Abstract
BACKGROUND: Few studies assess the association between county-level incarceration rates and stroke death, and none test mechanisms. We examine the link between county imprisonment rates and stroke death, testing pathways and identifying racial disparities. METHODS: In a cross-sectional design, we regressed stroke death onto imprisonment rates, adjusting for poverty, racial composition, education, unemployment, insurance, and violent crime. Using bootstrap methodology, we tested mediation through sports/recreational facilities and food environment, mental health provider and primary care physician (PCP) access, and community mental distress. Data spanned 4 years (2016-2019) and included 2260 counties. RESULTS: Adjusted models indicated a 0.08 (95% CI, 0.05-0.10) increase in stroke deaths for every 1-unit change in imprisonment rate. This association was mediated by food environment (indirect effect, 0.006 [95% CI, 0.000-0.014]), primary care physician access (indirect effect, 0.002 [95% CI, 0.000-0.006]), and mental distress (indirect effect, 0.014 [95% CI, 0.007-0.022]). Counties in the top versus bottom quintile of imprisonment rates had 86.26% larger Black populations and 23.46% smaller White populations. Counties in the top versus bottom quintile of stroke death had 88.94% larger Black populations and 16.19% smaller White populations. CONCLUSIONS: Our results complement evidence that living in high-jail-incarceration counties contributes to stroke death and associated racial disparities. We provide new evidence on prison incarceration rates and the pathways underpinning this association. County-level imprisonment rates and the identified mechanisms represent avenues for further research into how stroke death and disparities may be mitigated.