Violence-related deaths among people released from incarceration: protocol for a systematic review

IntroductionYoung people and adults released from incarceration have a risk of dying from violence that far exceeds that in the general population. Despite this, evidence regarding the incidence, elevated risk and predictive factors for violence-related deaths after release have not yet been synthesised. This information is important to inform the development of evidence-based approaches to effectively prevent deaths from violence in this population. This systematic review will synthesise the literature examining the crude mortality rates (CMRs), standardised mortality ratios (SMRs) and predictive factors for violence-related deaths among people released from incarceration.Methods and analysisWe searched key electronic health, social science and criminology databases (MEDLINE, PubMed, PsycINFO, Scopus, Web of Science, CINCH, Criminal Justice Abstracts) for peer-reviewed cohort studies published in English on 14th September 2020. Our primary outcome of interest is violence-related deaths occurring in the community following release from incarceration. We will not restrict study eligibility by year of publication or age of participants. The Methodological Standard for Epidemiological Research (MASTER) scale will be used to assess the quality of included studies. If there are sufficient studies and homogeneity between studies, we will conduct meta-analyses to calculate pooled estimates of CMRs, SMRs or predictive factors for violence-related deaths. If there is a sufficient number of included studies, meta-regression will be conducted to examine the influence of subgroups and methodological factors on the CMRs, SMRs or predictive factors. If the studies do not report sufficient data, or if there is substantial heterogeneity, findings will be presented in a narrative form.Ethics and disseminationThis review is exempt from ethics approval as it will synthesise findings from published studies that have already obtained ethics approval. Our findings will be disseminated through a peer-reviewed journal article, and national and international conference and seminar presentations.Trial registration detailsThis study is registered with PROSPERO (CRD42020209422).

Excess mortality among people with podoconiosis: secondary analysis of two Ethiopian cohorts

Background While morbidity attributable to podoconiosis is relatively well studied, its pattern of mortality has not been established. Methods We compared the age-standardised mortality ratios (SMRs) of two datasets from northern Ethiopia: podoconiosis patients enrolled in a 1-y trial and a Health and Demographic Surveillance System cohort. Results The annual crude mortality rate per 1000 population for podoconiosis patients was 28.7 (95% confidence interval [CI] 17.3 to 44.8; n=663) while that of the general population was 2.8 (95% CI 2.3 to 3.4; n=44 095). The overall SMR for the study period was 6.0 (95% CI 3.6 to 9.4). Conclusions Podoconiosis patients experience elevated mortality compared with the general population and further research is required to understand the reasons.

The influence of socioeconomic deprivation on dementia mortality, age at death and quality of diagnosis: a nationwide death records study in England and Wales 2001-2017

Background. Socioeconomic deprivation is postulated to be an important determinant of dementia risk, mortality, and access to diagnostic services. Nevertheless, premature mortality from other causes and under-representation of deprived individuals in research cohorts may lead to this effect being overlooked. Methods. We obtained Office of National Statistics (ONS) mortality data where dementia was recorded as a cause of death in England and Wales from 2001 to 2017, stratified by age, diagnosis code and UK Index of Multiple Deprivation (IMD) decile. We calculated standardised mortality ratios (SMR) for each IMD decile, adjusting for surviving population size in each IMD decile and age stratum. In those who died of dementia, we used ordinal logistic regression to examine the effect of deprivation on likelihood of being older at death. We used logistic regression to test the effect of deprivation on likelihood of receiving a diagnosis of unspecified dementia, a proxy for poor access to specialist diagnostic care. Results. 578,623 deaths due to dementia in people over the age of 65 were identified between 2001-2017. SMRs were similar across the three most deprived deciles (1-3) but progressively declined through deciles 4-10 (Mean SMR [95%CI] in decile 1: 0.528 [0.506 to 0.550], decile 10: 0.369 [0.338 to 0.400]). This effect increased over time with improving ascertainment of dementia. In 2017, 14,837 excess dementia deaths were attributable to deprivation (21.5% of the total dementia deaths that year). There were dose-response effects of deprivation on likelihood of being older at death with dementia (odds ratio [95%CI] for decile 10 (least deprived): 1.31 [1.28 to 1.33] relative to decile 1), and on likelihood of receiving a diagnosis of unspecified dementia (odds ratio [95%CI] for decile 10: 0.78 [0.76 to 0.80] relative to decile 1). Conclusions. Socioeconomic deprivation in England and Wales is associated with increased dementia mortality, younger age at death with dementia, and poorer access to specialist diagnosis. Reducing social inequality may be an important strategy for prevention of dementia mortality.

