EFFECT OF A FITNESS TRAINING/HEALTH EDUCATION INTERVENTION ON

CARDIOVASCULAR HEALTH OF INMATES IN KENTUCKY STATE PRISONS

Alison Connell, PhD, APRN

Biobehavioral Cardiovascular Health Promotion Intervention

In A State Prison SystemDebra Moser, DNS, principal investigator

Alison Connell, PhD, co-investigator

Terrie Lennie, PhD, co-investigator

Alison Bailey, MD, co-investigator

Misook Chung, PhD, project director

Funding: National Institutes of Health, NINR, RC2NR0119428

Background • Leading cause of death in inmates is cardiovascular

disease• Adjusted risk of death among recently released inmates

• 3.5 times that of non-incarcerated• Heart disease is the second most common cause of death in

recently released inmates

• Lower education, income levels and worse health literacy• 41 % of inmates in state and federal prisons have not completed

high school or its equivalent, compared to 18.4 % for the non-incarcerated

Wang EA, et al. Arch Intern Med. 2009;169:687-693. van Olphen J, et al. J Urban Health. 2006;83:372-381. Wolff N, et al. Psychiatr Serv. 2002;53:1469-1471.Binswanger IA, et al. N Engl J Med. 2007;356:157-165. Mumola C. Medical causes of death in state prisons. www.ojp.usdoj.gov/bjs/pub/pdf/mcdsp04.pdf

Study Purpose and Design• The long-term objective of the study was to improve the

cardiovascular (CV) health of inmates by implementation of a state-wide CV risk factor reduction program in prisons

• Specific aim: to determine the effect of a fitness training and health education intervention on:• Cardiovascular health as measured by time to 85% of maximal

heart rate using graded exercise treadmill test.• Self-reported lifestyle behaviors pre- and post-intervention.

Methods• Four prisons—4 groups in each prison, ~35 inmates per group

• Kentucky State Reformatory • Luther Luckett Correctional Complex• Eastern Kentucky Correctional Complex• Little Sandy Correctional Complex

• Recruited via flyers in dorms and recreation areas• Data gathered from inmates at four time points

• A multiple baselines design was used in which all participants receive the intervention, and all have a 3 month run-in period to establish their own baseline without intervention

• Baseline, pre-intervention, immediately post-intervention and 3 months post-intervention

• Intervention—12-week • Health education with behavior change strategy sessions delivered by certified

health educators—one hour once a week• Aerobic exercise program led exercise specialists—one hour twice a week

Measures• Submaximal treadmill test—85% of maximal heart rate

• Modified Bruce protocol

• Inmate Health Risk Assessment—self-report questionnaire• Exercise

• How often moderate physical activity (0-1, 2-3, 4 or more days a week)• How often vigorous physical activity (0-1, 2-3, 4 or more days a week)

• Diet• Usual fruits and vegetables a day (<3, 3-4, 5 or more)• Usual carbs a day

• Mostly white bread and few grains• Some carbs from fiber and whole grain• Mostly whole grain and high fiber

• Usual meat/dairy• Cheese, whole milk, fried foods 5-7 days a week, • 2% milk, fried food/chips 3-4 days a week• No-fat dairy, lean meats, rare fried foods

• Social support• Stress—how well cope• Tobacco use—smoke cigarettes every day, some days, not at all

Demographic data of sample (N = 378) n Percent

Age—mean 36.1 19 – 30 124 32.8

  31 - 45 191 50.5

  46 - 77 63 16.7

Race/Ethnicity Caucasian 238 63.0

  African American 129 34.1

  Other 11 2.9

Marital Status Single 240 63.5

  Married 51 13.5

  Separated/Divorced/Widowed 79 20.9

  Missing data 8 2.1

Education level Less than high school 76 20.1

  High school diploma 148 39.2

  Some college 106 28.0

 Associate, Bachelors, Masters, PhD or professional degree

48 12.7

Length of Sentence and Inmate Offenses n Percent

Length of latest sentence—mean 28.4 years

1 - 10 years 72 19.0

11 - 20 years 103 27.2

21 – 30 years 45 11.9

31 years – life 79 20.9

Inmate Offenses

Burglary, theft, robbery, received stolen property, fraud, credit card theft, forgery

132 34.9

Murder, manslaughter82 21.7

Sex crimes68 18

Violent crimes, assault, weapons crimes74 19.6

Trafficking, drug crimes38 10.1

Other crimes, escape, arson, kidnapping77 20.4

Intervention Participants• Total attendance in education and fitness sessions = 36

sessions• Education 12 sessions• Fitness 24 sessions

• For analysis divided into tertiles of total attendance• 0 - 6 sessions• 7 – 31 sessions• Over 31 sessions

• Age, education level and length of sentence were associated with participation.

