Original Article

Predictors of Drug Injection in High-Risk Populations of Prisoners with a History of Tattooing: A Cross-Sectional Study

Citation: Jafari S, Moradi G, Gouya MM, Azimian Zavareh F, Ghaderi E. Predictors of Drug Injection in High-Risk Populations of Prisoners with a History of Tattooing: A Cross-Sectional Study. J Res Health Sci. 2019; 19(1): e00435.

Introduction

Today, unsafe, shared injections is one of the most important ways of transmitting blood-borne diseases (BBD) ¹ . The risk of transmitting BBD is alarming in places with high prevalence of people who inject drugs (PWID). Prison is one of these places. The prevalence of PWID in prison varies from country to country but it was observed with the highest rates in Taiwan (62.8%) ² and in England (64%) ³ . In Iran, despite different estimations of prevalence in the provinces, this rate is reported to be 16% among all prisoners ⁴ .

The prevalence of BBD in prisons is associated with high-risk behaviors such as the history of drug injection ^5,6 , the history of tattooing ^7,8 , and homosexual sex ⁹ . Some individuals simultaneously have several high-risk behaviors. For example, the prevalence of tattooing is markedly high in prisoners who inject drugs ^10,11 . This can be justified by the almost identical nature of both high-risk behaviors which involve skin piercing and the insertion of an external object into the body by syringes. In these cases, the prevalence of BBD increases in individuals ¹² .

The high prevalence of PWID in prisons with undesirable levels of sanitary facilities and health care leads to increased unsafe and shared injections ¹³ and, ultimately, increased prevalence of BBD in this group ¹⁴ . In addition, the simultaneous presence of risk factors for BBD is contributing to the outbreak of disease in prisons and society due to the return of prisoners into the community.

The effective reduction of BBD in prisons is possible by reducing the associated risk factors. The behavioral surveillance surveys (BSS) are among the most reliable methods for tracking high-risk behaviors associated with BBD in high-risk groups such as prisoners ¹⁵ . Therefore, it is necessary to identify high-risk behaviors and the related predictors using the BSS to design appropriate and evidence-based interventions in order to increase health level in prisons and the community. In particular, there is no information on the drug injection and its related factors in key populations, such as prisoners with a history of tattooing.

We aimed to determine the prevalence of drug injection among prisoners with a history of tattooing using data from behavioral surveillance surveys in prisons during 2015-16.

Methods

Design of Study

This research is a cross-sectional descriptive-analytical study which is approved by the Ethics Committee of Kurdistan University of Medical Science with the code No. MUK.REC.1395.280.

Participants and Sampling Method

The present study is part of a series of repetitive BSS of Iranian prisoners carried out in 2015 and 2016. The studied population includes 5493 prisoners with a history of tattooing. They were selected through census sampling among 11988 prisoners who had been participated and provided written informed consent form for hepatitis B and C BSS in prisons of Iran during 2015-2016 from 55 prisons in 19 provinces ⁷ .

Data Collection Tool

The data for the national BSS were collected using face-to-face checklist-based interviews by trained interviewers. The checklist used in the national plan has 7 sections involving questions about demographic variables, non-sexual high-risk behaviors (history of drug injection, shared injection, piercing (Cupping or a process in which each pierce in whatever part of skin and mostly in soft parts of body like ear, nose, mouth, tongue, navel, and breast occurs by a needle for using jewelry) and tattooing), sexual high-risk behaviors (history of extramarital sex, number of heterosexual/homosexual partners and condom use), history of sexually transmitted infection (STI), and Hepatitis-related knowledge (including 6 questions toward ways of HBV/HCV transmission. Comprehensive knowledge was considered if the prisoner correctly recognized three ways of transmission). The checklist was constructed in 2009 based on international guidelines and protocol proposed for bio-behavioral surveys ⁴ .

Statistical Analysis

The analyses were performed using Stata/SE 14.0 survey package. Chi-square test was used to estimate the weighted prevalence of drug injection and to determine its relationship with the qualitative variables. Weighting was based on the post-stratification method and the post-weight instrument, and the distribution frequency of post-strata was determined using information about the willingness of subjects to participate in the BSS. In addition, multivariate logistic regression was used to estimate the final model based on variables with P<0.2 in the univariate analysis and to calculate the adjusted odds ratio (AOR) as well as the 95% confidence interval (95% CI).

Results

The mean age of participants in this study was 33.9 ± 8.3 yr. Most of the prisoners with a history of tattooing were male (96.4%), married (55.9%), non-academic education (97.1%), working (91.4%), and had a history of imprisonment (67.2%). In addition, a significant percentage of the participants were drug users (85.4%) and had a history of extramarital sex (67.5%). P values, the frequency distribution of demographic and behavioral variables is presented in Table 1.