Temporal trends in the healthy soldier effect in a cohort of Royal Norwegian Navy servicemen followed for 67 years

ObjectivesTo investigate temporal trends in the ‘healthy soldier effect’ (HSE) among 28 300 Royal Norwegian Navy servicemen who served during 1950–2004.MethodsStandardised mortality ratios (SMRs) for all causes, diseases and external causes were calculated from national rates for the entire study period (1951–2017), and for seven successive follow-up periods after the first recorded day of Naval service, for the overall cohort and for two subgroups: land-based personnel and vessel crews. Poisson regression, expressed as rate ratios, was used to compare all-cause mortality between the subgroups.ResultsIn the overall cohort, SMRs for all-cause mortality increased steadily during the first six 10-year follow-up periods, from 0.52 to 0.94, which was still lower than national rates. After 60 years, the lower mortality compared with national rates was no longer statistically significant (SMR=0.93). Low non-neoplastic disease mortality contributed most to the longevity of the HSE. For neoplastic diseases, there was a mortality deficit only for the first and third 10-year follow-up periods. External-cause mortality rose to national rates after 40 years. An HSE was present among vessel crews, but their total mortality rate was 24% higher than that among land-based personnel, who also showed a longer-lasting HSE.ConclusionsThe HSE eroded gradually over time but was still present at 60 years of follow-up for all-cause mortality. The effect was strongest and most long-lived for non-neoplastic disease, lasted up to 40 years for external causes, and was relatively short for cancers. Land-based personnel showed stronger and longer-lasting HSE than vessel crews.

Exploration of morbidity, suicide and all-cause mortality in a Scottish forensic cohort over 20 years

Background Premature mortality among patients experiencing forensic care is high. This paper examines the morbidity and mortality of all Scottish high secure patients in 1992/1993 and followed up 20 years later through the context of recovery. Aims To explore morbidity and delineate which patients are at greatest risk of premature mortality. To assess the extent of suicide and unnatural deaths. To establish which factors, if any, appear protective. Method Health and mortality data were extracted from national data-sets and death categorised as premature or post-expected age. Standardised mortality ratios were calculated to explore natural, unnatural and suicide deaths with Cox regression conducted to explore baseline demographics and premature death. Results During a mean follow-up of 21.1 years, 36.9% (n = 89) died, at an average age of 55.6 years. Of these, 70.8% (n = 63) died prematurely. Men lost on average 14.9 years and women 24.1 years of potential life. Five lives (5.6%) were lost by suicide and three (3.4%) by unnatural means. Conclusions In contrast to other mainstream and forensic cohorts, high rates of suicide and accidental deaths were not apparent. Risk of premature mortality is high. A greater focus upon physical health by community and in-patient services is essential.

Forensic psychiatry and Covid-19: accelerating transformation in forensic psychiatry

Swift medically led scientifically informed responses to the Covid-19 epidemic nationally have been demonstrably superior to other, non-scientific approaches. In forensic psychiatry and across all psychiatric services, urgent and clinically led responses have underlined redundancies and confusions in the governance of mental health services and a vacuum in policy makers. For the future, a greater emphasis on services for patients with schizophrenia and other severe, enduring mental disorders must aim at reducing standardised mortality ratios, managing risk of violence and improving hard outcomes such as symptomatic remission, functional recovery and forensic recovery of autonomy. This will require more use of information technology at service level and at national level where Scandinavian-style population-based data linkage research must now become legally sanctioned and necessary. A national research and development centre for medical excellence in forensic psychiatry is urgently required and is complimentary to and different from quality management.

The potential effect of the African population age structure on COVID-19 mortality

Currently (mid May 2020), most active cases of COVID-19 are found in Europe and North America while it is still in the initial phases in Africa. As COVID-19 mortality occurs mainly in elderly and as Africa has a comparably young population, the death rates should be lower than on other continents. We calculated standardised mortality ratios (SMR) using age-specific case fatality rates for COVID-19 and the age structure of the population of Africa and of other continents. Compared to a European or Northern American population, the standardised mortality ratio was only 0.22 and 0.25, respectively, corresponding to reduction of deaths rates to a quarter. Compared to the Asian and Latin American & Caribbean population, the SMR was 0.43 and 0.44, respectively, corresponding to half the death rate for Africa. It is useful to quantify the isolated effect of the African age-structure on potential COVID-19 mortality for illustrative and communication purposes, keeping in mind the importance of public health measures that have been shown to be effective in reducing cases and deaths. The different aspect of age pyramids of a European and an African population are striking and the potential implications for the pandemic are often discussed but rarely quantified.

