Health-related quality of life and its clinical and psychosocial correlates among men entering an in-prison substance-use rehabilitation programme in Indonesia: a cross-sectional study

Technical Summary: Health-related Quality of Life and its Correlates in Indonesian Prison Rehabilitation

Problem Statement
Quality of life (QoL) is increasingly recognized as a central patient-reported outcome for substance-use disorder (SUD) recovery, yet it remains rarely measured in incarcerated populations, particularly in low- and middle-income countries (LMICs). In Indonesia, where in-prison rehabilitation is legally mandated, patient-reported outcomes at the point of treatment entry are essentially undocumented. This study addresses the evidence gap regarding the multidimensional burden faced by men entering in-prison SUD rehabilitation, specifically examining whether QoL impairment is driven by the type of substance used or by broader clinical and psychosocial factors such as affective symptoms and family circumstances.

Methodology
This research employed a cross-sectional secondary analysis of routinely collected intake records from a male-only narcotics prison in West Java, Indonesia, covering the rehabilitation cycle of January–March 2020.

• Sample: The analytic sample consisted of 84 men (mean age 32.2 years) with complete WHOQOL-BREF assessments.
• Measures:
  • Outcome: Health-related QoL was measured using the WHOQOL-BREF (26 items), yielding four domain scores (Physical, Psychological, Social, Environment) transformed to a 0–100 scale.
  • Predictors: Clinical predictors included self-reported lifetime depression and anxiety (from the Addiction Severity Index, ASI) and interviewer-rated psychiatric severity. Psychosocial predictors included age, marital status, education, and pre-incarceration employment. Substance type (amphetamine-type stimulants vs. others) was also analyzed.
• Statistical Analysis: Domain scores were summarized as means. Bivariate associations were examined using Spearman correlations and Mann–Whitney U tests. Multivariable ordinary-least-squares regressions were fitted for each domain, adjusting for age, marital status, education, employment, depression, and anxiety. Given the testing of 24 coefficients, a domain-level Bonferroni correction ($\alpha = 0.0083$) was applied to distinguish robust findings from hypothesis-generating results. Sensitivity analyses included substituting self-reported symptoms with interviewer-rated severity scores and adjusting for institutionalization history.

Key Results

• QoL Impairment: QoL was substantially impaired across all four domains compared to Indonesian general-population norms. Scores were 14 to 22 points below norms, with the deepest deficits observed in the Physical (mean 42.1) and Environmental (mean 43.5) domains.
• Correlates of QoL:
  • Anxiety: Self-reported anxiety was associated with lower Social ($\beta = -10.8$) and Environmental ($\beta = -9.9$) QoL. While the Social association did not survive multiplicity correction, the Environmental association remained significant ($p=0.007$) even after Bonferroni correction.
  • Marital Status: Ever-married men reported significantly lower Environmental QoL ($\beta = -8.2$) compared to never-married men. This finding survived multiplicity correction ($p=0.004$) and remained robust in sensitivity analyses.
  • Substance Type: The type of substance used (including amphetamine-type stimulants) showed no detectable association with QoL, though the authors note limited statistical power for low-prevalence substances.
  • Sensitivity: An interviewer-rated psychiatric-severity score reproduced the Social-domain association without relying on self-report, providing partial corroboration. However, the Anxiety–Environmental association attenuated to borderline significance when adjusted for institutionalization.

Key Contributions

1. Baseline Documentation: This study provides the first documented patient-reported QoL baseline for men entering in-prison SUD rehabilitation in Indonesia, revealing a "double disadvantage" relative to both the general population and the instrument's midpoint.
2. Determinant Identification: The findings challenge the assumption that substance class is the primary driver of QoL in this setting. Instead, they identify affective burden (anxiety) and psychosocial circumstances (specifically family-related obligations) as the principal correlates of poorer QoL.
3. Methodological Rigor in LMIC Context: The paper demonstrates the feasibility of integrating validated, low-cost patient-reported outcome measures (WHOQOL-BREF) into routine correctional intake in resource-constrained settings, while transparently reporting multiplicity-corrected results to avoid over-interpretation of exploratory data.

Significance and Claims
The authors position these findings as hypothesis-generating rather than confirmatory, citing the cross-sectional design, modest sample size, and potential for shared-method variance. The study claims that:

• Clinical Focus: Rehabilitation programmes in resource-constrained settings may be more effective if calibrated to address affective and psychosocial burdens (specifically anxiety and family stressors) rather than focusing primarily on the specific class of substance used.
• Policy Implication: Routine, low-cost mental-health screening (particularly for anxiety) and the monitoring of patient-reported outcomes should be integrated into correctional rehabilitation. However, the authors caution that screening is only useful if paired with adequate referral capacity and psychosocial intervention pathways, as identifying needs without the means to address them risks raising unmet expectations.
• Targeted Intervention: The identification of the Physical and Environmental domains as the most impaired suggests that resource allocation should prioritize physical health assessment and attention to the material and relational environment alongside substance-focused counselling.