One-fourth of the prisoners are underweight in Northern Ethiopia: a cross-sectional study

Prisoners are exposed to a number of unfavorable health and health deterring factors including higher risks of mortality and injuries [1‐5]. A remarkable feature of prisoners is that they often arrive at health service centers with a number of health and social problems which can lead to a high risk of malnutrition [6‐8].

The literature indicates that prisoners face different nutritional problems ranging from several micronutrient deficiencies, re-emerging severe diet related diseases to delayed recovery, mental illness, sexual health problems, infectious diseases, a wide range of risk factors and increased risk of mortality [6, 7, 9‐20].

Studies reported that poor nutrition was significantly associated with severity of pneumococcal pneumonia and risk of acquiring tuberculosis infection [21, 22]. Several other studies showed that underweight and micronutrient deficiencies were associated with higher odds of respiratory infections [23‐25].

In general, in Africa, there is limited evidence on the various health problems of prisoners despite the relevance of such evidence on the health of the prisoners, their inmates, and the general community. In the case of Ethiopia, the prison health system seems to be not well integrated with the national health system and health problems of prisoners are mostly marginalized by researchers.

According to the 2015 report by World Prison Brief (WPB) and Institute for Criminal Policy Research (ICPR), in Ethiopia, the total prison population has grown by 66.9% since 2000, reaching 104,467 in 2010/2011 [26]. One of the basic human rights that prisoners, according to the Universal Declaration of Human Rights (UDHR) Article 25 (1), must have is access to adequate and healthy food choices [27] to meet their nutritional needs. Additionally, Mandela rule 22 states that “Every prisoner shall be provided by the prison administration at the usual hours with food of nutritional value adequate for health and strength, of wholesome quality and well prepared and served. Drinking water shall be available to every prisoner whenever he or she needs it.” [28].

To the authors’ best knowledge, the prevalence and associated factors of underweight has been scarcely researched from the perspective of prison settings. Therefore, this paper determines the prevalence and determinants of underweight among adult prisoners who had respiratory tract infections from 6 zonal and 3 district prison institutions located in Tigray region, northern Ethiopia.

In general, this study demonstrates that underweight affects one in every four of our sample population. Khat chewing, prolonged duration of incarceration and unemployment were significant determinants of underweight in the incarcerated population. Previous history of incarceration was also an important determinant with a borderline significance. Moreover, family support was a significant protective determinant of underweight among the prisoners.

One of the main goals of this study was to determine the burden of underweight among adult prisoners who had respiratory tract infections. We found that 25.2% of the adult prisoners were underweight, of which 35.8% were either severely or moderately underweight, which suggests that underweight is a significant public health problem among prisoners in Tigray region.

The high prevalence of underweight observed among the prisoners could be partly influenced by many factors. One of the important justifications comes from the clinical fact that respiratory infection by itself could lead to malnutrition [34] by mechanisms such as weight loss due to increased basal metabolic rate, poor appetite and metabolic losses of nutrients. However, malnutrition could also be a risk factor for increased risk of infections [35‐37] and may be an important indicator of prognosis from infectious diseases of the respiratory system [38, 39]. Additionally, multiple other studies have also demonstrated that prisoners were suffering from several micronutrient deficiencies that could predispose them to severe forms of infections in addition to other health problems such as depression and mortality [9‐11, 14, 19, 40‐44]. In our study, 9% of the prisoners were either severely or moderately underweight. Hence, implementing therapeutic feeding program for such prisoners and general food distributions for the mildly underweight and normal prisoners could lead a sharp decline of underweight rates [45] and contribute to prevention of epidemics in such vulnerable population. Since our study was implemented using cross-sectional design, as part of our study’s shortcoming, we are unable to demonstrate whether the respiratory infections had caused underweight or the reverse. However, the study indicates that nutritional needs of prisoners should be optimized to ensure adequate nutritional status of prisoners.

Moreover, morbidity from respiratory infections of at least two weeks could also be associated with poor access to appropriate health care service, as reported in several studies [46‐49]. This might be related to prolonged loss of appetite and loss of sleep. On the other hand, the high prevalence of underweight among the convicts could be due to low rations and quality of food served on top of severe prison related stress [50, 51]. Previous studies have also reported that prisoners faced a wide spectrum of nutritional problems [10‐12, 14, 41, 52‐54] and diets were not balanced [13, 54]. Nevertheless, it is important to note that our observed burden of underweight among the prisoners could be overestimated due to the fact that our study was based on prisoners who had respiratory/TB infection in which weight loss is a typical feature of such health problems.

One of the key determinants of underweight in the incarcerated population was chewing khat. Prisoners who chewed khat had a two-fold increased risk of becoming underweight. Sleep disturbance and loss of appetite associated with khat chewing could be the main explanations for the observed higher risk of underweight among khat chewing prisoners compared to their counterparts [55‐58], rendering them susceptible to subsequent immunosuppression and repeated cycles of respiratory infections [35]. Such a deadly vicious cycle of interaction of undernutrition and infection, combined with possible deficiencies of several micronutrients, might further lead the prisoners to higher risk of severe morbidity and mortality.

Our study showed that there was a 41% lower risk of underweight for prisoners who were getting family support. Although we could not find literature linking family support and nutritional status of prisoners, it is a straight forward observation in that those who secured family support could be more likely to eat enough, achieve emotional and social support that could neutralize possible stress, and maintain a healthy life style such as personal hygiene. We assume that these health promoting conditions could finally lead them to lower risk of underweight compared to their counterparts.

