Master of Public Health in Health Equity and Criminal Justice: Student and Alumni Feedback on the Development of a New Master of Public Health Concentration

Purpose: To describe Master of Public Health (MPH) student and alumni interest in a new Health Equity and Criminal Justice (HECJ) concentration, highlight their personal experiences with mass incarceration, and summarize their input on developing the concentration. Methods: From July to October 2017 current MPH students and alumni at Touro University California (Vallejo, CA) were electronically surveyed. Results: The 152 respondents included those who had focused exclusively on public health, and those who concurrently obtained clinical degrees in osteopathic medicine, pharmacy, or physician assistant studies. Approximately 90% of the current and former students surveyed believed HECJ to be an integral part of public health, and one in three respondents described being personally impacted by incarceration. More than half (64%) were interested in the HECJ concentration, and 81% of those respondents were interested in completing their field study internship at a correctional facility. Conclusion: The HECJ concentration will fill an educational gap and may provide a pedagogical model for training a future generation of public health professionals to mitigate the health impacts of the U.S. mass incarceration epidemic.


Introduction
The United States detains more people per capita than any other nation in the world, with five times the incarceration rate of most industrialized nations despite similar crime rates. 1 More than two million people are currently confined in federal, state, and military prisons, local jails, juvenile correctional facilities, and immigration detention facilities, reflecting an increase of 500% over the past four decades. 1,2 The impacts of incarceration also persist after release: approximately five million people in the United States are under direct supervision through probation or parole services. 3 Pervasive institutional racism plagues the U.S. criminal justice system and places disproportionate health, psychological, social, and economic burdens on communities of color, who are 67% of the total incarcerated population, while accounting for only 37% of the U.S. population overall. 1 One in three black men in the United States can expect to be imprisoned at least once in their lifetime, and despite similar rates of crime perpetration, black men are more than five times as likely to be incarcerated as white men, and Latino men three times as likely as white men. 4 These racial disparities in incarceration rates persist for women, who in 2018 made up eight percent of the total incarcerated population. 1 Being incarcerated presents unique health concerns for those incarcerated, such as increasing the risk of infectious disease transmission. [5][6][7][8] In addition, as individuals in the United States often serve long sentences, > 40% of incarcerated individuals are living with at least one chronic condition, including hypertension, asthma and diabetes. 9 Compared with the general population, the risk of mental illness is two to four times higher among incarcerated individuals. 10,11 Fifteen percent of men and 31% of women in jails have a serious mental illness such as schizophrenia, major depression, and bipolar disorder. 12 Substance abuse is also prevalent among incarcerated individuals: 68% of jailed individuals and over half of all individuals in state prisons have a diagnosed substance use disorder, five to seven times higher than the general population rates. 13 The relationship between mental health and incarceration is dynamic: mental illness can place individuals at higher risk of incarceration, whereas being incarcerated can also further exacerbate these issues. Furthermore, although incarcerated individuals face all these health issues from incarceration, their access to health services while incarcerated may be limited, or in fact put their health at risk. The California Department of Corrections and Rehabilitation (CDCR) has been sued over the inadequate health services provided for incarcerated individuals, and CDCR has been under federal receivership since 2006. 14 Upon release, the formerly incarcerated also lack meaningful access to health care and basic needs. Individuals are often released without necessary medications or plans for follow-up health care. 15 They disproportionately use emergency departments for primary care purposes and have higher rates of preventable hospital admissions compared with the general population. 16 Many re-enter society with no housing, employment, or social support, and may face discrimination in obtaining employment and housing. A large proportion of states still prohibit those convicted of drug felonies from accessing public assistance for housing and food. 17 These restrictions compound the lifelong negative impacts of incarceration and inadequate access to health care services that already disproportionately burden communities of color.
The U.S. incarceration epidemic extends beyond individual-level impacts to adversely affect families and communities. It is estimated that one in three U.S. adults has been arrested by age 23, 1 and between 70 and 100 million people in the U.S. have some type of criminal record. 18 These records may impact numerous aspects of health and stability such as employment, housing, public assistance, education, finances, and family. 18 A majority of incarcerated individuals are parents, and more than five million children under 18 in the United States have had an incarcerated parent. 19 Parental incarceration is associated with increased adverse childhood experiences, emotional difficulties, school issues, and decreased social engagement. 19 The field of public health already intersects with the U.S. correctional system at various levels, particularly to prevent and respond to communicable disease outbreaks, to promote sanitary conditions in prisons and jails, and to assure the provision of medical and mental health care. 20 We felt it was important to also explore the broader societal public health implications of mass incarceration in the United States and the implications of mass incarceration for issues of equity and public health. Consequently, Touro University California's (TUC) Public Health Program (PHP) began to consider developing a Master of Public Health (MPH) concentration to train students to work with communities impacted by incarceration.
As part of the concentration development process, we noted in our companion publication that community partners and potential employers were surveyed from regional and local governments, public health departments, correctional facilities, law enforcement, and other nonprofit agencies. 21 This study surveys current and former MPH students of the TUC-PHP regarding their interests, opinions, perceived educational needs, and experience with individuals, families, and communities impacted by incarceration.