The prevalence of drug injection among drug users was 20.2% (95% CI: 17.3, 23.5) and the prevalence of shared injection among PWID was 33.9% (95% CI: 27.2, 41.5). The prevalence of drug injection was significantly higher in men than in women (20.6% vs. 8.6%), in individuals with age 35 yr and over than those with age <35 yr (24.1% vs. 17.2%), in singles and divorced/widows than in married (22.5% and 24.7% respectively vs. 18%), in people with a history of imprisonment than in people without imprisonment record (24.2% vs. 10.1%), in prisoners with more than 5 times imprisonments than those with 1-2 times imprisonments (41.4% vs. 16.9%), and in inmates with a duration of imprisonment more than 5 yr than those with less than 5 yr (36.1% vs. 21.1%) (Table 1).

The results of multivariate logistic regression showed that the prevalence of drug injection among prisoners with a history of tattooing is associated with male gender (AOR: 3.02, 95% CI: 1.01, 9. 03), age≥35 yr (AOR: 1.89, 95% CI: 1.39, 2.56), being single (AOR: 1.62, 95% CI: 1.21, 2.18), being divorced/widow (AOR: 1.55, 95% CI: 1.02, 2.35), and a history of imprisonment (AOR: 2.70, 95% CI: 1.82, 4.00) (Table 2).

It is notable that the variables of the history of imprisonment, number of incarceration, and duration of imprisonment that had criteria (p<0.2 in the univariate analysis) to entrance in to the final model had correlation with each other. So, the variable of the history of imprisonment was entered into multivariate logistic regression model because of it′s higher significant OR. ((OR: 2.85, 95% CI: 2.18, 3.72), (OR:1.86, 95% CI: 1.59, 2.17), (OR:2.11, 95% CI: 1.73, 2.58), respectively)

Discussion

According to our study, the prevalence of drug injection among Iranian prisoners with a history of tattooing is 20.2%. Although there is no study on the prevalence of drug injection among prisoners with a history of tattooing, comparing this with the prevalence of drug injection among prisoners in neighboring countries of Iran (Pakistan 39% ¹⁶ and Azerbaijan 33.7% ¹⁷ ) showed that, despite the high prevalence of drug use in this group of individuals (85.7%), this rate is significantly lower for Iran. This may be due to differences in the pattern of drug use in Iran compared to other countries. However, comparing this rate with the prevalence of drug injection among Iranian prisoners (16%) ⁴ indicates a high prevalence of drug injection among prisoners with a history of tattooing. This finding consistent with another results ⁸ , illustrated that the prevalence of a high-risk behavior increases if there are other high-risk behaviors. Therefore, people with multi high-risk behaviors should be in priority for implementing harm reduction programs.

The findings revealed being single and being divorced/widow are associated with the prevalence of drug injection. Furthermore, drug injection is more frequent behavior in individuals who had extramarital sex. Although this difference is not significant. This highlight the importance of marriage in the community. In fact, married people are committed to adhering to ethical principles and, therefore, the odds of high-risk behaviors are reduced in these individuals. Accordingly, the statesmen take steps toward easy marriage in the society. In addition, it is important because extramarital sex and drug injection are the main identified transmission ways of BBD all-around the world and Iran also. Therefore, existing both of them can increase odds of infected. Therefore, implementing harm reduction programs with priority in prisoners with a history of extramarital sex and drug injection simultaneously can facilitate the achievement of 2030 goal ¹⁸ .

The prevalence of drug injection is associated with age≥35 yr and male gender. Since male with age group of 35-39 yr olds have the highest employment rate, addiction and its complication in this economically active population can cause serious and irreparable damage to the country's economy. Consequently, in designing interventions and harm reduction programs it is necessary to paid attention to male over 35 yr old as a vulnerable group.

The prevalence of drug injection was associated with a history of imprisonment. In agreement with this finding, drug use in prison was associated with prolonged imprisonment ¹⁹ . The odds of exposure to high-risk behaviors increases in incarceration. It is possible because of jobless, more leisure time, and the presence of high-risk groups such as PWID and sexually active. Despite the fact that prison is a place for correcting and reforming individuals, it is high-risk environment. Grouping in prisons based on criminal records and duration of incarceration and increasing supervision and restriction measurements in prisons are recommended.

Data were related to the BSS and the sampling method was multi-stage sampling, an important part of which is cluster sampling, selection bias is one of the most important limitations of this study. Therefore, weighting in the analyses was used to resolve the limitation.

Conclusion

The prevalence of drug injection is higher among prisoners with other high-risk behaviors and this rate is associated with male gender, age≥35 yr, being unmarried (single/ divorced/ widow), and history of imprisonment. Although some of these predictors may not be modifiable, they can be intervened. In this regard, grouping in prisons based on the criminal records and duration of imprisonment, providing appropriate training on high-risk behaviors and its complications resulting from it, implementing harm reduction programs for prisoners with a history of extramarital sex and drug injection, as well as facilitating marriage in the community are recommended. In addition, these people should be in priority for implementing harm reduction programs.

Acknowledgements

The researchers appreciate the sincere help provided by the State Prisons and Security and Corrective Measures Organization, and the Center for Communicable Diseases Control at the Ministry of Health and Medical Education, as well as all the prisoners who participated in the study.

Conflict of interest statement

The authors declare that there is no conflict of interests.