Sex-specific risks and trends in lung cancer mortality across occupations and economic activities in Switzerland (1990–2014)

ObjectivesTo assess lung cancer mortality across occupations and economic activities/industries in Switzerland using three statistical estimates.MethodsAll Swiss residents aged 18–65 during the 1990 or 2000 censuses were followed through 2014 to ascertain information on date and cause of death. For every occupation and economic activity/industry, causal mortality ratios (CMR) and standardised mortality ratios (SMR) were computed using national cause-specific mortality rates. We also calculated relative SMR (rSMR) and conducted analyses stratified by socioeconomic variables, job skill level and calendar periods.ResultsThe study sample comprised 5 834 618 participants (111 162 348 person-years). SMR and CMR led to similar results, while rSMR were generally higher. We found 18 occupations in men, 10 occupations in women and 3 industries in each sex with an excess of lung cancer mortality. Among men, rubber and plastic products machine operators, and workers in mining and quarrying, and construction industries were at high risk. Among women, motor vehicle drivers and workers in trade, repair of motor vehicles and of domestic articles and manufacture of goods industries showed the highest risks. In both sexes, hotel and restaurant workers presented an excess of lung cancer mortality.ConclusionMost of the activities and occupations in which we observed excess lung cancer mortality have previously been observed to involve occupational exposure to lung carcinogens. These findings suggest that the number of occupational lung cancer is likely underestimated by the official Swiss statistics. Further research should address this question and the exposure–effect relationships in the most at-risk occupational groups.

Occupational exposure to soft paper dust and mortality

ObjectivesOccupational exposure to soft paper dust is associated with impaired lung function. Whether there is an increased risk for asthma or chronic obstructive pulmonary disease (COPD) is unclear.MethodsWe studied 7870 workers from three Swedish soft paper mills, and defined high-exposed workers, as having been exposed to soft paper dust exceeding 5 mg/m3 for at least 5 years. The remaining workers were classified as ‘low exposed’. Person-years at risk were calculated and stratified according to gender, age and calendar-year. The follow-up time was from 1960 to 2013. The expected numbers of deaths were calculated using the Swedish population as reference and standardised mortality ratios (SMRs) with 95% CIs were assessed.ResultsThere was an increased mortality due to obstructive lung disease (asthma and COPD), among high-exposed workers, SMR 1.89, 95% CI 1.20 to 2.83, based on 23 observed cases. High-exposed workers had an increased mortality from asthma, SMR 4.13, 95% CI 1.78 to 8.14, based on eight observed cases. The increased asthma mortality was also observed among high-exposed men, SMR 4.38, 95% CI 1.42 to 10.2, based on five observed cases. The asthma mortality among low-exposed workers, both men and women, was not increased. The COPD mortality was not clearly increased among high-exposed workers (SMR 1.52, 95% CI 0.85 to 2.50).ConclusionHigh occupational exposure to soft paper dust increases the mortality due to asthma, and the results suggest that soft paper dust levels in workplaces should be below 5 mg/m3.

Developing a deprivation index to study geographical health inequalities in Ecuador

OBJECTIVES: To develop a deprivation index to study health inequalities in 221 areas of Ecuador, to describe the pattern of deprivation in Ecuador, and to explore the applications of the index to study health inequalities by analysing the association between deprivation and mortality in the study areas. METHODS: We performed principal component analyses of available indicators of the 221 cantons of Ecuador. A set of 41 sociodemographic, social capital, and subjective well-being variables were obtained from the 2010 National Population Census and the National Living Conditions Survey 2013–2014. To explore the application of the index in public health, the association between the index and standardised mortality ratios was estimated through a Poisson regression model. RESULTS: The final index was constructed with 17 indicators. The first component explained 51.8% of the total variance of the data. A geographic pattern and a positive association of the index with the standardised mortality ratios of the cantons were observed in both men and women. CONCLUSIONS: We constructed a deprivation index that can identify disadvantaged areas in Ecuador. This index could be a valuable tool for the detection of vulnerabilised populations and the development of interventions and policies adapted to local needs.