Methods
All current and former students of the TUC-PHP program as of October 2017 were eligible to complete the survey, including students from TUC's dual degree programs: MPH/Doctor of Osteopathic Medicine (DO), MPH/Master of Science in Physician Assistant Studies (MSPAS), and MPH/Doctor of Pharmacy (PharmD). All methods were approved by the TUC Institutional Review Board before the beginning of the study, and respondents were required to give informed consent before completing the survey.

Survey design and distribution
Cross-sectional survey consisting of demographic, yes/no, short answer, and multiple-choice questions were administered to TUC students and alumni through the data collection platform Qualtrics. The survey response period was 12 weeks from July to October 2017. All responses were anonymous.
An electronic survey link was sent to TUC's student and alumni e-mail lists. At the time of survey distribution there were 274 enrolled students, and the alumni list contained 720 contacts. The survey link was also posted to the electronic course site of several courses and also to the TUC Facebook page asking all current and former students to complete the survey. Students were offered a chance to win a $50 Amazon gift card upon completion of the survey.
The questions were designed to gauge current student and alumni interest in a new MPH concentration focused on criminal justice and public health, including curriculum topic suggestions, and respondent experience with individuals, families, and/or communities impacted by incarceration. Respondents were asked about their opinions on a number of statements regarding the U.S. criminal justice system and public health on a 5-point Likert scale with options ranging from ''Strongly Disagree'' to ''Strongly Agree.''

Data collection and analysis
Data were collected and managed through Qualtrics. All responses were anonymous and kept confidential, viewable only by the authors of this study.
Quantitative variables were summarized with frequency counts and proportions. The open-ended fields were analyzed by parsing out themes.
The results were first analyzed as an entire group, and then stratified by both alumni status and degree program. No a priori hypotheses were made regarding differences in survey responses by either current students versus alumni or among the three degree types.

Results
One hundred fifty-two current and former students responded to the anonymous survey; 109 were current students and 43 were alumni (Table 1) Twenty-one percent of the respondents were completing or had received an Independent MPH; 56% were MPH/MSPAS, and 22% were MPH/DO or MPH/PharmD. Fifty-nine percent of students had selected the Community Health Concentration and 41% had selected the Global Health Concentration for their MPH studies.
Most current and former students agreed (or strongly agreed) with all statements regarding public health and incarceration ( Table 2). The statement receiving the highest proportion of agreed responses was ''Families of incarcerated and previously incarcerated individuals are more likely to experience mental health issues such as depression'' with 92% of respondents in agreement. The statement with the lowest proportion of agreed respondents was ''Race/Ethnicity impacts who gets arrested, prosecuted, and incarcerated.'' However, the proportion that strongly agreed was still 78%. There were no striking differences among the three MPH degree tracks on their opinions on public health and incarceration.
A majority of respondents indicated that they would have been interested in a concentration focused on Health Equity and Criminal Justice (HECJ; Table 3).
The proportion that responded favorably differed by degree track, with 50% Independent MPH, 66% of MPH/MSPAS, and 70% of MPH/DO or MPH/ PharmD respondents answering affirmatively. Many of the interested respondents (n = 85) also indicated that they would have been interested in completing a Capstone project focusing on HECJ: 77% of Independent MPH and 52% of MPH/DO or MPH/PharmD would have been interested.
More than 80% of all interested students, regardless of degree track, reported a desire to have completed their field study at a correctional facility, and all of them responded that they believed it was important/useful for TUC to have an HECJ concentration as part of the MPH program.
Respondents who said that they would have been interested in an HECJ concentration were asked in an open text field to explain what interested them in the HECJ concentration and why they thought it would be important/useful for TUC to have this concentration as part of the MPH program. The most common responses regarding HECJ interest were consistent to the themes: ''HECJ is an interesting, relevant topic,'' ''HECJ is integral to public health as a social determinant,'' and ''it would be useful to learn how to improve the situation with a public health approach.'' When elaborating on why it would be important for the TUC-PHP to have this concentration, a majority of responses were consistent with the following themes: ''HECJ is integral to public health,'' ''there is strong student interest in HECJ, this concentration would be an additional option for students,'' ''HECJ is an understudied, overlooked topic,'' and ''HECJ resonates with TUCs commitment to social justice.'' Specific responses regarding interest in the HECJ concentration included the following: ''Health equity is a central action theme of public health, and in my opinion, the reason we do the work we do. Understanding powerful forces that impact health equity, such as criminal justice, is critical to being an effective public health leader. I would have pursued this track if available at the time.''-Current Student, MPH/DO, Community Health Concentration ''Touro is one of the only schools I've heard of that has ''social justice'' in its mission statement and core values dialogue. If that's true, which I believe it is for Touro, then I think it's all the more reason to make sure that subject such as this are brought to light.   important to include in a curriculum for an HECJ concentration (Table 4). Of the topics listed, ''Incarceration impacts on families'' (91%), ''Incarceration impacts on individuals'' (82%) and ''Incarceration impacts on communities'' (82%), were highly favored over topics such as ''Recidivism'' and ''Penalization and Crime Classification (48%).'' Four respondents also selected ''Other'' and wrote in suggestions that included more narrow criminal justice topics, including ''social groups formed within prison and why''; ''intersection of gender identity and incarceration''; ''drug policy and public health alternatives to drug criminalization''; and ''undocumented immigrants.'' Several included topics that were not specific to criminal justice, including ''research methods in social epidemiology''; ''multilevel modeling,'' and ''statistical programming.'' Finally, current and former student respondents were asked if they had any ''personal or professional experience with individuals, families, or communities impacted by incarceration.'' Thirty-five percent of students said that they did have personal or professional experience. This proportion did differ by degree track with 45% of MPH/DO or MPH/PharmD students responding with this experience, MPH/MSPAS 31% and Independent 27%. The 50 students who responded affirmatively to this question were asked to describe their personal or professional experience. Family, patients, and ''work'' were the most common themes reported.