Funding

This study was conducted under the financial support of the Deputy of Research and Technology of Kurdistan University of Medical Sciences.

Highlights

References

1. World Health Organization. Global hepatitis report 2017. Geneva: WHO; 2017.
2. Feng MC, Feng JY, Chen YH, Chang PY, Lu PL. Prevalence and knowledge of sexual transmitted infections, drug abuse, and AIDS among male inmates in a Taiwan prison. Kaohsiung J Med Sci 2012; 28(12):660-6. [ Google Scholar]
3. Wright NM, Tompkins CN, Farragher TM. Injecting drug use in prison: prevalence and implications for needle exchange policy. Int J Prison Health 2015; 11:17-29. [ Google Scholar]
4. Navadeh S, Mirzazadeh A, Gouya MM, Farnia M, Alasvand R, Haghdoost AA. HIV prevalence and related risk behaviours among prisoners in Iran: results of the national biobehavioural survey, 2009. Sex Transm Infect 2013; 89(Suppl 3):iii33-iii6. [ Google Scholar]
5. Hodžić H, Bajramović A, Obradović Z, Mahmić Kaknjo M. Intravenous drugs abuse as the main risk factor of increasing hepatitis C infection prevalence in prisoners in Zenica, Bosnia and Herzegovina. Med Glas (Zenica) 2017; 14(1):73-8. [ Google Scholar]
6. Belaunzarán-Zamudio PF, Mosqueda-Gomez JL, Macias-Hernandez A, Sierra-Madero JG, Ahmed S, Beyrer C. Risk factors for prevalent hepatitis C virus-infection among inmates in a state prison system in Mexico. PloS One 2017; 12(6):e0179931. [ Google Scholar]
7. Moradi G, Gouya MM, Azimizan Zavareh F, Mohamadi Bolbanabad A, Darvishi S, Aghasadeghi MR. Prevalence and risk factors for HBV and HCV in prisoners in Iran: a national bio‐behavioural surveillance survey in 2015. Trop Med Int Health 2018; 23(6):641-9. [ Google Scholar]
8. Hellard ME, Aitken C, Hocking J. Tattooing in prisons—not such a pretty picture. Am J Infect Control 2007; 35(7):477-80. [ Google Scholar]
9. HIV transmission among male inmates in a state prison system--Georgia, 1992-2005. MMWR Morb Mortal Wkly Rep 2006; 55(15):421-6. [ Google Scholar]
10. Mir-Nasseri MM, MohammadKhani A, Tavakkoli H, Ansari E, Poustchi H. Incarceration is a major risk factor for blood-borne infection among intravenous drug users: Incarceration and blood borne infection among intravenous drug users. Hepatitis Monthly 2011; 11(1):19-22. [ Google Scholar]
11. Rowhani-Rahbar A, Tabatabaee-Yazdi A, Panahi M. Prevalence of common blood-borne infections among imprisoned injection drug users in Mashhad, North-East of Iran. Arch Iranian Med 2004; 7(3):190-4. [ Google Scholar]
12. Khani M, Vakili MM. Prevalence and risk factors of HIV, hepatitis B virus and hepatitis C virus infections in drug addicts among Zanjan prisoners. Arch Iranian Med 2003; 6(1):1-4. [ Google Scholar]
13. Luciani F, Bretaña NA, Teutsch S, Amin J, Topp L, Dore GJ. A prospective study of hepatitis C incidence in Australian prisoners. Addiction 2014; 109(10):1695-706. [ Google Scholar]
14. Vilibic-Cavlek T, Gjenero-Margan I, Retkovac B, Kolaric B, Bisko A, Banozic-Blagus Z. Sociodemographic characteristics and risk behaviors for HIV, hepatitis B and hepatitis C virus infection among Croatian male prisoners. Int J Prison Health 2011; 7(1):28-31. [ Google Scholar]
15. Amon J, Brown T, Hogle J, MacNeil J, Magnani R, Mills S, et al. Behavioral Surveillance Surveys BSS. Guidelines for repeated behavioral surveys in populations at risk of HIV. 2000.
16. Memon AR, Shafique K, Memon A, Draz AU, Rauf MUA, Afsar S. Hepatitis B and C prevalence among the high risk groups of Pakistani population A cross sectional study. Arch Public Health 2012; 70(1):9. [ Google Scholar]
17. Polonsky M, Azbel L, Wegman MP, Izenberg JM, Bachireddy C, Wickersham JA. Pre‐incarceration police harassment, drug addiction and HIV risk behaviours among prisoners in Kyrgyzstan and Azerbaijan: results from a nationally representative cross‐sectional study. J Int AIDS Soc 2016; 19:20880. [ Google Scholar]
18. UNAIDS. UNAIDS data 2018. Geneva: UNAIDS; 2018.
19. Rowell TL, Wu E, Hart CL, Haile R, El-Bassel N. Predictors of drug use in prison among incarcerated black men. Am J Drug Alcohol Abuse 2012; 38(6):593-7. [ Google Scholar]