• There was no difference in intervention participation by marital status (p = .96) or by self-report of level of health (p = .79).

Intervention Attendance• Fewest fitness and education sessions (0-6 sessions)

• 19-34 years old• Have less than high school, or high school diploma education• Shorter sentence (less than 20 years)

• Most fitness and education sessions (> 31 sessions)• Over 35 years• Over 30 year sentence

Demographic data 0 -6 sessions

7-31 sessions

Over 31 sessions

Х2 df P value

Age by quartile 19 - 28 39 30 13 16.83 6 .01 29 – 35 24 33 28 36 - 42 29 18 29 Over 42 26 26 31

Education < High school 30 17 20 17.6 6 .007 High school diploma 55 42 32 Some college 23 37 28 College degree 10 11 21

Length of sentence 1-10 years 35 17 17 12.6 6 .05 11- 20 years 34 38 27 21-30 years 15 13 15 > 30 years 21 20 31

Health Status Excellent to poor 4.7 8 .79 Marital Status 0.67 4 .96

Results: Time to 85% of maximal HR • By third assessment n = 186• Those who attended more than 31 sessions of the total

education and fitness improved their cardiovascular fitness as measured by the time to get to 85% of their maximal heart rate (p = .01)

• When analyzed using just the fitness sessions• Highest tertile of fitness sessions attended (over 20 sessions) • (p = .003)

Lifestyle Choices• Inmate Health Risk Assessment

• Exercise• How often moderate physical activity (0-1, 2-3, 4 or more days a week)• How often vigorous physical activity (0-1, 2-3, 4 or more days a week)

• Diet• Usual fruits and vegetables a day (<3, 3-4, 5 or more)• Usual carbs a day

• Mostly white bread and few grains• Some carbs from fiber and whole grain• Mostly whole grain and high fiber

• Usual meat/dairy• Cheese, whole milk, fried foods 5-7 days a week, • 2% milk, fried food/chips 3-4 days a week• No-fat dairy, lean meats, rare fried foods

• Social ties—no change ( p = .85) • Stress—no change (p = .28) • Tobacco use—smoke cigarettes every day, some days, not at all

Self-reported Changes in Behavior• Exercise

• Inmates with the highest attendance (>31 sessions) reported that they continued to exercise on non-intervention days

• 26.8% who had been 3 or less days a week at baseline, reported exercising 4 or more days a week post intervention (p = < .001)

• Diet• Increasing fruits and vegetables from less than 3 servings a day to over

3 servings a day• No change in behavior

• Increasing fiber, whole grain from mostly white bread and few whole grain• 30.9% of highest intervention group who ate almost all white bread added

fiber through whole wheat or high fiber (p =.04)

• Decreasing fried/fatty foods and drinking 2% milk • 31.9% of highest intervention group changed from whole milk to 2% and

eating fried or fatty foods from 5-7 d/wk to 4 or less days a week (p = .04)

Cigarette Smoking• Baseline 39.5% some or every day (N =378)

• 20.2% at KSR—tobacco-free prison (staff and inmates) • 49.0% at other three prisons—smoking allowed outdoors

• Post-intervention • 11.5% at KSR• 41% at other three prisons

• 13 out of 180 (7.2%) who reported smoking “every day” or “some days” reported smoking "not at all" by end of study• 8 were in highest attendance group and 5 were in the middle

intervention group (7-31 sessions)

• 9 out of 180 (5%) who reported smoking “not at all” at baseline, reported smoking every day by 3rd assessment

Conclusion• Inmates who participated in the most intervention sessions

• Demonstrated improved cardiovascular health as measured by the time to reach 85% of their maximal heart rate

• Made modifiable lifestyle changes such as • Increasing exercise• Decreasing fried foods, whole milk, and increasing fiber in their diets

• Inmates who had longer sentences, over age 35, and more educated were more likely to participate in the entire intervention

• Limitations• Attrition: N = 378 at baseline and n = 180 by the third assessment