Discussion
Although public health as a field has acknowledged the public health significance of mass incarceration, the authors are not aware of any Council on Education for Public Health-accredited MPH program that offers specialized training focused on the public health implications for individuals and communities impacted by the criminal justice system. Previous study 21 discovered that community partners and potential employers of TUC MPH graduates were strongly in favor of the development of an MPH concentration focused on the intersection of public health and incarceration. The study shows that this support is also present among current and former MPH students.
Most student and alumni respondents were in favor of the development of the HECJ concentration, and more than half would have chosen it if it had been an option at the time of their enrollment in the program. This demonstrates strong support from students for development of this concentration. More than 80% of those who expressed interest in this new concentration indicated that they would have wanted to complete their field study at a correctional facility. This is in line with findings from a previous survey of community partners and potential employers. Respondents to that survey indicated that direct experience in a correctional facility or working with formerly incarcerated individuals is one of the most important components of training in HECJ. 21 A subset of student and alumni respondents reported previous personal or professional experience with incarcerated individuals, which affirms the scope of the issue in the United States and the number of lives it touches. They reported having experienced the impacts of incarceration through a family member, and a majority (91%) of these students would like to see ''Incarceration impacts on families'' covered in the curriculum. This highlights a particular focus area of interest for the development of this concentration, which will not only include the health impacts of incarceration on the individual, but also those on the family and community connected to them.
This study has a few limitations. The sample was not random because the survey link was posted to the TUC PHP Facebook page, and e-mailed to student and alumni distribution lists. These dissemination methods also made it impossible to determine if respondents were accurately reporting their affiliation with TUC. It is possible, but unlikely, that respondents falsely reported that they were students or alumni. Duplicate entries could not be prevented, but based on the variation in responses this also seems unlikely. The respondents of this study of current and former students vary in their career paths, training, age, race/ethnicity, and concentration, yet almost all share the belief that mass incarceration is a major public health issue. This aligns with national, state, and local public health agencies.
The American Public Health Association (APHA) has long-held opposition to the social practice of mass imprisonment. APHA continues to support alternatives to incarceration and deeper evaluation of the root causes leading to the disproportionate incarceration rates of people of color 22 and has also released a number of public health policy statements on other aspects of criminal justice: law-enforcement violence and over-policing, 23 re-entry support, 24 solitary confinement, 25 mental health and substance abuse services for incarcerated individuals, 26 smoking cessation in incarceration settings, 27 and sex education in correctional facilities. 28 The National Association of County and City Health Officials has also acknowledged mass incarceration as a public health crisis disproportionately impacting children, families, and communities of color. 29 The California Department of Public Health affirms this assertion and supports mitigating community trauma by addressing issues such as community relationships with law enforcement, and mass incarceration. 30 Furthermore, many local health departments throughout California are utilizing core public health skills to engage with the criminal justice system, 31 and recent studies also support the assertion that mass incarceration is a public health problem.
Recent studies describe how mass incarceration drives health inequity, 32 examine incarceration as a health risk and provide suggestions for next steps in public health research, training, and practice, 9 and outline a call to action involving the development of new partnerships, the power of data, and an emphasis on public healthfocused policy solutions. 33 Training TUC MPH graduates in HECJ will provide them with the tools and knowledge to work effectively with individuals and communities in a variety of settings, and to respond to the research and advocacy needs to address the health inequities propagated by mass incarceration.

Conclusions
Given the apparent student and alumni interest, the importance of the focus area for public health and pop-ulation equity, and resonance with core social justice values, the PHP at TUC is moving forward with developing and implementing the HECJ concentration. This offering at TUC will be impactful due to the wide range of students trained annually, including > 60 students who will be practicing as clinicians along with the MPH degree, whether as pharmacists, physician assistants, or providers of osteopathic medicine. This is particularly relevant because there are no national standards for teaching health care workers about correctional health, and few clinical programs with related topics as part of the curriculum. 34 The HECJ concentration will provide an opportunity to equip a new generation of clinicians and public health professionals to more deeply understand the intricacies, humanity, and context of the populations they serve.