal health among Hispanics was explored by Gonz-
alez-Guarda, Florom-Smith and Thomas (2011) in
through both a biological and a statistical pathway
provides a strong counter to the dominant bio-
medical discourse and a way for public health
nurses to consider the interconnected social and
medical factors that work together to create health
The classic literature on pathways to crime is
male-centered, with little acknowledgment of gen-
der 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, child-
hood 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 pro-
vided by syndemic theory is rare. Such an analytic
approach has important implications for interven-
tion and would provide a research basis for a multi-
factorial approach to working with women in the
criminal justice system.
thatcontribute to health disparities
Kelly et al.: Syndemic Model of Women in Community Jails119
The purpose of this study was to test whether varia-
tions in substance abuse, mental health diagnoses,
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 appli-
cation of a syndemic model fit the experiences of
women in the criminal justice system of local com-
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 Kan-
sas City metropolitan area (with one facility on the
Missouri side of the state line and two on the Kan-
sas 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
approximately half of the women housed in the
jails, given the study period, average daily popula-
tion, 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 char-
acteristics, 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 recruit-
ment script and consent form to each potential par-
ticipant in English. After the women signed the
informed consent document
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 dur-
ing 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.
and agreed to
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. Educa-
tion was assessed by asking participants whether
they had completed high school or a GED exam. We
also included several variables—sociodemographic,
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, Te-
plin, Abram & Jacobs, 2002; Wingood & DiClem-
ente, 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. Neighbor-
hood 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 pos-
sible 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 sum-
mary score of all types of violence, with higher
scores indicating a greater level of neighborhood
Mental health was assessed by asking partici-
pants if a doctor or nurse had ever told them that
they had depression, anxiety, schizophrenia, or
Public Health NursingVolume 31Number 2March/April 2014
Drug dependence items were based on DSM IV
criteria. For example, participants were asked six
questions about drug use in the year before incarcer-
ation. 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 docu-
menting 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 ask-
ing participants three questions about how often
they had been hit, pushed or shoved, or kicked or
punched before age 16 (Walsh et al., 2008). (Cron-
bach’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, insult-
ing, screaming) into one question and treated this
as a dichotomous variable, the psychometric prop-
erties of this question are unknown.
The primary hypothesis was tested in two stages
using SPSS. Pairwise correlations between the mea-
sures were calculated using either tetrachoric or
polychoric correlation, depending on the measure-
ment level. Thecorrelation
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 incar-
ceration. 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.
The priori theory model with a single latent
factor showed an unacceptable fit to the data: v2
(20) = 386.7,p < .001,
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: v2
(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 sex-
ual abuse, childhood physical abuse, partner abuse
and mental health problems may be reduced to a
single latent variable, consistent with syndemic the-
ory. The significant covariance between errors that
was added suggested that another unmeasured fac-
tor, in addition to a syndemic factor, may connect
CFI = 0.853,RMSEA =
Kelly et al.: Syndemic Model of Women in Community Jails121
partner abuse and mental health problems. The
final model with unstandardized path coefficients is
shown in Figure 1.
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 physi-
cal 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 inter-
ventions (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 com-
munities 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. Interven-
tions offered inside of correctional facilities by pub-
lic 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
TABLE 1. Characteristics of Women in Kansas City Jails,
N = 290
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
History of physical or sexual abuse
before age 16
Intimate partner violence in year
Has ever exchanged sex for drugs
Drug-dependent in prior year
Level of neighborhood violence,
Number of days in jail in past year,
Lifetime number of arrests, mean (SD)
Lifetime months in jail or prison,
aLevel of neighborhood violence in past 6 months, high
summary score = greater perceived neighborhood violence.
TABLE 2. Unstandardized Loadings for Indicators of the Syndemic Factor from Confirmatory Factor Analyses
Priori theory modelFinal model
Standard error Beta estimate
Childhood sexual abuse
Childhood physical abuse
Mental health problem
Physical health problem
Note. Variance of the latent factor is set to 1. Full model fit: v2(20) = 386.7, *p < .001, CFI = 0.853, RMSEA = 0.252. Final
Model fit: v2(1) = 0.6, p = .4386, CFI = 1.000, RMSEA = 0.00.
Childhood sexual abuse
Mental health problem
Childhood physical abuse
Figure 1. Syndemic Model for Women in the
Criminal Justice System
Public Health NursingVolume 31Number 2March/April 2014
inclusion of substance abuse as a statistically signif-
icant 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, incar-
ceration 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
increasingly find that their employers are not the
federal, state or local government entity running
the correctional facility, but rather, for-profit corpo-
rations (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 politi-
cal 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 forexample, http://www.ncchc.org/pubs/
CC/legal_nursing.html or http://www.spokesman.
called-inhumane/ or http://www.nytimes.com/2005/
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 acknowledg-
ing 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 gen-
eralizing 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 sex-
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 intercon-
nected 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 prob-
lems. 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
nurses in a strong position to lead the interdisci-
plinary teams necessary to address the serious
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