Another important finding was that every one year additional imprisonment significantly translated to a 7% higher risk of underweight. This could imply that compared to prisoners who were imprisoned only for 1 year, those prisoners who were imprisoned for five years had approximately 35% higher risk of becoming underweight. Prior studies have also reported that longer duration of imprisonment was associated with significantly lower vitamin D level and lower values of serum proteins, mean corpuscular volume and haematocrit [12, 19, 54]. Within two years of incarceration, a 22 year old Nigerian detainee was found to develop severe underweight characterized by irreversible severe sensory and motor neuropathy of lower limbs and pulmonary TB [59]. Such severe underweight, also referred as “hunger disease”, was also reported to be associated with death [51]. The higher risk of becoming underweight with longer duration of imprisonment could probably be due to harsh living conditions that might arise from long term exposure to psychological stress, overcrowding, possible humiliation, hunger, morbidity, poor personal hygiene and sanitation [51]. In a study done elsewhere, longer duration of incarceration was also associated with risk of drug use [60]. To further explain how longer duration of incarceration relates with underweight, in our analysis, we constructed a statistical scenario that examined if individuals with strong family support who were employed prior to their incarceration have better nutritional status early in their incarceration. If so, this might justify that food provided by prison institutions is of poor nutritional value over time. However, the analysis of the interaction of family support, duration of incarceration and employment status does not support the constructed scenario. Therefore, further research should be done to disentangle how longer duration of incarceration influences nutritional status of prisoners. Nevertheless, we strongly recommend that nutrition interventions in prison setups should be approached in an interdisciplinary and holistic perspective considering the duration of confinement and other public health factors, including overcrowding and poor environmental sanitation, to effectively address nutritional problems and promote overall health of prisoners. Moreover, prospective research should also aim to identify the critical time that prisoners become at risk of underweight and develop other nutritional disorders in order to widen the window of intervention opportunity.

Moreover, we have observed 54% higher risk of underweight for prisoners who had history of previous incarceration with a borderline significance. Studies have shown that re-imprisonment was significantly determined by mental health, previous jail, younger age, drug and alcohol use [61‐64]. Additionally, prisoners with previous history of incarceration had 40% more risk to have general medical problems [15] and poor clinical outcomes such as lower odds of HIV-1 suppression [65]. The findings of the abovementioned previous studies could also explain for the high burden of underweight observed in our study.

Unemployed prisoners were significantly associated with increased risk of underweight compared to farmers. Similarly, studies done in different settings have revealed that unemployment was associated with food insecurity, malnutrition and TB [66‐69]. Poor economic access due to unemployment before incarceration could expose prisoners to risks of poor food quality, low food ration and other health related risk factors which may have led these prisoners to excess risk of underweight.

On the other hand, this study was able to demonstrate that TB, HIV sero-positivity and younger age were also associated with higher risk of underweight, but these associations were statistically insignificant. The absence of significant association between TB/HIV status and risk of underweight could be underestimated due to the small number of such clinical cases which might have neutralized the potentially pronounced reverse effects of these infections on the nutritional status of the prisoners.

This study has three important shortcomings which must be mentioned for cautious utilization of the results. First, this study was implemented among prisoners who had respiratory tract infections. Therefore, we assume that our findings may not be generalizable to all other prisoners in the sense that the level of underweight might have been overestimated due to the fact that weight loss is one of the typical features among individuals who are TB putative cases. Second, potential confounding variables of underweight such as mental health status were not adjusted in the multivariable analysis because it was the study’s exclusion criteria due to the assumption that the data may not be reliable enough if the data would have come by interviewing such cases. A notable consequence of this is that our findings and conclusions could have been affected by a residual confounding although we did not quantify the level of this confounding. Third, despite the detailed training given to the data collectors as well as supervisors, strict implementation of our study procedures and measurements of the variables to enhance the validity and precision of our study, our attempt of quantifying the dose, frequency and duration of smoking and khat chewing was not precise enough. Due to this limitation, we were forced to perform our analyses simply based on the status of smoking and khat chewing. This might have limited our understanding of the potential effects of such unhealthy practices on the outcome variable.

This study, covering the whole major prison sites in the regional state and the first of its kind from Ethiopia, enquires into the extent of the problem of underweight, which is mostly an overlooked public health problem in the marginalized prison population particularly in developing countries. Hence, this study extends our knowledge about underweight and its associated factors in prisons in the context of Ethiopia which may have an enormous implication in initiating possible nutritional interventions in such a vulnerable population.

To conclude, the prevalence of underweight in the prison setups was high. Moderate and severe forms of underweight constitute more than one-third of the prevalent underweight cases. Absence of family support, khat chewing, longer duration of incarceration and unemployment were strong determinants of underweight. Previous history of incarceration and morbidities due to TB and HIV were also important factors worth considering, although the associations were statistically insignificant. We strongly recommend that political leaders, researchers and non-governmental organizations (NGOs) come together to integrate holistic nutritional interventions to address underweight and reform the environmental health conditions to address underweight and promote overall health status of prisoners. Implementing therapeutic feeding programs for severely or moderately underweight prisoners should be one priority component of any nutritional interventions in prison settings.